adolescent reproductive and sexual health strategy(RCH-II), Adolescent health programmes

1. PRESENTER
DR MANISHA
JUNIOR RESIDENT
DEPARTMENT OF COMMUNITY MEDICINE
PGIMS ROHTAK

2. 
 BACKGROUND :
 PIONEERS
 EXISTING POLICY AND PROGRAMME
SCENARIO
 ARSH : THE PROGRAMME
 ARSH in HARYANA
 REFERENCES
Contents

3. 
BACKGROUND
 DEFINITIONS
 PROBLEMS OF ADOLESCENTS
 WHY INVEST IN ADOLESCENT HEALTH DEVELOPMENT
 STRATEGIES FOR PROMOTION OF ADOLESCENT HEALTH

4. 
 The term adolescence is derived from the Latin word
“adolescere” meaning to grow, to mature.
 Adolescence: 10 – 19 years
 Early Adolescence: 10 – 13 years
 Middle adolescence: 14 – 16 years
 Late adolescence: 17 – 19 years
 Youth: 15 – 24 years
 Young people: 10 - 24 years
Background
However The Government Of
India, in National Youth Policy
defines adolescents as 13-19
years

5.  Characteristics
• A – Aggressive, Anaemic, Abortion
• D – Dynamic, Developing, Depressed
• O – Overconfident, Overindulging, Obese
• L – Loud but lonely & Lack information
• E – Enthusiastic, Explorative & Experimenting
• S – Social, Sexual, & Spiritual
• C – Courageous, Cheerful, & Concern
• E – Emotional, Eager & Emulating
• N - Nervous, Never say no to peers
• T – Temperamental, Teenage pregnancy
Problems of
adolescence

6.  General health problems
 Malnutrition:
• Inadequate diet
• Anemia : most important
 For adoloscents 15-19yrs anemia(mild-39.1), (Mod-
14.9)& (Severe-1.7)—(NFHS-3)
• Obesity and eating disorders
• Extreme eating disorders e.g.bulimia and anorexia
 Mental health problems:Depression is common
 Early & unprotected sex:
• high number of unwanted pregnancies and unsafe
abortions and the steep rise in HIV infection.
Problems of
adolescence

7. 
Today’s adolescents are tomorrow’s
parents, teachers and community leaders.
Why invest in Adolescent Health
Development

8. 
 To reduce death and disease in adolescents:
 An estimated 1.7 million young people aged from 10 to 19 die each
year due to accidents, violence, pregnancy related problems or
illnesses. Young people 15-24 years old have the highest rates of
sexually transmitted infections, including HIV/AIDS.
 Almost one-third of the 40 million people estimated to be
living with HIV/AIDS worldwide are between the ages of
15 and 24 yrs
 Approximately 60 percent of all new cases of HIV/AIDS are
among the same age group.
Why invest in Adolescent Health
Development

9. 
 225 million adolescents comprising nearly 1/5th (22
%) of India’s total population (Census 2001).
 Of the total adolescent population, 12 %belong to
the 10-14 years age group and nearly 10 % are in the
15-19 years age group.
 Females comprise almost 47 % and males 53 % of
the total adolescent population.
 More than half of the currently married illiterate
females are married below the legal age of
marriage.
 Nearly 20 % of the 1.5 million girls married under
the age of 15 are already mothers (Census 2001).
Why invest in Adolescent Health
Development

10. 
 Age specific fertility rate in the age group of 15-19
years contributes to 19 % of the total fertility rate.
 Nearly 27% of married female adolescents have
reported unmet need for contraception (NFHS 3).
 Most sexually active adolescents are in their late
adolescence.
 Over 35% of all reported HIV infections in India
occur among young people in the age group of 15-
24 yrs, indicating that young people are highly
vulnerable.
 The majority of them are infected through
unprotected sex.
Why invest in Adolescent Health
Development

11. 
NFHS 3 HARYANA

12. 
DLHS 3 INDIA

13. 
DLHS 3 INDIA

14. 

15. 
DLHS 3

16. 
 To reduce the burden of disease in later life:
• Malnutrition in adolescence can lead to lifelong health problems
• Failure to care for the health needs of young pregnant women
damage their own health and that of their babies.
• Some of the highest infection rates for STIs are in adolescents.
• Diseases of late middle age, such as lung cancer, bronchitis and
heart disease, are strongly associated with smoking habit.
Why invest in Adolescent Health
Development

17. 
 To invest in health today and tomorrow:
• Healthy and unhealthy practices adopted today may
last a lifetime.
• Adolescence is a period of curiosity, when young
people are receptive to information about themselves
and their bodies, and when they begin to take an active
part in decision making.
 To protect human capital:
• In some societies 2 out of 3 adolescents are involved in
productive work . Damage due to injury, illness or
psychological factors the cost is primarily a human
one, but there is also a cost to society.
Why invest in Adolescent Health
Development

18. A =Adoption of healthy life style
D=Develop appropriate i.e. strategy discourage early
marriage and teenage pregnancy
O=Organize adolescent/ youth friendly clinic
L=Life skill training, legal support, liaison with peers,
parents
E=Educate about sexuality, safe sex, spirituality, responsible
parenthood
S=Safe, secure and supportive environment to be provided
C=Counselling/curriculum in school inclusive of family life
education
E=Enable & empower for responsible citizenship
N=Networking for experience sharing
T=Training for income generation, teen clubs
Strategies for promotion of adolescent
health

19. 
• AFHS in India was first taken by Safdarjang Hospital in
New Delhi
• The National Institute of Research in Reproductive
Health started AHFS Jagruti” in Mumbai for
providing specialized sexual & reproductive services
for adolescent boys & girls
• MAMTA an NGO started AFHS in some villages
including of Ambala district. It consists of
community based Youth Information Centres (YIC’s)
supported by peer educators, health facilility based
youth clinics at primary health centres & youth
friendly centres at first referral unit
PIONEERs

20. 
 In four districts of Madhya Pradesh a pilot project of
AFHS launched as name “Jigyasa” by The Family
Planning Association of India(FPAI)
 Haryana is the first state in the country to launch a
distinct Adolescent Reproductive & Sexual Health
(ARSH) program providing AFHS at government
health facilities.
PIONEERs

21. 
 In NRHM a national strategy for Adolescent
Reproductive and Sexual Health (ARSH) has been
approved as a part of the RCH II.
 Special attention is to be given to gender and equity
differentials at every stage of implementation.
 The RCH II ARSH strategy is to be implemented
within the framework of inter-sectoral convergence
emphasized by the NRHM.
Existing policy and
programme scenario

22. 
 The National Population Policy 2000 identifies
adolescents as an underserved group for which
health, specifically reproductive and sexual health
interventions are to be designed.
 The Tenth Five Year Plan(2002-2007) recognizes
adolescents as a distinct group for policy and
programme attention.
 The National Youth Policy 2003 recognizes 13-19
years as a distinct age group, which is to be covered
in programmes of all sectors, including health,
education, science and technology etc.
Existing policy and programme scenario
contd…

23. 
In this regard, the Youth Ministry has devised special
programmes for adolescent health and empowerment.
 Special focus is to be given on linking up with the
VCTCs and establishing appropriate referrals for
HIV/AIDS and RTI/STI infections.
 In this regard, operational linkages are being
proposed between the RCH II and all other
interventions, for young people in the National
AIDS Control Programme III.
Existing policy and programme
scenario contd…

24. ARSH at a glance
strategy
Standards for
implementation • What to implement
Implementing
guidelines
• How to implement
Policy and Institutional
framework
Operational framework
Logical framework
• Who will implement

25. 
 Policy level actions would need to be considered by
DoH&FW like administrative guidelines,consistency
and clarity of delivery and access to services,
identification of a core package of services for
adolescents at all levels of health care.
 At District level,the RCH Society is responsible for
overall implementation and regular monitoring. The
District RCH officer will be the focal point.
 Met through the existing network of CHCs,PHCs
and subcenters
 It is recommended to select only those PHCs
which are 24-hour functional centres, in the first
phase of implementing the RCH II ARSH Strategy.
Policy and Institutional framework

26. 
 Depending on availability,private providers can de
involved
 Partnerships are also being attempted with members
of FOGSI,local chapters of the IAP,NGOs and other
departments and stakeholders groups.
 Synergy with other health initiatives, in
particular,NACO,is to be promoted esp.with School
Health Programmes.
Policy and Institutional framework

27. Reproductive and Child Health Program
(RCH II) – Adolescent Reproductive and
Sexual Health (ARSH) Strategy
Overall objective of ARSH Strategy is to contribute to the
RCH II goals of reduction of IMR, MMR ,TFR and
Reducing incidence of STIs and HIV
Objective to be met by:
(i) Reducing adolescent pregnancies
(ii) Meeting unmet contraceptive needs
(iii) Reducing number of adolescent maternal deaths by
increasing access to adolescents for pregnancy, childbirth
and safe abortion services
(iv) Linkage with National AIDS Control Program

28. 
 A two- pronged strategy
 One: falls within overall scale and coverage of RCH-
II Programme.DoH &FW will incorporate adolescent
issues in all RCH trining programmes and all RCH
training material for CBC. This will entail that
interventions for addressing unmet needs for
contraception and pregnancy care,prevention of STI
(+HIV/AIDS) will have specific activities to reach
out to adolescents.
 Two :in selected districts. Require special efforts to
reorganize services at the PHCs on dedicated days
and dedicated timings for adolescents. This depends
on local capacities to deliver,staff availability and
orientation.
RCH-II ARSH Strategy

29. RCH-II ARSH Strategy
Development of National Standards
• National Consultation: September 2005
• Consultative process involved: National and
State Program Managers, NGOs, INGOs,
Professional Associations, AH Experts,
UNFPA, WHO
Development of Training package
• Orientation Programme based on WHO-OP
• Separate OP for Health Workers

30. Key interventions under ARSH
Existing services to be reorganized for
adolescents to cover preventive, promotive,
curative and counselling services
Capacity building of on meeting service needs
of adolescents
Communication activities to be undertaken for
awareness and demand generation
Incorporate ARSH indicators in routine MIS
Linkages with National AIDS Control
Programme

31.  The key ‘friendly’ characteristics of services for
adolescents are at the levels of the user, provider and
health system.
 User’s prospective:
Accessible
Acceptable: Meets expectation
 Provider’s and managers prospective:
Appropriate: Required care
Comprehensive: All-Rx & counselling
Effective: Positive impact on healh
Equitable :All esp. the poor, vulnerable,
marginalized and difficult-to-reach groups
STANDARDS FOR QUALITY AND
FRIENDLY REPRODUCTIVE
AND SEXUAL HEALTH SERVICES FOR
ADOLESCENTS

32. Launch of National Standards
and Training Package
 Launched by Secretary,
Health on 9 May 2006
 Dissemination to State
programme managers,
CBOs, NGOs,
Professionals….

33.  1.Health facilities provide the specified package of health
services that adolescents need.
 2. Health facilities deliver effective health services to
adolescents
 3. Adolescents find the environment at health facilities
conducive to seek services
 4. Service providers are sensitive to the needs of adolescents
and are motivated to work with them
 5. An enabling environment exists in the community for
adolescents to seek the health services they need.
 6. Adolescents are well informed about the availability of
good quality health services from the service delivery points
 7. Management systems are in place to improve/sustain the
quality of health services
Seven standard statements of the
ARSH

34. 
 INDICATE the minimum and core actions to be
undertaken if strategy is to be effectively
implemented.
 These can be further adapted to meet the state and
district specific requirements ,as appropriate.
 The operational guidelines in seven sections are
organized in terms of the seven standard statement
discussed above.
OPERATIONAL GUIDELINES

36. 
 Package of services: to all adolescent married and
unmarried girls and boys
1. Promotive services:
• Focused care during antenatal period
• Counselling & provision of emergency contraceptives
• Counselling & provision of reversible contraceptives
• Information/advice on SRH services
2. Preventive services:
• Services for TT and prophylaxsis against nutritional
anemia
• Nutritional counselling
• Services for early and safe termination of pregnancy and
management of post abortion complications

37. 
3.Curative services:
• Treatment for common RTI/STIs
• Treatment & counselling of menstrual disorders sexual
concerns of males and female adolescents
4. Referral services:
• Integrated Counselling and Testing Centre
• Prevention of Parent to Child Transmission
5. Outreach services:
• Periodic health checkups and community camps
• Periodic health education activities
• Co-curricular activities

39. 
Service Providers:
1.Adequate and appropriate (identified) service
providers are in place.
2.They are aware of their roles and responsibilities.
3.They have the competencies required to provide the
specified health services effectively.
Location, ambiance, and supplies:
1.Availability of a separate room for the clinic
2.Timing and frequency of organising the clinic
IEC and resource materials:
Informational/educational materials directed at
adolescents should be available.

40. 
Sub-centre Level
 IFA tablets
 Drugs for dysmennorhoea
 TT vaccine and syringes
 Essential ANC equipment
 Haemoglobinometer, supplies for Hb estimation
 Emergency contraceptives
 Contraceptives and communication materials for adolescents
PHC Level
 Clinic is to be organized once a week
Materials and supplies as listed above should be ensured in adequate
quantities at the PHC
CHC Level
 A clinic at a dedicated time may be organized at least twice a
week.At least one doctor and two support staff could provide
services at this level

42. 1.Staff:
 Designated staff must be present.
 They should put the adolescents at ease for them to
avail the services they need and are being offered.
 Follow-up
2. Registration Procedures:
 simpler.
3. Privacy and Confidentiality:
 Personal details, address, etc. of clients will be kept
confidential.
 window curtains and a bed-screen
 No one else is allowed when one client is already
there.

43. 5. Appropriate signboard
 location of clinic and its operational timings.
 Display board of the PHC may indicate the
availability of services for adolescents
6. IEC
 Relevant posters
 Communication materials may be displayed.

44. Section 4:CAPACITY BUILDING OF
PROVIDERS
4th STANDARD: Service providers are
sensitive to adolescent needs and are
motivated to work with them

45. 
 The capacity-building must address
• competencies; relating to clinical management
• interpersonal communication skills
• Perspectives and attitudes on certain sensitive
adolescent issues like sexuality
Selection of providers:
 Sub-centres/PHCs:
• Medical Officer in-charge
• LHV/ANM/MPW-M (posted at headquarters)
• ANMs/MPW-M (posted at sub-centre attached to PHC)
 CHCs and District Hospitals:
• Medical Officer (preferably a Lady Medical Officer).
Section 4: CAPACITY BUILDING OF
PROVIDERS

46. Standard 4: Training Package

47. Section 5:ENVIRONMENT
BUILDING
5th STANDARD: An enabling
environment exists in the
community for adolescents to seek
services

48. (i) At the district level
A one-day ARSH orientation by the
DHO / RCHO for district level officers
of different departments, including
civil society representatives. To
facilitate inter-sectoral coordination,
especially with WCD, school and
youth sectors.
A one-day orientation is to be
organized by the DHO/RCHO for
district- level ZILA PARISHAD
members.
(ii) At the block level
One-day meeting of PRIs and WCD/
Education /Youth Departments is to
be organized by the Medical Officers.
to build a supportive environment
for adolescents to seek information
and services
Special focus is to be on role of PRIs
in monitoring teenage pregnancy and
early marriages
(iv) At the PHC level
A half-day meeting is to be organized
by the LHV/ANM for self help
groups’ office bearers and Village
Health Committee members.To
generate support of women for
participation of unmarried
adolescents in the village group
communication activities
(iii) At the village level
The ANMs, while participating
in the meetings of women’s
groups or self help groups or
VHCs, must generate support
for adolescents’ need for
information and services.

49. Section6:COMMUNICATION WITH
ADOLESCENTS
6th STANDARD: Adolescents are well
informed about the health services

50. 
(i)Outreach: Communication activities are to be
conducted at the level of village outreach, aanganwadi
centre and/or youth group.Such group communication
activities are to be conducted once a month
(ii) Sub-centre :ANMs and male health workers are to
be responsible for conducting once a month group
communication activities in schools and youth
groups.This is to be linked to school health activities
(iii) PHC :Medical Officers from PHCs
To conduct health checkups once in six months under
the school health programme.
MOs and ANMs may periodically visit schools to
inform adolescents about the availability of services.

51. 
(iv) DHO is to ensure that all sub-centres and PHCs
are equipped with locally relevant communication
and counselling materials handy for service
providers and adolescents visiting the health
centres.
 IEC and BCC materials developed under RCH 2
are to incorporate adolescent issues

52. Standard 2, 5, 6
Developing IEC Material on
Adolescent Issues
 Wall posters
 Pamphlets
 Media messages

53. 

55. 
 Service Register
For this purpose, each PHC/CHC facility is to maintain
an ARSH Service Register, which will generate data on a
monthly basis. That will reflect on
(i) Data from service register
(ii) Progress on training and communication activities
 Monthly Format

56. 
1. Reporting month and year :
2. Name of State and District :
3. Name of Block, PHC :
input related Indicator During the month Cumulative
(i) % of Sub centres having communication material for adolescents
(ii) PHC having adequate supplies of ECPs y/n
Progress related Indicator During the month Cumulative
(i) Total number of clients who attended the facility a. Boys b. Girls
(ii) Number of group meetings held against planned
(iii) No. of service providers trained in providing ARSH Services.
(iv) No. of new pregnancies below 20 years registered during the month (married/
unmarried; 10-14 yr/15-19 yr)
(v) Total number of teenage pregnant women attending ANCs
vi) No. of teenage PW delivering in the institutions
(vii) No. of teenage girls that availed MTP services (married/unmarried; 10-14yr/15-
19yr)
(viii) No. of adolescent girls and boys that accessed contraceptives services by method
(condoms, OCP, ECP, IUD)
(ix) No. of adolescent girls and boys that availed RTI/STI treatment
(x) No. of adolescents referred to CHC, DH, tertiary facilities
7. Any comment on profile of adolescents accessing services
8. Specific comments on networking, referrals and follow-up

57. The framework of services in the RCH II ARSH
Strategy in the National PIP:
 Target group :beneficiaries of the adolescent
friendly reproductive and sexual health services
 Service package: the health problems/issues to be
addressed
 The health facilities and service providers
involved.
Operational framework

58. Level
of care
Service
provider
Target
group
Flow of
service
delivery
activities
Services
Sub-
centre
HW(F) Unmarried
male&
female
Married
male&
female
During
routine
sub
Centre
clinic
•Enrolment of newly married couples
•Provision of spacing methods
•Routine ANC care & institutional
deliveries
•Referral for early & safe abortion
•Education on prevention of RTI/STIs
•Nutritional counselling on anemia
prevention & menstrual hygeine
•Immunization for pregnant adolescent
mothers

59. Level of
care
Service
provider
Target
group
Flow of service
delivery
activities
Services
PHC/CH
C/DH
HA(F)LHV
or
MO
Unmarried
male&
female
Once a wk teen
clinic at PHC
for 2hrs
•Contraceptive condom
programming
•Management of menstrual
disorders
•Education on prevention of
RTI/STIs and their
management
•Counselling & services for
pregnancy termination
•Nutritional counselling &
counselling for sexual
problems
•Immunization for pregnant
adolescent mothers

60. 
 A number of NGOs are involved in the
implementation of IEC programme for adolescents.
 Salaam Baalak Trust : children at railway stations ,
adolescent street children.
 Ruchika Social Service Organisation at
Bhubaneswar, Orissa
 Prerana-Delhi
 SEWA-Ahmadabad,
 Chetna, Sutra-Himachal Pradesh
 NIMHANS-Bangalore
 Institute of Social Services-Delhi
 ADITHI-Bihar

61. 
 Haryana is one of the first states in the country to
launch the Adolescent Reproductive And Sexual
Health (ARSH) programme on 26th oct,2007.
 SWACH(Survival for Women & Children Health)
Foundation a national NGO was granted a project
to implement ARSH strategy in the public health
system in rural parts of district Ambala, Haryana
ARSH in HARYANA

62. 
 Adolescents would be reached by peer group
educators , keeping in view that the adolescents
open-up easily to peer age-group rather than
parents or any other senior
 Four peer educators per sub-centre would be
identified so as to cover both male and female
adolescent population.
ARSH in HARYANA

63. Adolescent Friendly Clinic at the
Village Sub-center

64. 
Other Adolescent Health Programs:
1. Kishori Shakti Yojana : To improve the health and nutritional
status of girls
2. Balika Samridhi Yojana: To Delay the age of marriage
3. Reproductive and Child Health Programme
4. Adolescent Friendly Health Services:
5. National AIDS Control Programme
6. Family Life Education

65. 
 National consultation on RCH II ARSH strategy
 Adolescent health and development
implementation guide RCH II
 International Institute of Population Sciences and
ORC Macro.
 National Family Health Survey – 3, 2005-06.
 Modules on Orientation Programme
of Adolescent Friendly Reproductive and Sexual
Health Services
References

66. 
 NACO. Youth: National Behavioral Surveillance
study. New Delhi: National AIDS Control
Organization, Ministry of Health and Family
Welfare, GOI; 2006.
 www.icrw.org.
 www.savethechildren.org
References