The issue of reproductive health and sexual rights of adolescent boys and girls, under-age marriage, and adolescent pregnancy within and outside marriage remains a policy blind-spot in India. This is in spite of the fact that multiple surveys have highlighted the prevalence of child marriage and early pregnancy in India (Hyperlink Part 1 of the article here). Ironically, women's issues have been consistently reduced to the lens of health, family and violence in the development discourse since independence. Yet, attention to adolescent girls in particular, and their sexual and reproductive rights has been almost absent until recently.
The unmet need for reproductive and sexual health services and counselling is propounded by studies that suggest that adolescents and youth have not received relevant information on sexual matters from frontline workers and healthcare providers and are largely uncomfortable in obtaining contraceptive supplies from them, even when it is available (International Institute for Population Sciences and Population Council, 2010). In fact, reports suggest that adolescent girls rank the lowest in terms of awareness about sexual health, family planning methods, risky sexual behavior and their rights (RKSK Strategy Handbook, Government of India, 2014).
The unmet need for reproductive and sexual health services and counselling is propounded by studies that suggest that adolescents and youth have not received relevant information on sexual matters from frontline workers and healthcare providers.
During our field work for example, while adolescent boys, who seasonally migrated to Punjab and Delhi in search of work, were familiar with contraceptive methods such as condom and emergency pills, and STDs such as HIV/AIDS, adolescent girls would often plead ignorance during the interviews.
Until the National Adolescent Reproductive and Sexual Health (ARSH) strategy released in 2006, there was no policy that directly addressed adolescent SRH. The National ARSH strategy mandated setting up of Adolescent Friendly Health Clinics (AFHC) to provide preventive, curative and referral health services to adolescents in a safe and respectful environment. However, a number of evaluations of AFHCs over the past decade has revealed its policy failure: uneven implementation, limited awareness, inadequate training and sensitisation of health care providers, lack of utilisation by adolescents, insufferably poor quality, and unavailability of supporting infrastructure. These clinics have failed to operate regularly and provide services with respect and privacy to adolescents (Santhya et al 2014).
Our recent field work on ARSH suggests that often AFHCs exists only on paper,with no dedicated staff, training or infrastructure to meet the needs of adolescents in rural Bihar. None of the adolescent boys and girls we spoke to had ever heard of an AFHC, or a clinic with corresponding description, but only about the block level Primary Health Centre (PHC), which they hardly ever visited. Unmarried boys and girls in fact told us that they prefer availing private health care facilities for common ailments instead of consulting ASHAs or visiting Anganwadi Centres and PHCs, the latter is meant for married women or severe ailments, they added.
ASHAs themselves acknowledged that they hardly ever interact with unmarried girls.
The National ARSH strategy also mandated training of ASHAs to interact with unmarried adolescent females in order to capitalise on the success of their access to the community. This goal, however, remains unfulfilled. In cases where ASHAs have been trained to address adolescent SRH needs, their focus in practice has remained on facilitating the incentive system based institutional delivery scheme for married women or facilitating female sterilization (Planning Commission 2011; Santhya et al 2011). During our field work, ASHAs themselves acknowledged that they hardly ever interact with unmarried girls, except when the latter themselves approach them during VHSND (Village Health Sanitation and Nutrition days), most often with issues related to irregular menstruation.
Policy efforts have not been accompanied with infrastructural support, adequate trainings of frontline workers and awareness generation among the community. ASHAs, ANMs and Staff nurses have in most cases received very rudimentary training and sensitisation on adolescent SRH, their needs and unique challenges with regard to imparting information to adolescents and mitigating their own inhibitions (Santhya et al 2014).
Rashtriya Kishor Swasthya Karyakarm (RKSK), one of the recent government programs aimed at improving ARSH seeks to address some of these challenges, and builds upon the National Adolescent Health Strategy released by Government of India in 2013. RKSK seeks to further strengthen ASHAs and mobilise community leaders such as peer educators to raise awareness and access to contraceptives and reproductive health supplies such as sanitary napkins within the community. It seeks to strengthen and extend AFHCs, by setting up daily AFHC at Community Health Centre level and weekly AFHC at PHC level and complementing it with referral services. While these two components are a continuation of the earlier policy, and need improvement in terms of implementation, the operational framework of RKSK focuses on overall health and well-being of adolescents including nutrition, SRH, menstrual hygiene management, mental health, violence and substance abuse by converging various stakeholders.
Rashtriya Kishor Swasthya Karyakarm (RKSK), one of the recent government programs aimed at improving ARSH seeks to address some of these challenges, and builds upon the National Adolescent Health Strategy released by Government of India in 2013.
An ambitious and well-intentioned scheme, RKSK's biggest challenge remains implementation in terms of awareness generation, community mobilisation and uptake, successful convergence, sensitised and tailored trainings of frontline workers and peer educators, and timely and appropriate infrastructural and resource availability and support. While RKSK focuses on overall well-being of adolescents, in the absence of a supporting environment with alternative life-choices, decision making autonomy and capacity building to enable adolescent women to lead a fruitful life if they delay marriage and pregnancy, its aims will remain severely curtailed.
The aim to achieve overall development of adolescents should not mask more specific and severe challenges existing in the countryside: underage brides, adolescent pregnancies, social pressures to conceive which conflict with ARSH messaging, and absence of awareness and sensitisation among married and unmarried young men to name a few. It is important to converge policies on ARSH with life skill training, awareness generation, and behavior change campaigns in the absence of which young women will have little option.
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