Thirty percent of India’s total population comprises of adolescents and youth aged 10 to 24 years  . To provide friendly services to the adolescents, the Ministry of Health, Government of India (GOI) launched the Adolescent Reproductive and Sexual Health Strategy  in 2005 under the umbrella of National Rural Health Mission (NRHM) as part of Reproductive and Child Health (RCH-II) programme. This strategy intended delivering a comprehensive package of services for adolescent boys and girls including preventive, promotive, curative, counseling and referral services; focusing on sexual and reproductive health by re-organizing the existing public health system and developing linkages between RCH-II and National AIDS Control Program (NACP-III). Implementation Guide  outlined the necessary interventions that could make the clinics functional recommending all core domains of adolescent friendly care  . A set of tools were developed by World Health Organization (WHO) which used multiple level assessments to validate the quality of each indicator  . World Health Organization (WHO) Job aids  on adolescent health also ensured uniform management of clinical issues by the trained healthcare providers.
Maharashtra being one of the implementing states, established adolescent health services at District and sub-district hospital settings. However, the district hospital settings lacked community outreach services and manpower to generate demand for services, as their mandate was mainly curative services. Although one post of ARSH counselor was dedicated to this clinic, there were limitations of her/his single handed reach to the community. District hospitals have specialized expertise and their services are utilized for issues that cannot be tackled at the primary health care settings. Since these services were not established below the district level, an implementation research study was undertaken to capacitate the primary health care facilities and test the operational feasibility to provide services to adolescents.
Preliminary work by our institute included working with the district programme managers for developing a district action plan for linked RCH-ARSH and HIV services in the year 2007. In addition to this, tools to assess the service readiness of the public health system, IEC material (posters and pamphlets) in local languages for demand generation and translation of Government of India (GOI’s) Auxiliary Nurse Midwifery/Lady Health Visitor (ANM/LHV) training module in Marathi language for capacity building of health care providers to deliver adolescent friendly services were developed and shared with the state government. Financial assistance was received from WHO in the preparatory phase. This work was utilized for planning and implementing the study in Karjat block of Raigad district of Maharashtra. The block had a mix of tribal and non-tribal population and comprised of eight government health facilities viz. one Sub- district hospital (SDH), one Rural hospital (RH) and six Primary Health Centers (PHCs) located equally in tribal and non-tribal areas each, covering a total population of 2, 17, 363. A quarter of this population belonged to schedule tribes with 60% literacy. The main occupation was agriculture or petty business. There were no major industries in the block.
This paper pertains to process documentation related to products developed and challenges faced during establishing, strengthening and sustaining the Adolescent Friendly Health Services at sub-district health facilities in the block. The paper also outlines the interventions that worked and those that did not.
This prospective intervention study was conducted from 2009 until 2014 (5 years) with an aim of documenting the process of implementing ARSH services below district level as per the Implementation Guide developed by Government of India. Entire Karjat block of Raigad district was chosen for the study due to operational feasibility and that it had a good representation of tribal and non-tri- bal populations. All health facilities i.e. six PHCs, one RH and one SDH were included for interventions. The situation analysis included health facility assessment of quality health services provided to the adolescents. Using a check list which identified infrastructure needs along with drugs and consumables, a range of services and quality of care available to adolescents was assessed. Health care providers were interviewed to assess their knowledge on adolescent health issues, training needs and community outreach services provided to adolescents. Needs assessment of the adolescents and youth was done by eight Focus Group Discussions among adolescents and young people aged 10 - 24 years, two each among married and unmarried boys and girls respectively. Quality assessment tools developed by WHO  were used to monitor the adolescent friendly health clinics during the study in each phase. Scores were assigned in percentages to the variables specific to each standard. Strategies were implemented to address the shortfalls observed in each assessment.
Based on the findings of the situation analysis (Table 1), interventions categorized into four broad areas were designed namely 1) establishing Adolescent Reproductive and Sexual Health (ARSH) clinics by strengthening health facilities 2) sensitizing community and reaching out to adolescents; 3) strengthening inter- and intra-sectoral linkages and 4) monitoring evaluation and accountability of the health providers.
1) Establishing Adolescent Friendly Health Clinics (A&YFHCs) by strengthening the existing public health facilities:
Designated adolescent and youth friendly health clinics named “Maitri”
Table 1. Situation analysis of ARSH services in the block.
(Friendship) were established at all eight health facilities in the block for all adolescents ensuring audio visual privacy. However for the purpose of the study the age group catered included youth as well. The logo and content of the Maitri clinic sign board (Image 1) was finalized in coordination with United Nations Population Fund (UNFPA) and Government of Maharashtra (GOM). Information and education materials on common adolescent health issues along with a self-learning audio visual CD developed by the state government for advocacy with gatekeepers and two CDs on adolescent health education (separate for boys and girls) developed by Marathi Vidynan Parishad were provided to all eight health facilities along with essential medicines to treat common ailments. Schools, anganwadi centers and gram panchayats were also supplied with IEC material. Separate service registers in a particular format were designed to document information on adolescents.
Training of sixteen Medical Officers was conducted using the RCH-II ARSH
Image 1. Sign board of Adolescent Health Services in local language of the study site (Marathi).
training modules  and WHO Adolescent Job aid  . One hundred and eleven Paramedical staff, three hundred and nineteen Anganwadi Workers, one hundred and forty three ASHA workers were also trained in several batches. Pre- and post-training assessments were followed by refresher trainings and feedback regarding difficulties faced on job. The facilities were inaugurated during 2009- 2010 by prominent local politicians in presence of local adolescents, youth, tea- chers and parents. Rallies, street plays on various adolescent health topics along with mass health checkup camps marked these events.
2) Sensitizing gatekeepers and reaching out to adolescents:
A local committee was set up for the A&YFHCs with representatives from local self-government, health care providers, a paramedical staff adolescents (1 boy and 1 girl), school teacher and legal representative, if available to get community support for the ARSH activities. To create adolescent friendly environment in the community multiple group meetings were conducted with gatekeepers, mainly the Panchayat members (200 members of 50 panchayats including Sarpanches), 135 School teachers and parents of adolescents. Adolescent health education programs were undertaken for married and unmarried adolescents in the community either through schools and ICDS workers.
3) Developing inter- and intra-sectoral linkages (Table 2):
The study also attempted to link ARSH services with the existing HIV (Human Immuno Deficiency Virus) services. Official permissions were obtained to permit counselor and lab technician of Sub-district and rural hospital to assist in providing ARSH services at PHC level.
Linkages were developed between A&YFHCs, school health services and NGOs. ANMs accompanied the school health team during school health checkups to conduct awareness program and identify cases that were referred to Adolescent Friendly Health Centers (A&YFHC). Standard Operating procedures were developed to establish these linkages. The existing WIFS (Weekly Iron and Folic Acid Supplementation) program at school level was also linked with the ARSH services and teachers were encouraged to refer any students who were non-compliant or reported any health problems. Trained ASHAs were paid cash incentive of Rs. 10/- for every referred case to the clinic or during camps in the last phase of the project in consultation with the state government.
Peer volunteers were selected from the NSS cadets at different colleges as well as from the community. They were sensitized and were given an agenda to advocate adolescent issues in their respective villages and refer clients to the A& YFHCs.
4) Monitoring and Evaluation:
Quarterly meetings with the state, district and block officials for health, Integrated Child Development Services (ICDS) and Education departments were held to review the progress. For each health facility progress towards achieving the targets were discussed and challenges faced and problems solved were presented. This exercise helped to identify problems and plan corrective interventions. Assessment of quality of services against the seven standards as laid down in the ARSH Implementation Guide were carried out every year at each A&YFHC using Quality Assessment tools developed by WHO.
Training health care providers led to significant improvements in their knowledge, attitude on adolescent problems and their approach of dealing them (Table 3). Issues like contraception to be provided to unmarried adolescents or counseling on masturbation were challenging issues to convince providers mainly the grass root functionaries as it questioned their own beliefs and social norms. The community based activities enabled creation of an adolescent friendly environment leading to increased attendance of adolescents at the A&YFHCs. MIS helped to record age and sex disaggregated information on adolescent-specific problems.
Quarterly intersectoral meetings encouraged good practices and sensitive issues dealt in adolescent friendly manner were discussed. Problems that needed intervention by the district and state level officials were identified and actions were taken to pursue the same with respective departments. Based on the flow of clients to the clinic, the once a week clinic was modified to any day clinic ensuring adequate time was given to the adolescent clients. Providers were encouraged to allow anonymous registration if adolescents so demanded to facilitate adolescents access services providing privacy. Providers had constraints to tackle unmarried pregnancies and provide contraceptives to unmarried girls. They were repeatedly asked to refer to the implementation guide which provided guidance regarding ARSH services to adolescents.
Involving Peer Volunteers, NSS groups and Adolescent health committee had limited scope for reasons mentioned in Table 2. Their roles and responsibilities need to be more clearly defined. The total number of cases referred by ASHAs during the study period was 828. A number of coordinated activities were ar-
Table 2. Interventions to facilitate intra and inter-sectoral linkages and its outcome.
ranged due to networking with education institutes, NGOs and other sectors that improved linkages and referrals.
Table 3. Improvement in knowledge about ARSH issues among paramedical staff post training ie after 3 days (correct response) n = 133.
Quality Assessment reflected an increased overall composite score for all seven standards from 28 at baseline to 81 at the end of four years signifying that the standards for adolescent friendliness were achieved.
There was a steady increase in the attendance of girls and boys seeking preventive and curative services for a number of reproductive health issues (Table 4). These belonged to mainly rural and tribal areas both school and non-school going. The MIS of the health system does not capture details of the socio-de- mographic characteristics. However they were all local residents availing services. Seeking answers on adolescent growing-up issues was the most common reason to approach Adolescent Friendly Health Centers (A&YFHC) along with menstrual problems among girls, nutrition related issues, reproductive tract infections and skin disorders. They were also offered immunization (booster dose DT at 10 years) and screening for sickle cell anemia mainly at the tribal health centers. Among the 10 - 19 year old clients, approximately 80% of adolescents were unmarried and this was exactly opposite among the 20 - 24 year olds where majority of girls were married.
4. Contribution to State-Wide Scaling up of A&YFHCs
Process and products developed over the project period were handed over to the officials of the government of Maharashtra for possible adaptation for the state programme. Design and content of the sign board for the A&YFHC―the “Maitri” Clinic has been subsequently used for all A&YFHCs in the state government programme and has helped recognition and branding of these clinics. Government of India’s ANM training package was translated in local language Marathi for the project and has been used for state-wide trainings. Adolescent-specific IEC materials developed during the pre-project phase were transformed into five posters and three pamphlets by the state government (Image 2). Standard Operating procedures to establish the linkages between A&YFHCs and School Health Services were shared with the state government. The project investigators at our institute were nominated on the Task Force Committee of the Government of
Table 4. Presenting complaints by 23,570 adolescents and young people during utilization of services.
*Nutritional concerns-Anemia, underweight, Vitamin deficiency etc. **Growing up Concerns such as height weight, body image, breast development, sexual attraction, acne, masturbation etc.
Image 2. Information Education material on adolescent reproductive health issues in local language of the study site (Marathi).
Maharashtra to provide technical assistance in rolling out the adolescent health programme in the State. At the end of the project, the eight A&YFHCs have been sustained through the budget provision made by the state health department in their annual program implementation plan.
This study in collaboration with Government of Maharashtra was piloted to test integration of adolescent friendly health services within the public health system at primary health care level in a block at a time when ARSH services in the state of Maharashtra were available only up to the district and sub district hospital level.
The study succeeded in identifying the strengths and weakness of health system as to what interventions can health system undertake on its own and which interventions need collaboration and linkages with other programmes and institutions. Successful interventions were: Community activities to create enabling environment for adolescent health; strengthening of existing health facilities to develop A&YFHCs based on the Implementation Guide for Adolescent Reproductive and Sexual Health; involvement of ASHAs for mobilizing adolescent clients in the community by providing incentives; establishing linkages of the A&YFHCs with school health services; integration with HIV services; and networking with local NGOs. Attendance by adolescents in the A&YFHCs progressively improved over time presenting with a broad range of problems to very sensitive and private issues like sexual health. We observed that special efforts are needed to attract male clients to these A&YFHCs through targeted outreach activities. SOPs for establishing linkages between several existing services and different programs were found effective and shared with the State and district officials. Creating an enabling environment in the community facilitated improved utilization of services satisfying the key indicator of quality of care  .
The study found that it is challenging for the overburdened health system to single handedly manage all dimensions of interventions that are necessary to implement the national Adolescent Reproductive and Sexual Health strategy. Innovative approaches like Youth Information Centers  have been reported in literature to conduct outreach activities that help mobilize adolescent clients. Improved awareness and health seeking behavior of adolescents following outreach activities have also been reported  . Having multiple actors but no ownership or accountability of health parameters by various stake holders has led to the poor response of ARSH program in India  . This could be best accomplished by fostering intra and intersectoral linkages. A study comparing two models of adolescent service delivery found utilization of school health services better than dispensary based health clinics and adolescents reported more of psychological and behavioural problems  . However, these models are difficult to replicate and sustain as they involve a full time dedicated health staff at every school. So a more feasible model could belinking these two services, as has been recommended by our earlier study  . It is important for school health services to include sexual and reproductive health education along with school health checkups inclusive of reproductive health with good referral linkage to A&YFHC.
Most programs for adolescents evaluate the clinic service uptake. This seems to be a poor indicator especially when the services are rolled out at the community level with involvement of sub-centers and PHCs. Most adolescents are a healthy group and do not have many health problems. We cannot expect huge numbers crowding our Out Patient Departments. Through outreach programs preventive and promotive services are provided which in itself is an important service component. Equipping them with appropriate information to reduce risky behaviour and promoting healthy lifestyle remains the major element of the outreach program. The issues addressed in these activities and change in knowledge and attitudes of these young people after attending these activities are unaccounted for in the routine MIS.
The data from few intervention studies published earlier illustrate that adolescents typically seek multiple services at any one visit, with counselling being the most popular service, followed by medical examination  . Each client re- ceives separate services but is treated as a single client thus reflecting limited attendance at the health facility. Boys and girls reported similar problems as that from urban areas  . For a broad based programme, it is important to measure impact of these interventions on key indicators such as age at marriage, age at first birth, ANC and reduction in maternal and infant morbidities and mortalities along with reduction in incidence of sexually transmitted infections. However, this was the limitation of the study due to its short period of observation which helped measure only output and not these important outcomes. Monitoring the impact of ARSH program is difficult through routine HMIS, as age segregated data on indicators of maternal health; RTI/STI and contraception are not available.
With the increased urbanization and delay in age of marriage the young people beyond 19 years also form a vulnerable group. Hence expanding the age- group of adolescents from 10 - 19 to 10 - 24 years could help bring a larger population under the program as seen in the study. Policy issues regarding imparting sexuality education in schools, anonymous registration, issues of privacy and confidentiality, tackling of unmarried pregnancy, providing contraceptives to unmarried girls etc. should be clarified further so that such services could be delivered effectively to adolescents.
Our study has revealed that the health system found it challenging to generate demand for ARSH services supported by good quality of care. Chandra, Lane and Wong have recommended that implementers should adopt only the best practices from evidence that already exists and avoid strategies (eg. Peer education) which have not worked in the field of ARSH  . With the introduction of a broader agenda of Rashtriya Kishor Swasthya Karyakram  that covers many other aspects of adolescent health and behaviours, health systemhas to respond to many other components of adolescent health beyond ARSH to achieve the targets of this ambitious program. While RKSK has its own advantage of being very holistic, the skills of the providers for improved coordination to roll out this program become extremely crucial.
Collaboration and networking are key strategies to improve adolescents’ access to services supported by a favorable adolescent friendly atmosphere both in the community as well as health facility by trained sensitive providers. Regular monitoring of activities and maintaining records in the form of MIS is crucial to identify gaps and introduce strategies to address them. Refresher training of health providers is very essential to address their concerns when they start providing adolescent services. The research agency facilitated testing strategies to strengthen the health system to address the adolescent sexual and reproductive health issues and documenting the outcomes. There is a need to network with organized and unorganized sectors such as education, ICDS, NGOs working in the field of adolescent health and development to work as a team and address the multifaceted needs of the adolescents. Such a strategy will be crucial while implementing the recently launched Rashtriya Kishor Swasthya Karyakaram (RKSK) the new national adolescent health programme in India.
We wish to acknowledge the financial support received from World Health Organization (WHO) for first year and Government of Maharashtra for three consecutive years. We duly acknowledge the technical support provided by Dr. Neena Raina and Dr. Arvind Mathur at World Health Organization (WHO) South East Asia Regional Office (SEARO), New Delhi and the administrative support provided by all the Additional Directors’ I/C of adolescent health in the state government and their offices during the study period namely Dr. Ashok Chitale, Dr. Smita Ganu. We also wish to acknowledge the support leant by District health authorities Raigad and the Taluka Health Officers’ and their staff for facilitating conduct of the research study. Integrated Child Development Services(ICDS),District AIDS Prevention Control Unit (DAPCU) and School health officials in the block deserve a special mention. The entire cadre of health providers from Medical Officers to Accredited Social Health Activists (ASHA) were part of the team who actually implemented the work at ground zero. The independent team of researchers who facilitated conduct of the quality assessment also deserve a special mention. Non-Government Organization (NGOs) and a number of other support persons and organizations who contributed in their respective capacities during the conduct of various activities are also acknowledged. We acknowledge the CDs (documentaries) on sexuality education developed and shared by Marathi Vigyan Parishad, Mumbai and the school and college teachers and students who participated in training sessions and organized students’ awareness programs. We also thank the Director and the research team from NIRRH and all the adolescents who supported in this activity.