Dashboard India: Demand Generation Male Engagement

India Toolkit: Demand Generation

Involving Men to Increase Uptake of Family Planning Services

Purpose: This tool provides guidance on devising gender intentional and male engagement strategies to promote shared decision making for increasing the uptake of modern contraceptive methods.

Audience:

Additional Director/Joint Director
General Manager-FP and Urban (National Health Mission (NHM)
Chief Medical Officers (CMO)/Additional Chief Medical Officers (ACMO)
Chief Medical Superintendents (CMS)
Nodal Officers- Urban Health and Family Planning
Divisional Urban Health Consultant (UHC)
District Program Manager (DPM)
Urban Health Coordinator (UHC)
District Community Process Managers (DCPMs)/City community Process Manager
Medical Officer In-charge (MOIC)/Staff Nurse- Urban Primary Health Center (UPHC)
Person In-charge of Private Health Facilities
Facility Counsellor
NGOs/Health Partners

Background: Male participation and gender integration is crucial for ensuring accessible, inclusive and responsive family planning services that meet the needs of all community members. However, these aspects are challenging as deep-rooted societal norms have created mythical/bias/unrealistically impression that reproductive, child health, family planning are the responsibility of women. Additionally myths, misconceptions and negatively impact around male family planning methods such as non-scalpel vasectomy (NSV) . Perceptions of weakness and lack of pleasure led most men to be disinterested in this method. This reduced the number of clients for NSV procedures, which indirectly affected the providers’ ability to perform the procedure due to limited cases and opportunities to practice this skill/procedure. This is reflected in the National Family Health Survey (NFHS-V), which reveals that the modern contraceptive prevalence rate in India is 56.5%, of which male methods represent only 9.8%. Out of the 9.8%, 9.5% are condom users, while only 0.3% are NSV users. Thus, there is need to revive male methods – especially NSV – to contribute to family planning efforts and this requires a specific male engagement strategy.

The TCI tutorial below features a webinar held in May 2020 introducing the proven solution TCIHC uses in India to help local governments improve male participation in family planning.

Evidence of Effectiveness

TCI India launched the male engagement strategy in February 2019 as an 11-month demonstration project. The Male Engagement Team Leads (METLs) of TCI India in each city coached 10-12 outspoken accredited social health activists (ASHAs) to engage men in family planning counseling, which typically had not been performed in the past due to cultural and gender norms.

The coached 230 ASHAs across 20 intervention cities executed male engagement activities, explained communities about the range of family planning choices available including NSV, dispelling myths related to NSV and referring eligible clients to nearby service-delivery points. The IEC material developed by the government on family planning and NSV were used for discussing modern contraceptive methods with men. The four high-impact male engagement activities were executed – 1) Group meetings were conducted at crowded chaurahas (cross-road), 2) Engaged key influencers of the workplace to conduct meetings at small and home-based industries. 3) A detailed line-listing of rickshaw pullers associations and parking places were made where rickshaw pullers were counseled and 4) Evening meetings were conducted in the slums to counsel individuals and couples on FP methods with a special focus on NSV.

The trained public and private sector surgeons were engaged for service delivery. The tertiary facilities, government accredited private facilities and equipped urban Community/Primary Health Centers were the focal service delivery points. TCI India coached facility staff to counsel potential NSV clients on the procedure, side-effects, recovery time and follow-up.

As per TCI India PMIS data, across 20 intervention cities from February 2019-January 2020 a total of 4,080 chauraha meetings, 2332 evening meetings, 251 workplace meetings and 1712 rickshaw puller meetings were conducted by ASHAs. Around 40% of the men reached were interested in learning more about NSV and were individually counseled by ASHAs on all contraceptive methods. As per HMIS (public sector facilities) and Hausala Sajheedari government-portal (private accredited facilities) * data for the period February 2019-January 2020 a total of 3,015 NSV procedures were done across 20 intervention cities. This recorded an 87% increase in NSV adoption by men in the 20 TCI India-supported cities and a 75% increase in UP from February 2019 to January 2020, compared with the same time period from the previous year (February 2018 to January 2019). During the 11-month demonstration period, TCI India supported 27% (20) cities that contributed 81% NSV numbers in overall state performance and 73% (55) cities contributed only 19% NSV numbers. Around, 75% NSV acceptors were served by the public sector surgeons and 25% were served by the private sector empanelled surgeons.

*Refer TCI India’s Engaging with the Private Sector- Expanding the Provider Base for Meeting the Family Planning Needs of the Urban Poor appraoch to learn steps of accreditation and empanelment of private service providers.

Guidance on Promoting Shared Decision Making and Male Participation in Family Planning

The following steps have been instrumental:

1. Identify gender-sensitive trainers

Identify gender-sensitive trainers for capacity building of health staff and CHWs to promote shared decision making and increasing male participation: Gender biases can affect the quality of care provided to individuals seeking family planning services. This capacity building should include annual training of counsellors and facility staff (both male & female) on how to identify and address biases that may lead to inequitable access to services or inadequate care. The training should impart knowledge on the following:

Using gender-neutral and gender-inclusive words/language such as people, folks and not men, women.
Being intentional in meeting couples together during household (HH) visits to provide family planning information, method, referral; and also promote inter-spousal communication, men’s role in maternal and child care like accompanying wife during ANC/delivery/PNC visit, immunization of the child etc.
Identify ‘gender champions’ and ‘champion Family Planning couples’ during ‘Saas bahu beta sammelan’ who can inspire others with their story. Moreover, build the capacity of ASHAs in organizing exclusive NSV happy user meetings monthly in the community with the support of ANM and other community health workers to dispel myths and motivate the community. Similarly, ASHAs with the support of ANMs can develop innovative strategies for utilizing willing NSV happy users to support government initiatives.
Facilitating gender sensitive games and IEC that can be used by CHWs during HH visits to address gender biases, promote inclusivity, ensure informed choice, and address power dynamics that can impact access and use of services.
Despite the limited number of male staff nurse, it is crucial to sensitize existing male staff nurses along with lab technicians about the importance of involving men in FP. Provide special training to enhance their counseling skills. Following the sensitization, allocate responsibilities to them to visit other facilities and motivate eligible men to utilize FP services.

2. Identify/create a pool of trained providers on NSV technique

Identify/create a pool of trained providers on NSV technique and Sensitize the service providers to create a welcoming environment for men: Perceptions of weakness and lack of pleasure has led most men to be disinterested in the male FP method. This has reduced the number of clients for NSV procedures, which has indirectly affected the providers’ ability to perform the procedure due to limited cases and opportunities to practice this skill/procedure. Thus, annual training calendars should be made with added requirement of refresher training each year. In accordance, organize trainings of providers on NSV method and match it with hands-on skills. Also, the availability of NSV kits as per Government of India guidelines at the facility where the surgeon is going to be deployed should be ensured.

3. Create dedicated male engagement mobilizers

For increasing demand aggregation efforts, a team of both men or women (who can be community health workers (CHW) also), who are not hesitant to talk with men about male family planning methods and are very articulate and passionate about their work should be identified for example utilize city health coordination committee (CCC) meetings to involve male field workers from National Urban Livelihood Mission’s (NULM) self-help groups in male mobilization department (read high-impact practice: Convergence of Services. These mobilizers should be oriented on gender sensitive language and counselling about the NSV method so that they can do group sensitization or one-on-one sensitization with men at the following places where they congregate and at times when they can actually pay attention to family planning discussions:

Interventions at male congregation points like Chauraha (Cross Roads): Chauraha are places where most men gather at a fixed time daily for ‘finding odd jobs as laborers’. Labourers hold most myths about NSV as they do hard physical labour. As men congregate, mobilizers install a canopy and conduct games with family planning messaging and NSV and distribute handouts (Refer to the NSV handbill- https://nhm.gov.in/images/pdf/programmes/family-planing/IEC/print/NSV_Leaflet.pdf). Winners are announced, and one-on-one counselling is done with those people who stay back for further enquiry. As appropriate, the mobilizers refer interested men to nearest government or accredited private provider (trained in NSV) for adopting NSV method.
Workplace Interventions: The mobilizers visit, identify and engage with men working in formal/informal industries and clarify myths surrounding NSV, wage-loss compensation, further helping them to understand the merits of NSV as a method of family planning. Post-counselling, the mobilizers refer clients to nearby facilities.
Rickshaw Puller Intervention: This group holds some of the strongest myths related to the impact of NSV on their ability to perform their job. The steps followed in approaching them includes engagement with their associations and visiting parking points, where the mobilizers could counsel and connect them with the services.
Evening community meetings in the slums: As men in the slums are mostly available in the evenings, this time is good for engaging men in one-on-one or group discussions on family planning methods.

4. Ensure in-clinic counseling and Fixed Day Static (FDS) service for NSV

Form a comprehensive team of both male and female staff nurses to counsel men and women. Ensure that once the client reaches the facility, they are counseled by a staff nurse/provider on all of their family planning options so that they can make an informed choice. Plan a dedicated day (FDS) exclusively for providing NSV services, each month, in health facilities equipped and offering male sterilization services. If the client agrees to sterilization method, then consent should be taken and documented. (refer to TCI India FDS approach)

5. Sensitize Adolescents and Youth (AY) on Sexual and Reproductive Health (SRH) Issues

To induce shared decision making and gender sensitivity, males must be sensitized on SRH issues and gender equality at young age. It is important to reach adolescent boys with SRH information because when boys are exposed to gender equality family planning programming, they are more likely to use contraceptive methods and support their spouse/partners in the future. The Nodal officers can utilize the CCC meetings to organize SRH and gender sensitization workshops in schools and colleges in coordination with the education department (read high-impact practice: Convergence of Services). The Nodal officer and UHC with support of MOIC should develop plan for conducting monthly orientations in nearby public sector schools/madarsa for students in 8th class and above on the topics such as, risks of pregnancy, contraceptive methods, mensural hygiene, safe and unsafe periods and plan parent orientation sessions on adolescent SRH issues.

The CMO should establish UPHCs as adolescent-friendly health clinics and initiate facility adolescent health days at UPHCs to provide accessible, equitable, comprehensive and quality health services, including SRH services to AY (to learn the steps of transforming UPHCs into AFHCs, read high-impact practice on Adolescent and Youth-Friendly Health Clinics). Organize community adolescent health days in the catchment areas of urban ASHAs with the support of ANMs and Rashtriya Kishore Swasthya Karyakram (RKSK) counselors to provide SRH information to adolescent boys and girls. In community adolescent health days, utilize simulation games like RKSK’s Kranti Bhranti, an interactive game, to spread awareness on SRH issues.

6. Utilize Media Channels to Boost Male Participation in FP

Leverage mass media platforms such as television and radio to broadcast advertisements promoting spousal communication and male contraceptive methods. Capitalize occasions like World Population Day and NSV fortnight by featuring a mobile caller tune emphasizing male engagement in FP. Additionally, ASHAs should establish WhatsApp groups for eligible couples in their respective slums, particularly those with Android phones, facilitating the exchange of concise videos, messages, and creative content on male involvement. Extend this outreach by circulating text messages through ASHAs to individuals with non-Android phones. Moreover, within existing WhatsApp groups for ASHAs and ANMs, periodically disseminate reminders of their roles and responsibilities to enhance engagement.

Roles and Responsibilities

Role	Responsibility
General Manager FP/Urban/ Joint Director/ Additional Director	Review the performance of cities on male adopting a family planning method in the NUHM/FP review/Divisional review meeting. Issue guidance to all the cities to refer this tool as one of the guidance documents on devising gender intentional and male engagement strategies to promote shared decision making for increasing the uptake of modern contraceptive methods.
CMO	Facilitate and guide the concerned officers (Additional CMO RCH/Nodal officer family planning) to create the gender- sensitized pool of trained providers and master trainer of NSV in the district, pool of trained mobilizers for male participation. Facilitate and guide the concerned officer (Additional CMO RCH/Nodal Officer family planning) to budget for the above. Coordinate with State NHM/Directorate to ensure scheduled training in authorized training centers (i.e., Center of Excellence) with updated guidelines (refer manual for male sterilization, October 2013, Annexure XI- guideline for training of medical officers on male sterilization, GOI:). Send a directive to all rural and urban facility-in-charges and in-charge accredited private facilities to obtain fixed day static services (FDS) calendar for NSV by facility, and allocate and approve resources Ensure that empaneled providers are available for conducting NSV in both public and accredited private facilities Monitor quality and outputs by facility
CMS/Facility In-charge (in case of private facilities)	Nominate ‘potential and interested providers’ for NSV training Coordinate with CMO for ensuring the scheduling of induction or refresher training on NSV as per the requirement of the providers Coordinate with CMO to conduct mobilizer training on male participation. Develop the FDS calendar for NSV for all higher order facilities and selected UPHCs equipped to provide NSV services. Establish FDS teams for NSV service provision Ensure the mandate of FDS is met as per government guidelines (refer to TCI India FDS tool: https://tciurbanhealth.org/lessons/fixed-day-static-approach/, and Standards & Quality Assurance in Sterilization Services (GOI, Nov. 2014)
Nodal Officer Family Planning	Create the gender- sensitized pool of trained providers and master trainer of NSV in the district, pool of trained mobilizers for male participation. Support DPM to ensure to budget the cost of training of providers on NSV, hiring of mobilizer and their training in PIP Ensure execution of scheduled training in authorized training centers (i.e. Center of Excellence) with updated guidelines (refer manual for male sterilization, October 2013, Annexure XI- guideline for training of medical officers on male sterilization, GOI) Coordinate with CMO to issue directives to all public facilities and accredited private facilities for preparing FDS calendar for NSV services in the district Ensure timely allocation of budgets related to training, FDS, wage loss compensation to clients are received by the public facilities on time Ensure hiring, deploying and training of mobilizer to increase male participation for demand generation for NSV Coordinate and oversee all quality parameters and work as an interface between district leadership and facilities Monitor demand generation activities undertaken by mobilizer and FDS for quality, and ensure data validity and reliability Ensure client verification for accredited private facilities per government guidelines
Facility Counsellor	Develop the FDS calendar for NSV Establish FDS teams for NSV service provision Supervise facility readiness Ensure informed choice and method specific counselling is done per guidelines Ensure that clients are appropriately screened. If not eligible for NSV services, counsel the clients about other appropriate contraceptive methods Ensure wage loss compensation for sterilization clients Minimize client waiting time at the facility on the day of FDS Ensure that all of the clients who accepts NSV services have signed the consent form, medical case record checklists, mandated ID cards, bank details (only in case of public facilities) and client follow-up cards for further use and action Maintain the day-to-day client line listing database at the facility level

Monitoring and Reviewing Outcomes

A gender sensitive male participation strategy can be monitored by including NSV, male participation in maternal and child care as a regular agenda item for discussion in the District Quality Assurance Committee (DQAC) and District Health Society (DHS) meetings and monthly meeting of Medical Officers-In-Charges’ convened by CMO. On these forums, data generated from HMIS and private sector data on NSV from Hausala Sajheedari web portal can be reviewed on the following indicators:

Number of men accompanying wife during ANC/delivery/PNC visits
Number of facilities providing NSV
Number of providers trained on NSV
Number of Chauraha meetings planned compared to the number of Chauraha meeting held
Number of Rickshaw Puller meeting planned compared to the number of Rickshaw Puller meeting held
Number of workplace intervention meetings planned compared to the number of workplace intervention meeting held
Number of evening meetings in the slums planned compared to number of evening meetings held
Number of NSV acceptors over a period of time
Number of facilities providing NSV FDS

Further, spot checks by the CMO and the facility–in-charge of private sector should be undertaken to ensure attention to quality parameters and resolution of bottlenecks.

Monitoring the reasons for which men are screened out/postponed for service provision can provide important information on quality of care and provider barriers to services. This information can be obtained by noting the reasons for screening out/postponement in the client register.

Data Quality Assurance: Although there is a tendency to collect and report service provision from FDS together with information from routine service days, separate record keeping for a period of time is recommended for monitoring.

Cost Elements

The following cost elements are required for increasing male engagement and NSV services, which may exist in the Program Implementation Plan (PIP) of the current year but if not, they can be requested in the next year’s PIP.

Cost Elements	FMR Code
Male sterilization fixed day services	Women and Men Fixed Day Sterilization Services FMR-RCH.6.42.OOC
Compensation for male sterilization	FMR-RCH.6.43.DBT.01
Family Planning indemnity scheme	FMR-RCH.6.47.DBT
Mission Parivar Vikas: Demand generation activities	Mission Parivar Vikas FMR- RCH.6.46.OOC.03 Saas bahu beta sammelan FMR-RCH.6.46.OOC.01 Saarthi Vahan FMR-RCH.6.46.OOC.02)
Male sterilization fortnight IEC and Monitoring	FMR-RCH.6.49.IEC.02 FMR-RCH.6.49.PME.2

* Source: NHM PIP Guideline, 2022-24

This table illustrates the manner in which cost elements are provisioned in a government PIP, thus providing guidance on where to look for elements related to a strategy such as ‘male engagement.’

Sustainability

Institutionalizing the role of mobilizers to promote shared decision making and create continuous demand for male family planning methods, and ensuring trained providers to provide these methods would sustain the male participation strategy. Also, champions can be identified among mobilizers who can be recognized in ASHA sammelans; and also acceptors can be recognized in this forum, where they can share their experience to motivate others. In addition, the most important thing to make anything sustain is ‘review’ of these activities on a monthly/quarterly/annual basis by DHS and similar authorities.

TCI APP USERS PLEASE NOTE

You will only receive CERTIFICATES by email – when earning a score above 80% – and will not be able to view or print a certificate PDF from the TCI app.