Strengthening of Family Planning Service Delivery through 18 Urban Health Centers (UHCs) in 2 districts of Uttarakhand | USAID Health Care Improvement Portal
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Strengthening of Family Planning Service Delivery through 18 Urban Health Centers (UHCs) in 2 districts of Uttarakhand

Improvement Report
Dr. Vineet Kumar Srivastava, National Program Manager, Jhpiego

Topics: Behavior change and communication, Documentation/data collection, Family planning, Hand hygiene, Human Resources/Workforce Development, Infection control and prevention, Motivation/incentives, Patient Safety, Performance evaluation, Performance management, Policy, Program management, Recognition/remuneration, Service integration, Supervision, Sustainability, Task definition, Training, Waste management

Region and Country: India

Organization: JHPIEGO
The Report

 Located at the foothills of the Himalayan mountain ranges, the state of Uttarakhand came into existence in the year 2000. It has a population of 10.1 million people with a decadal population growth rate of 19.17%1. It is one of the 8 Empowered Action Group (EAG) states in India. EAG States are those with high fertility rates and have been lagging in reproductive and child health. The EAG was created by the Ministry of Health and Family Welfare (MoHFW) to ensure special focus on health policies to attain India’s Millennium Development Goals (MDG 4: Reduce child mortality; MDG 5: Improve maternal health). At present, infant mortality rate in the state is 38% (SRS 2010) , Maternal mortality ratio is 359 (SRS 2007-09), contraceptive prevalence rate is 59.3% (NFHS III) and the total fertility rate is 2.6 (NFHS III).

30.55% of Uttarakhand’s population lives in urban areas[1].Uttarakhand’s urban population has seena quantum jump in the last 10 years (decadal urban growth is 41.9% vs decadal rural growth which is a much lower 11.3%1). In fact, urbanization trends in the past decade show that while the overall urban population is growing at about 3% annually, slum population is growing almost twice as rapidly at 5 to 6%[2].This has led to unequal growth and a large urban population living in slums or in vulnerable conditions. It has been noted that health indicators for the urban poor are far lower than what the urban average data denotes2. Unfortunately, the public health infrastructures largely skewed to the rural areas (55 Community health centers, 239 Primary Health Centers and 1765 Sub Centers in the rural areas (98%) vs 18 District hospitals in urban areas and 19 Sub divisional hospitals in semi urban areas (2%)[3]). This is a big concern for the state government as they have not been able to make the basic health services accessible to this vulnerable population. Providing quality primary health services for the urban poor has become a priority for the Uttarakhand government.
To extend the accessibility of healthcare services to this vulnerable group, a public private partnership model was developed under the National Rural Health Mission to establish Urban Health Centers which would be managed by local NGOs. Each Urban Health Centre (UHC) has been established to cater to a slum population of 15000 on average. The technical and the logistic support would directly come from the public health system. The major objectives and strategies identified were:
·         To provide integrated and sustainable system for primary health care delivery with focus on
urban poor living in slums and other health vulnerable groups in cities.
·         To enhance capacities among city stakeholders to plan and implement urban health
·         To strengthen linkages between communities and primary level health facilities and referral
system from primary to secondary facilities.
·         To improve health status of the urban poor through increased coverage of key reproductive
child health services and adoption of healthy behaviors.
In spite of its intentions to provide quality healthcare through the Government of Uttarakhand’s investment in the UHCs, the initiative was not showing results. Some major lacunae existed in the form of wide variance in services provided between different UHCs and an overall lack of servicequality. The reasons were limited capacity of service providers and poor program management skills. And most importantly, while the State had enumerated the number of services to be provided by the UHCs, there were no standards prescribed for the level of quality in service provision. Moreover, there were no linkages between maternal, neonatal and child health (MNCH) and family planning (FP) services leading to missed opportunities for providing comprehensive services to the citizens who came to these Centers. There was minimal priority given to FP services at the UHCs.

[1] Census 2011
[3] Rural Health Statistics 2010

 Working in close collaboration with the Government of Uttarakhand (GoUK), Jhpiego, under the US Agency for International Development’s (USAID) flagship Maternal and Child Health Integrated Program (MCHIP), has significantly contributed to the progress ofMNCH including strengthening of Family Planning service delivery at these UHCs.

Jhpiego, under the MCHIP program, introduced a quality assurance process called Standard Based Management and Recognition (SBM-R). SBM-R is a practical management approach for improving the performance and quality of health services. It is a proactive approach, focusing not on problems but rather on the standardized level of performance and quality to be attained. SBM-R follows four basic steps:
  1. Setting performance standards that are constructed around clearly defined service delivery processes or a specific content area
  2. Implementing the standards in a streamlined, systematic way
  3. Measuring progress to guide the improvement process toward these standards
  4. Rewarding achievement of standards through recognition mechanisms

The Jhpiego team, under the USAID-supported MCHIP project, provided technical assistance to the Government of Uttarakhand in strengthening the family planning service delivery through these UHCs. A number of activities were undertaken to strengthen family planning service delivery through 18 Urban Health Centers in districts of Haridwar and Dehradun.
·         Jhpiego assisted the providers in developing performance standard tool for quality FP service delivery;
·         Helped them conduct baseline assessment to identify the gaps and develop a UHC wise customized improvement plan;
·         Based on the assessment, the capacities of the service providers’were strengthened in the areas of technical knowledge and skills;
·         Appropriate infrastructure improvements were undertaken to ensure quality services and
·         Proper recording, reporting and supportive supervision mechanism was established.
To start with, Jhpiego carried out a rapid assessment in January 2011,which helped in analyzing the situationin about 50% of the UHCs and identified gaps in their infrastructure, human resources, equipment and supplies; and reviewed the family planning service delivery for performance and quality of services. This assessment also served as a tool to make recommendations to the Government of Uttarakhand on the existing family planning service delivery process and identified opportunities for extending services more effectively.
Following the assessment, Jhpiego used its trademark Standards-Based Management and Recognition (SBM-R) approach to bring about improvement in the quality of family planning service delivery at the UHCs.
A“standards settingworkshop” was held in February 2011 to introduce this approach for improving the quality of services being provided. The following were identified as key areas for provision of quality FP services:

The workshop gave an opportunity to the participants to review the performance standardsand adapt themas per the relevance and operational feasibility for Urban Health Centers in Uttarakhand. The standards were field tested at selected facilities and inputs from service providers were incorporated before finalizing. This was followed by a one day Supportive Supervision workshop in the same month for the supervisors from the NGOs, district and state officials for orienting them and improving skills.Supportive Supervision visits were made and baseline assessment of all UHCs was facilitated to assess the current status of service delivery as per these performance standards. Jhpiego conducted trainings on Contraceptive Technology Update and Family Planning Counseling, IUCD insertion/ removal and Infection Prevention for the relevant healthcare providers from 18 UHCs of both the districts between March-May 2011. Jhpiego intermittently facilitated the concurrent progressin the strengthening of the services through review meetings of the standards achieved inSeptember and November 2011 respectively for strengthening and institutionalizing the process as well as to observe improvement with focus on service delivery and facilitating recognition of sites that meet the standards. In between, supportive supervisory visits were also conducted by the team and facilitated internal assessments. Jhpiego also developed a pool of supervisors within the UHC and GoUK system for institutionalizationand sustainability of the intervention. The standards and the verification criteria have been used as different tools by stakeholders. The supervisors have used it as a monitoring tool, the providers as a service provision checklist etc.


 Consequent to the SBM-R approach, the UHCs in both the districts have shown improvement in family planning service delivery and quality of care. The following areas have shown perceptible change:

·         Infrastructure- Reorganized, additional space added, relocated to more spacious buildings, privacy maintained.
·         Human Resource- Capacity of LMOs and ANMs build on FP Contraceptive technologies, Counseling, Clinical training on interval IUCD insertion and removal, Infection prevention practices.
·         Equipment & Supplies -Adequate for essential FP services including supplies for infection prevention.
·         FP Service Delivery- Doctors and Auxiliary Nurse Midwives (ANMs)initiated interval IUCD insertion; conducting referral for FP services not provided at UHCs; follow-ups on the book clients initiated for replenishments of the contraceptives commodities.
·         FP Counseling- Initiated adopting method-mix approach.
·         Recording and Reporting- Improved including documentation for counseling and referrals.
·         Supportive Supervision- NGO, district & state officials conducting regular supervisory visits.

The progress in standards achieved is visible from the graph below:

 The progress in service delivery is evident from the table below


Convinced by the success of the 18 UHCs, the GoUK has scaled up the intervention in the remaining 3 UHCs and they have now proposed to establish 18 more UHCs in this year’s PIP across the state allocating a budget of INR 3.6 million (USD 180,000 approx.).


1.       With a standardized performance improvement tool such as SBM-R,the quality of services can be improved and brought up to a standardized level.
2.       SBM-R also helps in providing transparency in the role of each individual involved with the UHC- provider knows his role and also what he will be monitored on.
3.       With the SBM-R process they know the goals and the steps to be taken to achieve them.
4.       Implementation of performance standards has also helped providers in identifying the required resources and logistics for enabling improvement and service delivery.
·         Frequent attrition in trained human resources  employed through NGOs
·         Space constraint in UHCs due to their location in or around slum areas
·         Absence of an institutional biomedical waste disposal mechanism