Empowering the women of Delhi with an IUD

Day 10. PSI.

Our first full day in Delhi was spent with Populations Services International, otherwise known to most of the world as PSI. PSI is 3rd largest NGO in the world. That is huge! Leading programs include targeting malaria, child survival, HIV, reproductive health and non-communicable disease. In India particularly, PSI has been working there for almost 30 years - working effortlessly on HIV/AIDS, reproductive health, malaria prevention and child survival. Our day was focused on learning about the reproductive health programs. We began our day in the PSI office of Delhi learning about the Freedom 5 project, or the promotion of IUDs in women of reproductive age (WRA) amongst vulnerable and poor women. Our two hours at PSI was very similar to sitting in class at GW - learning about the objectives, goals, and impact of this project. The goal of this initiative is to increase the use of IUDs by 1.1% by 2012. Now, that at first seems small but let's talk about the number of women that live in Delhi - 1.1% will make an impact!

After gaining an understanding of the mission of this initiative, we were guided to a specific neighborhood the Freedom 5 program is implemented. We first went to a clinic that is often visited by poorer families. Here we spoke with the physician on call to learn more about the women that come in asking for an IUD. According to the physician, most women come in after their fourth or fifth child at which time they are ready to stop having children (at least for awhile)!

We then went to a specific locality where health promoters were conducting their work - going door-to-door obtaining information on who lived there, the number of children, what languages they speak, etc --essentially a census, a very detailed census. This allowed the health promoters to be more strategic in talking to women and families about PSI, family planning and IUDs. It was incredible to watch. These health promoters had so much information one each household in the entire neighborhood. They knew their health issues (more than just the reproductive health concerns). As these women gained credibility in the neighborhoods, they gained relationships with the families living there and were able to have honest conversations around family planning and also help women understand the process and implementation of an IUD. There were a number of things I found to be quite interesting today.

1. In many instances women asked to wait for their husbands to come home from work so they could have the conversation of family planning together AND the mother-in-law was the one in most households who remained the barrier to obtaining proper family planning tools. It made sense but wasn't my first thought. I initially just assumed husbands would be the largest barrier in implementing this program.

2. How is this being sustainable. Yes, wonderful health promoters are going into the field and teaching women the notion of family planning and empowering them through education and birth control essentially, but what happens after that? Once women have IUDs inserted - are they teaching others the power of education and smaller families particularly in lower income neighborhoods?

3. How is this being evaluated? There seems to be a lack of data when it comes comparing women who discuss and implement family planning vs. not.

Our day spent in these neighborhoods was extremely educational. Learning from PSI, an internationally known integral NGO it was calming to see how a program is conceived in a conference room and then fully implemented in the field. Our other days in India, we focused on smaller firms that had more narrowed mission spaces. Seeing that even larger NGOs can continue on a focal point was refreshing. I think at times, I get caught up thinking that larger firms fall into the corporate traditional enterprise and the smaller firms though they are doing amazing work get caught in the struggle of limited funds and low resources. Today affirmed that it really does not matter where you work -- the programs get initiated the same way and the work gets implemented with determined, honest, and passionate individuals.

Affirmation at PSI

Our first meeting in Delhi was with Population Services International (PSI). PSI is the third largest NGO in the world and is the undisputed leader (in my mind anyway!) in global health program marketing and communications, as well as program efficacy. Their interventions bring aid to millions of people around the world and their programmatic efforts span a variety of topics including malaria, reproductive health, safe water, and others.

Our meeting with PSI inspired me on many different levels. The most basic, yet perhaps the most important, is that it reaffirmed the lessons that we are learning in the classroom through the MPH program at GWU. This was truly an opportunity to see classroom knowledge being applied in the field, with success. As we listened to the very sophisticated reproductive health program presentation, it was so affirming to see simple things like health and behavior objectives incorporated into the presentation. I find myself sometimes actually being in awe of people who are successful in their careers, in areas where I would want to work and this was truly a moment where I thought “hey! I can definitely do that” and this feeling is directly attributed to my classroom experience at GWU. It’s funny, isn’t it, how sometimes you have to travel halfway around the world to have an affirming experience for what you are completing back home.

The PSI program for reproductive health is extremely well thought out, and has many components. My friend and classmate Kelly Healy has done simply an unbeatable job outlining the program in her blog today so I will spare another identical recap and will instead blog about what I found to be the best aspect of the program: the use of contraceptives through empowerment.

It was stressed numerous times during our discussion that empowerment was the major objective of the program, a sentiment that I truly appreciate. Giving women a contraceptive without information or skills is akin to giving them nothing at all. The PSI program uses a variety of techniques to truly empower women. Their outreach program identifies leaders in the community and trains them as Interpersonal Communicators (IPC). These IPC’s then go out into their own community, where they are already known, to educate and provide tools to empower women to talk to their husbands about contraception and understand where and how they can get it. PSI uses the Freedom5 intrauterine device (IUD) to do this. The IUD is a cost effective, long lasting (5 years), proven effective and reversible form of birth control that is sustainable for these communities.

From my perspective, there is so much that PSI is doing right in the area of reproductive health. Their programming combines grassroots community efforts on the ground with high-level social media campaigns that reach masses of people with just one television advertisement. They truly are a world-class organization and are worthy of every cent of funding.

The meeting with PSI also provided a type of full-circle experience for me as I reflect on this course as a whole. In addition to affirming classroom lessons from the MPH program as a whole, meeting with PSI provided great contrast and similarity to some of the smaller, more community-based NGO’s we met with in Mumbai and Delhi. Comparing a PSI program to an Acorn India (the NGO we met with in the Dharavi slum in Mumbai) provides a case study in its own right on the full spectrum of social entrepreneurship as well as NGO’s who are truly making a difference in communities, from the top to the bottom. PSI may have more money and resources to put together a power point, speak at a conference or provide marketing materials --- but is what they are doing so different from Acorn or Impact India? I don’t think so.

I appreciate so much about what PSI is doing in India, and around the world. Their funding allows for true market research to be conducted – resulting in more efficient, effective and targeted program. Now, if only every NGO could have such funding! It can be easy to become blinded by the celebrity and sophistication of programs from PSI; however, it is so important to remember that their mission is the same as any of the other smaller NGO’s we’ve seen in India. PSI wants to help people, they have identified target areas in which to do so, and they create programs for communities that provide education, resources and support.

Day 7 – Social Marketing in Action

After a lovely dinner in Delhi with Nandita Chopra, the NIH Representative to India, we headed off Wednesday a.m. for a busy day with Population Services International (PSI), looking specifically at its Women's Health Project. I knew going into this day that I was going to love it because a) I love women’s health and b) PSI is pretty much THE organization when it comes to health communication and social marketing. From the very beginning of the meeting when they flipped on the projector and started talking about objectives (SMART objectives like we learn about in class!), we could see the difference between a small, local NGO and a multi-national one like PSI. The team we met with walked us through the integrated program they have in place to reach women, healthcare providers, pharmacists, and opinion leaders. The scope of the project is too large to recap in one blog, so I’m going to focus on the interpersonal communicators (IPCs), which I was later able to watch in action.

The IPCs are primarily charged with increasing awareness about and use of intrauterine devices (IUDs), which are a safe and effective long-term (but not permanent) method of birth control. Most women choose an IUD after having several children, when they want to limit their family sizes, but have not completely ruled out more children. The IUD PSI promotes is called Freedom5, because it lasts for 5 years.

To raise awareness of IUDs, PSI has trained a team of IPCs to go into urban areas throughout several districts in northern India. The IPCs gather household information and, after determining that there is a women of reproductive age (WRA) who could benefit from an IUD, provides information and referrals. There are two good things I saw about this approach that no doubt reflect PSI’s experience and knowledge. First, the IPCs do not just provide information on IUDs, they educate the women about the “contraception basket,” including condoms, oral contraceptive pills, injections i.e. Depo-Provera, and IUDs. Secondly, the IPCs are not incentivized based on the number of IUDs inserted, which might lead to more forceful interactions with women. Instead, they are encouraged to meet certain targets for the number of women they speak with each day. If a woman is interested in IUDs, the IPC gives her a referral card and information for a nearby clinic. If the women goes to the clinic, the referral card serves as a tracking device to see how many women visit a doctor and how many actually get an IUD inserted.

When we went into the field, we met up with four of the IPCs and an IPC coordinator. Jenn M. and I had a chance to observe a one-on-one session with an IPC and a woman in her home. She invited us without reservations into her home where she shooed away two men, who looked to be maybe her son and father or father-in-law and had us sit on a bed in a small room. The IPC began speaking with her in Hindi and gathering the household data including her age and information about her children. We learned that she had four children and used condoms, but was hesitant about an IUD because she thought her husband would disapprove. Her reaction when we asked if she wanted more children was clear, she grasped her stomach and said no. It was clear that this family was struggling with the small means it had, so one could easily understand why the woman wanted to limit her family size. So the IPC gave her some additional information to keep in case she decided to pursue an IUD in the future. In public health classes we are always talking about community outreach workers and it was very neat to see one in action.

In addition to outreach via IPCs, PSI runs a call center that does follow up calls to women who have IUDs inserted (and give consent to follow up) to counsel them on any side effects or concerns one-month after the procedure. The outreach program is also integrated with a mass media campaign that promotes the idea of an IUD being a lock with a key. When we visited a clinic in the partner network we saw this advertisement posted on the wall. PSI said the campaign has already been very successful, with a 60% reach. Of the women reached, 50% reported that they talked with their husband about an IUD, 10% went to a provider, and 5% got an IUD. While these numbers may seem small, they are actually quite significant for a health promotion campaign. The mass media campaign augments the personal outreach because it can also help influence a woman’s husband and mother-in-law, who in this culture have a strong influence on decisions about contraception.

One of my favorite parts about the day with PSI was when PSI’s maternal and child health lead Sanjeev Dham flipped the conversation around and asked us for our criticism of the Women's Health Project. He really valued our insights, which included thoughts on expanding the program and strengthening evaluation.