One of the oldest and pioneering non-profit organisations, HLFPTT has for more than two decades been working towards ensuring safe motherhood and better child health. Sharad Agarwal, CEO, HLFPPT talks about the progress made so far and the company’s future plans in an interview with Shalini Gupta
Tell us something about the implementation of ‘Targeted Condom Social Marketing Programme’ in high priority districts of six states.
Since 2008, HLFPPT is promoting the idea of safe sex through increased condom usage among men in reproductive age group (15-49 years old) under the Targeted Condom Social Marketing Programme. This large-scale, multi-phase programme, funded by the National AIDS Control Organisation (NACO), particularly focuses on high-risk groups comprising migrant workers, truck drivers, female sex workers (FSWs), men having sex with men (MSMs) and general population as well. Through a cohesive social marketing approach, we are working on an end-to-end supply chain management of subsidised condoms (under the brand names of Deluxe Nirodh and Rakshak). Basically, we endeavour to create a perpetual demand for subsidised condoms among target audience; and also work towards increasing availability and access and regular supply of condoms in rural and remote areas.
In its latest phase (December 2012-December 2014), we conducted the programme in six high-focus states including Madhya Pradesh (36 high priority districts), Uttar Pradesh and Uttarakhand (63 high priority districts), and all across Andhra Pradesh, Delhi and Bihar. We have sold 505 million pieces of condoms through 788,575 outlets and have contacted 51.1 million men (15-49 years old) for promotion of condom usage in the last phase.
What projects are currently underway in the fields of maternal health and women’s health in particular?
HLFPPT places immense thrust on women’s health issues, particularly on mother’s health as it firmly believes that only healthy mothers can nurture healthy families. We have instituted an innovative social franchising model of hospitals and clinics, under the brand name of Merrygold Health Network (MGHN) that is serving underserved communities at urban and rural levels in the states of Uttar Pradesh, Rajasthan, Bihar, Odisha and most recently, Andhra Pradesh, through multiple partnerships. MGHN facilitates high quality prenatal and antenatal services, institutional deliveries, safe abortions and family planning services, besides general OPDs and other services at reasonable rates and promotes the idea of safe motherhood among communities at large.
It started in Uttar Pradesh in 2007, with support from State Innovations in Family Planning Projects Services Agency (SIFPSA) and USAID, where the network has now expanded across 37 districts, comprising 64 Merrygold Hospitals (at urban level), 180 Merrysilver Clinics (at rural level) and 4150 Merrytarang members (community level volunteers). So far, we have provided antenatal care to 822,537 expecting mothers and facilitated 152,531 institutional deliveries (data till March 2014).
Buoyed by its success in UP, we have eventually replicated the MGHN Model in the states of Rajasthan (supported by Merck) and in Bihar and Odisha under Project Ujjwal (supported by DFID, UK). Incidentally, these are some of the states with highest MMR, unwanted pregnancies and malnutrition in India.
In Rajasthan, the programme started in 2013 and it facilitated 2,483 institutional deliveries and 17,519 antenatal and post-natal care services through 19 social franchisees across 10 districts in its inception year. In Bihar and Odisha, 31,425 people have availed family planning and safe abortion services at 299 social franchising clinics instituted under Project Ujjwal. Most recently in August 2014, we have taken the programme to Andhra Pradesh, where we have established nine Merrygold hospitals in five high focus districts and included around 292 Merrytarang members so far.
Which states in particular are more challenging and why? Recount any success story of having surmounted a major obstacle.
We have been operational across 23 states in India, and to be honest, each state has confronted us with its unique challenges involving demographic, topographic, socio-economic, cultural and political aspects. So, while covering the masses is a concern in highly populous states of Uttar Pradesh and Bihar, reaching out to disperse tribal communities residing in remote hamlets across the vast terrain of Rajasthan is not easy. We are also operational in states with volatile issues of internal security such as naxalism-hit Chhattisgarh and Jharkhand or highly vulnerable Jammu & Kashmir.
Then, there are socio-cultural dynamics. For instance, while working on one of our highly successful programme, Swagati (2004-14) which was focussed on reducing HIV and sexually transmitted infections (STIs) prevalence among vulnerable groups (FSWs, MSM and transgenders) residing in coastal districts of Andhra Pradesh, our team faced strong resistance from communities initially. Identifying home-based sex workers, who comprised the largest group of FSWs, was extremely difficult as these were married women with families who operated in a discreet manner.
However, our two decades of experience has taught us that change doesn’t come overnight. It requires consistent efforts, building trust among communities, strong passion and commitment to create an impact.
Any challenges that you faced in the implementation of the Female Condom Project in nine states of India, particularly given the socio-economic set-up?
We essentially worked with FSWs with the idea to empower them with female condoms (FCs) as an alternative method for safe sex practice in addressing their vulnerabilities and building their negotiation skills. Majority of FSWs were home-based sex workers (67 per cent), followed by brothel-based (17 per cent) who reported that they were familiar with FCs, however, they considered FCs only as an alternative when male condom wasn’t available. It was specifically challenging in enhancing FC usage among FSWs with regular partners. It was also difficult in investing time and efforts on FSWs preparedness for FC usage in new areas, especially with wide variation in the socio cultural and typology variance of the target population.
However, we undertook consistent behaviour change communication through peer educators and outreach workers; advocacy efforts at state/district/community level for creating enabling environment for FC; communication events; and strategic planning. Our efforts helped FSWs overcome the cultural reservations and fear of pain that were inhibiting them from adopting FCs. Eventually, majority of FWSs stated that they got so empowered with FC that they were able to handle any kind of situation as they reported that they have acquired negotiation skills. And most of them reported that their level of comfort to use FC had increased with progressive use.
You are also working towards building capacity of health service providers on IUCD and pregnancy testing cards in high priority states of India. What gaps were observed here? And how are they being filled?
Intra Uterine Contraceptive Device (IUCD) is among the most effective contraceptive methods for spacing that can safely be placed in women for a long period without causing any side-effects. However, despite its wide awareness among married women (74 percent), its prevalence rate continues to be as low as 1.9 per cent in India (DLHS). A common deterrent for IUCD adoption is the associated risk of Reproductive Tract Infections (RTIs) and Sexually Transmitted Infections (STIs) due to low confidence among Health Service Providers (HSPs) on IUCD insertions and lack of essentials at health facilities.
In 2011, we conducted a study with FHI 360 (formerly Family Health International) on IUCD, which observed that in most states, capacity building of HSPs on IUCD was not in practice. Consequently, the study recommended to “provide comprehensive training of all levels of healthcare providers on IUCD counselling, insertion and follow-ups, with special focus on supervised insertions”.
Through this programme, our quest is to make a significant contribution in addressing this gap and help India fulfil its FP2020 Commitment of “training 200,000 health workers on providing IUCDs”. So far we have successfully trained 20,000 HSPs, covering 15,000 health centres across 11 states with nearly 400 districts. Initially, we observed low levels of IUCD acceptance among women – inhibitions and myths persisted. Also, HSPs lacked in skill and practice on IUCD insertions.
Under our programme, we started training HSPs on ‘no touch technique’; selection of right clients for IUCD; and significance of infection prevention, counselling, and follow-ups. Over the last three years, the training has boosted confidence level of HSPs and increased trust among women.” For hands-on-practice, we have introduced the concept of “practice on Zoe Model” followed by live insertions under the guidance of subject expert. The programme is not only confined to improving skills of HSPs, but also helps them in improving post-training performance by helping them increase number of IUCD insertions through regular follow-ups and supportive supervision.
Besides, we are functioning as effective facilitators in improving health facility readiness in providing IUCD insertions. Rural communities in intervention states are especially benefiting from the programme as three fourth of the trained HSPs are from sub centres and primary health centres at villages. Additionally, we have also introduced an online HMIS to track the performance and continuity of the services provided by trained HSPs.
How many girls have been trained so far in degree colleges of Uttarakhand on adolescent and reproductive health under project Roshni? What have been the learnings in this programme?
Roshni Pariyojana was a significant programme targeted at training adolescent girls in Uttarakhand on adolescent and reproductive health issues in order to bring awareness and behaviour change among them. We provided training to 26,153 adolescent girls studying in 87 degree colleges spread across the state by organising 544 sessions. The core strategies adopted were capacity building, advocacy, behaviour change communication and monitoring and evaluation. The objective was accomplished using a cascading model of training – Lead Trainers from HLFPPT who trained the 32 master trainers at state/district level, who in turn, trained adolescent girls in colleges.
Post training it was widely felt, both by the trainers as well as the trainees, that such initiatives by the government authorities bring increased awareness and sensitisation among the youth, and would surely enable in balancing the sex ratio and decreasing maternal mortality rate in the long run. We also realised that adolescent health along with life skills education should be promoted for adolescent boys for nurturing a healthy society.
What are the new partnerships and projects in the coming years?
Last year has been fruitful in many ways. We have replicated our unique social franchising model – the Merrygold Health Network – to Andhra Pradesh, following its success in UP, Rajasthan, Bihar and Odisha. Going ahead, we intend to scale-up the network pan India, whereby we see immense scope to align with the corporate sector under their corporate social responsibility (CSR). Our recent partnership with The Essar Group and Suzlon Energy for operating Mobile Medical Units in West Bengal, Chhattisgarh and Rajasthan is a feather in the cap of our extending network.
In fact, our expanding CSR portfolio itself is a story to watch out for, which is escalating not only in terms of our partners or geographical presence, but also vis-à-vis our diversifying thematic area in Reproductive & Child Health (RCH). This year is very promising for us as we are now foraying into RCH Allied Health Services, placing due emphasis on Water, Hygiene, & Sanitation (WASH), nutrition and skill building. We are adapting to the changing dynamics of healthcare service delivery and devising innovative, cost-effective solutions like sanitary napkin vending machines and incinerators, and condom vending machines for both male and female condoms. We are already in talks with many corporates for these and would start implementing these models soon, starting from Delhi-NCR with support from Jindal Steel and Power Limited (JSPL).