With India’s adolescent and youth population on the rise, the country’s government has sought to address this group’s unique challenges. India’s Ministry of Health & Family Welfare created the Rashtriya Kishor Swasthya Karyakram (RKSK) program to respond to the critical need for adolescent reproductive and sexual health services. Focusing on contraceptive use in young first-time parents, the program employed several strategies to strengthen the health system to respond to adolescent health needs. This required a trusted resource within the health system who could approach this cohort. Community frontline health workers emerged as the natural choice.
ASHA | Accredited Social Health Activists | NCDs | Non-communicable diseases |
AYSRH | Adolescent and youth sexual and reproductive health |
ORC | Outreach camps |
ARSH | Adolescent reproductive and sexual health | PSI | Population Services International |
ARS | Adolescent responsive services | PHCs | Primary health centers |
AHD | Adolescent Health Days | RKSK | Rashtriya Kishor Swasthya Karyakram |
ANM | Auxiliary nurse midwives | RCH-II | Reproductive and child health program |
ESB | Ensuring Spacing at Birth scheme | SRH | Sexual and reproductive health |
FTP | First-time parent | TCIHC | The Challenge Initiative for Healthy Cities |
FDS | Fixed-Day Static | UHIR | Urban health index register |
HMIS | Health Management Information Surveys | UHND | Urban health and nutrition days |
mCPR | Modern contraceptive prevalence rate | UPHCs | Urban primary health centers |
NFHS | National Family Health Survey |
Worldwide, the adolescent and youth population is on the rise. Matching this global trend, India currently has over 358 million young people who are 10–24 years old. Of these, 243 million are aged 10–19, accounting for 21.2% of the country’s population.
As in much of the world, the needs of India’s young people vary substantially by intersecting societal factors such as:
Many of them are out of school or work and in vulnerable conditions. They are likely to be sexually active and are exposed to several health risks such as injuries, violence, alcohol and tobacco use, and early pregnancy and childbirth.
Many of them have limited access to accurate information and services. They face several challenges due to structural inequalities, including:
These challenges are even more acute for adolescents residing in low-income urban settings.
Responding to this critical need, India’s Ministry of Health & Family Welfare included adolescent reproductive and sexual health (ARSH) as a key technical strategy under its Reproductive and Child Health (RCH-II) program. In 2014, the ministry launched a new adolescent health program, Rashtriya Kishor Swasthya Karyakram (RKSK), that underscores the need for strengthening the health system to respond to adolescent health and development needs.
RKSK identifies six strategic priorities for adolescents:
The National Family Health Survey (NFHS 4, 2015–16) shows that the age group with the lowest contraceptive prevalence rate are married women 15–24 years of age—more specifically, young, married first-time parents. The survey provides a growing body of evidence for program implementers like Population Services International (PSI) and other stakeholders. The demand for contraceptives among young, currently married women is moderate, around 50%. Only around a third of this demand is met through modern contraceptives. This is perhaps due to India’s social norms, which expect young women to start a family as soon as they are married. According to NFHS 4, only 21% of sexually active women 15–24 in India have ever used any modern contraceptives.
NFHS 4 revealed that Uttar Pradesh, a state in northern India, had a high unmet need for a birth-spacing method among married women between the ages of 15–19 (20.4%) and 20–24 (19.1%). With over 200 million inhabitants, Uttar Pradesh is the most populated state in India and the most populous country subdivision in the world. The evidence showed that health outcomes for mothers and babies were significantly better if they waited two years between pregnancies. Yet, inequitable gender and cultural norms around fertility and provider bias lead many young married mothers in Uttar Pradesh (and elsewhere) to have closely spaced pregnancies that compromise their health.
This age group (15–24 years) faces a unique set of challenges different from those faced by older married women with regards to accessing and using family planning services. The problems these women face include:
In 2017, The Challenge Initiative for Healthy Cities (TCIHC) started providing coaching support to local governments in Uttar Pradesh to implement evidence-based family planning programs. Of these, five cities (Allahabad, Firozabad, Gorakhpur, Varanasi, and Saharanpur) were selected to add adolescent and youth sexual and reproductive health (AYSRH) and contraceptive use in young first-time parents (FTP) to the existing FP program in September 2018. TCIHC based its desk review of RKSK guidelines and strategies identified that RKSK has a cascade approach to introduce adolescent and youth strategies. This meant their strategies of introducing Adolescent Health Days (AHD) at primary health centers (PHCs) or community AHD were being implemented in rural areas. After rural areas were reached, RKSK planned to introduce these strategies to urban areas. The introduction of these strategies to low-income urban segments was, therefore, one of the last priorities.
TCIHC advocated with RKSK and presented a coaching-mentoring strategy. Coupled with demonstrating results on the benefits of rolling out adolescent and youth interventions (with an emphasis on contraceptive use in young first-time parents) in urban pockets in five cities of Uttar Pradesh, their strategy (click to expand):
The TCIHC experience from five cities revealed that ASHAs can prioritize young and low-parity women, specifically first-time parents, for family planning by:
This practice also aids in the maintenance of a registry of young married FTPs aged 15–24 years and prioritizes the category for household visits. The coaching enables them to easily identify FTPs with unmet FP needs and counsel them to access FP services using a Fixed-Day Static (FDS)/Antral diwas (“spacing day”) approach. Under this, UPHCs provide assured, quality family planning services, including long-acting spacing methods, on widely publicized fixed days and at times known to the community.
Some notable outcomes are (click to expand):
Furthermore, implementing programs using adolescent responsive services (ARS)—an approach to adolescent and youth services that integrates them into the health system in a systemic way—face several challenges in India. Such challenges impact the quality of SRH services for young people of all genders, including first-time parents. These challenges include:
PSI addressed these challenges through the TCIHC project by:
Investments in adolescents and contraceptive use in young first-time parents respond to their specific needs in a non-judgmental manner. Overall, adolescents tend to shy away from accessing health services. From studies, we know around 26% of adolescents are less likely to visit public health facilities or camps as compared to women of older age groups. Adolescents tend to access private-sector spaces (such as pharmacies), where short-term family planning methods (pills and condoms) are easily available over the counter, especially in urban areas. Young people need broader choices for FP, the private sector plays a crucial role in this context. Further, city health functionaries need to focus on integrating AYSRH needs into their routine agendas, so programs and initiatives are leveraged and optimally utilized.
Learn more about adolescent and youth reproductive health by catching up on the Connecting Conversations series, hosted by Family Planning 2020 and Knowledge SUCCESS.