The ARSH Strategy put adolescent health on the agenda for the first time in India; this was in part due to the establishment of dedicated AFHCs and community engagement through NGO partners. However, programme planning appears to have been weak, and human and financial resources were not deployed in an optimal manner. For example, NGOs were contracted in some states, but their engagement was discontinued mid-way through the programme with a change in government. To a large extent, the ARSH Strategy remained in ‘project-mode’ throughout its life span, an assessment that reflects the challenges in integrating it fully into the broader health system. From the available data, adolescents do not appear to have been involved in its governance.
RKSK’s design incorporated learning from the ARSH Strategy, particularly in relation to the need for adequate human and financial resources. A clear organogram was developed to define the human resources required for each programmatic component from state to block level. Despite this new standardized framework, key positions remained vacant at state and district levels at the time of the RPR, and most nodal officers at both these levels had a number of other responsibilities that they considered as important as RKSK. Adequate budgets were allocated at the state level for implementation of RKSK, but rules and regulations on their use were considered by key informants to be too rigid, thus limiting the responsiveness of the programme to the different needs across times and places. Likewise, programme activities were not well coordinated; for example, in several cases, training on the Menstrual Health Scheme (MHS) occurred months before necessary commodities, such as sanitary pads, had been secured. As with the ARSH Strategy, adolescents do not appear to have been involved RKSK’s governance.
The ARSH Strategy focused solely on the provision of SRH services to adolescents through AFHCs operating at block or higher levels of the health system. ANMs, ASHAs (wherever available) and PEs were employed to drive demand amongst adolescents, though incentive and support structures for these cadres were lacking. In some states, NGOs were actively involved in community engagement activities. However, there were still challenges that affected the ability of adolescents to access services, including cultural resistance, distance to AFHCs and absence of follow-up services at the community level.
RKSK was designed to be more comprehensive, with SRH being addressed within a broader approach to adolescent health. This, alongside the change in name, helped pave the way for greater acceptability amongst health providers, and amongst communities and adolescents, themselves. The scale-up of community engagement and demand generation activities with expanded access to AFHCs and counselling services, has led to increased service use in some districts. Uttarakhand, Haryana and Maharashtra saw increases in service use during the financial year 2016–2017 as compared to the previous year, whilst Madhya Pradesh saw a sizeable decrease.
Adolescent friendly health clinics
Through RKSK, AFHCs have been integrated into district and sub-district hospitals, community health centres (CHCs) and some primary health centres (PHCs). At the clinics, adolescents are able to access counselling services, health services, and referrals for other specialist needs. Whilst RKSK has attempted to bring services ‘closer to home’ for adolescents than they were under the ARSH Strategy, many still have difficulties in accessing services due to geographical barriers. Further, capacity-building for ASHAs and ANMs under RKSK has been prioritized over that of facility medical officers, whose buy-in is crucial to ensuring the RKSK’s continued success. As with governance, young people are not afforded a role within the AFHCs.
This RPR found evidence that the Protection of Children from Sexual Offenses Act is creating confusion amongst providers regarding the provision of SRH services to adolescents. The Act criminalizes sexual acts with minors (people under age 18) and makes no exception for consensual sexual relationships between minors. It mandates that those with knowledge of such offenses report them to the relevant authorities, under threat of imprisonment. Given these reporting restrictions, it appears that providers are inclined to deny SRH services to young people in some states.
Counselling services in clinics, schools, and community settings have been strengthened and expanded under RKSK. While many female and male counsellors dedicated to adolescent health were recruited and trained in the first 3 years of RKSK, vacancies remained in almost every district; this was particularly true for male counsellors. Apart from the initial trainings for adolescent health counsellors, no refresher trainings were carried out. Further, without an adequate monitoring system in place, it was not possible to measure the quality and content of the counselling provided. However, there is evidence that counsellors’ heavy caseloads at the AFHCs and the lack of transport allowance and corresponding security arrangements negatively impacted their outreach services, particularly to hard-to-reach areas.
Adolescent health days
AHDs is a novel mode of connecting adolescents with services and of engaging parents, community leaders and young people, through RKSK. The AHDs are organized and facilitated by ANMs, ASHAs, PEs, and counsellors. However, there is evidence that the lack of a structured plan for the AHDs meant that they were implemented in an ad hoc manner across the four states. Similarly, outcomes for AHDs are not clearly defined nor monitored.
Through RKSK, PEs are meant to engage with young people at the community level, including at AHDs and monthly AHCs. Thousands of PEs were recruited and completed initial trainings in the four states. In one state, PEs have been using innovative technology-based information, education and communication (IEC) materials for community education. In most states, PEs are being supervised and supported on a monthly basis at the AHCs by ANMs who are based at sub-centres. These ANMs are oriented on how to mentor and support the PEs. Adolescent health counsellors are also involved in responding to the PEs’ questions. Across several states, there were doubts about whether the methods used to recruit PEs were appropriate, and there were concerns about the adequacy of their training and support. Likewise, a lack of monitoring systems to track PEs’ activities leaves questions about their reach in the communities where they operated. There is evidence that the absence of a transport allowance or financial incentive is affecting PEs’ motivation and retention rates, and that cultural and parental objections negatively impact their involvement.
Weekly iron folic acid supplementation
The MoHFW launched the WIFS programme in 2012 to respond to the high prevalence of anaemia amongst adolescents through supervised weekly ingestion of an Iron Folic Acid (IFA) supplement and biannual helminthic control. When RKSK was launched, WIFS was included as one of the key components of the programme. The WIFS component relies heavily on partnership with the Education and Women and Child Development Departments. In most states, government school teachers within programme catchment areas have been oriented on the provision of the tablets to students. However, reluctance amongst teachers to dispense the tablets remains one of the greatest challenges; this is influenced by negative publicity following the hospitalization of young people in more than one setting who experienced side effects after taking the tablets at school.
Menstrual hygiene scheme (MHS)
The MoHFW launched the MHS in 2011 with the aim of increasing awareness of menstrual hygiene, promoting access to and use of high quality sanitary napkins and ensuring safe disposal of sanitary napkins in an environmentally friendly manner. The MHS in its entirety was not operational in any of the four states due to procurement challenges. However, Anganwadi workers, ASHAs and ANMs provided menstrual hygiene education to adolescents through Education Department-sponsored life skills education and/or health education sessions.
Under ARSH, a structured monitoring system was established for clinic-based services and a number of third party evaluations were conducted. Monitoring was largely administrative and it seems unlikely from the evidence available for this review that the limited data collected were used for programme planning or quality improvement. Documentation was limited in all states, resulting in a dearth of evidence and data for this review.
Under RKSK, a structured monitoring system for clinic- and community-based services was established, from community to state and national levels. Several states are using community feedback, third party surveys and innovative mechanisms, such as video conferencing and WhatsApp, for monitoring and troubleshooting, indicating intentional usage of data for programme planning and quality improvement. Nonetheless, most monitoring efforts focus on administrative indicators, such as the number of trainings conducted and clients served. The programme lacks insight on the quality of the services and activities provided, including from adolescents’ perspectives. There are specific challenges with WIFS related to the separation of health and education monitoring systems; these challenges manifest in the tardy submission of incomplete reports. No data were available for some components of RKSK, including mental health, substance misuse and injuries and violence.
There was no evidence of linkages with other state departments during the implementation of the ARSH Strategy. Partnerships existed with local NGOs that had on-going programmes for adolescents; however, challenges with these partnerships led to their discontinuation in most states.
‘Convergence’ is a key strategy within RKSK, as set out in the programme’s operational framework. In all states, attempts have been made to forge partnerships with various government departments, including Education, Women and Child Development and Panchayati Raj.Footnote 2 In Madhya Pradesh, NGOs were systematically involved in community engagement and service delivery activities, whilst their involvement in the other three states was ad hoc. Challenges with interdepartmental collaboration were identified in all four states. In particular, it was evident that the Education Departments were not completely on board; as a result, its concerns – particularly with WIFS – went unaddressed and teachers remained wary of being held accountable for negative health outcomes. Efforts to institutionalize convergence have stalled due to the lack of formalized structures for other departments’ engagement, apart from attendance at quarterly RKSK meetings.