Author: Ram Aravind | 09-Jan-2021
In a country like India, with wide socio-economic and cultural disparities, a centralised approach to program design runs the risk of excluding the target group from accessing social welfare benefits, such as health and education. This is the case with India’s Rashtriya Kishore Swasthya Karyakram (National Adolescent Health Program), in which Adolescent Friendly Health Clinics are a critical component for adolescents to seek holistic health services. Can participation of adolescents inform the design of the clinic, the most relevant health services and the approach of health service personnel, to strengthen bottom-up delivery of public health policy and programs? Ram Aravind’s blog, in the ongoing series on the Our Health Our Voice participatory action research, shares the possibility of engaging adolescents and institutionalising their participation in creating a system designed to meet their health demands.
Adolescent-Friendly Health Clinics (AFHCs) is an initiative mooted as a ‘safe space’ for adolescents to seek counselling as well as referral for sexual and reproductive health, nutrition, mental health, domestic violence, safety, and drug and substance abuse. As an important component of the Rashtriya Kishore Swasthya Karyakram (RKSK), AFHCs are expected to bolster health-seeking behaviour among India’s 254 million adolescents.
“As of 2020, India had 8,000 AFHCs across the country catering to 250 million adolescents. That works out to one AFHC for 30,000 adolescents. The gap is further widened when it comes to the number of counsellors; there is one counsellor for a population of 1.5 lakh adolescents,” remarked a researcher of health systems in a learning circle organised by PRIA on adolescent-related health systems. Evaluations of the scheme from across the country have highlighted the fact that adolescents have little or no knowledge about the facility as well as services offered.
In PRIA’s participatory survey among 330 adolescents living in five informal settlements in Gurugram, 91% of the adolescents reported poor awareness of AFHCs located in their city. Poor awareness apart, the Peer Educator program, which is the community engagement component of RKSK, has been discontinued in some states in India, further driving a wedge between the health systems and the target group.
If adolescents were to design an AFHC, which supported them to exercise independent health-seeking behaviour, what would it look like and what facilities would it offer?
It would be situated closer to their homes. There would be young male and female counselors at the clinic, so that adolescents feel comfortable to open up on confidential health-related issues. It would have friendly staff so that the young boys and girls feel welcome. There would be more context-specific social and behavioural change communication materials developed in local languages available at the clinic. Sexual Reproductive Health services would not be available only for girls; boys too could avail of them. This is what 29 adolescents envisioned, in a participatory exercise conducted under the Our Health Our Voice action-research study.
As part of the exercise, the adolescents undertook a visit to the AFHC located nearest their settlements. The ‘nearest’ facility was, however, 20 km away from their homes. As one adolescent remarked “If I have to use this facility, I will have to pay at least Rs 200 (around $2) for transportation. Where do my parents have the money for this luxury?” When the adolescents went inside the clinic, they were greeted by impolite support staff, whose behaviour they felt would intimidate youth, especially those in early adolescence. There was no counsellor whom they could talk to. The clinic timings coincided with their school timings – was RKSK offering a choice between seeking health and seeking education for these adolescents?
On the eve of India’s Independence Day (15 August), when 29 adolescents gathered to share their aspirations about how adolescent friendly health systems could be made accessible as well as receptive to their needs and demands, I could not have vouched for a better occasion to demand for integration as well as institutionalisation of adolescent participation into policy decisions that affect their health and well-being; democracy in health-seeking.
Eager to translate their demands into actions and based on their lived experience as ‘India’s adolescents’, the boys and girls presented their aspirations in the form of a manifesto to city-level health officials in Gurugram, notably the civil surgeon who heads the health system in the city as well as the deputy civil surgeon in charge of adolescent health schemes.
Their demands were:
As I write this, I am proud to say that the adolescents have found their first share of success. The civil surgeon has announced that the Peer Educator program is to be revived in Gurugram and the adolescents, who were co-researchers in our study, will be trained to effectively carry out outreach on adolescent health as well as undertake referral at the level of urban informal settlements by the Health Department, Gurugram.
Participatory researchers believe that “knowledge is a tool for taking action to create a more socially just and healthy world and for deepening democracy.” Empowering adolescents from under-resourced settings through evidence-building will enable them to develop agency over matters that affect their life choices. The law-makers should provide this support, create an eco-system in which adolescents feel safe to talk about their health issues, and secure sustained participation of the community in improving health outcomes among urban adolescents.
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