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12-15 Feb 08 Bali: India Presentation 1
IndiaMinistry of Health and Family Welfare
Adolescent Reproductive and Sexual Health Strategy under RCH Programme
Implementation of approved standards
12-15 Feb 08 Bali: India Presentation 2
INDIA AT A GLANCE
AREA=3,287,240 SQ KMRURAL %=94.86
No. of States/UTs: 35No. OF DISTRICTS=609
No. OF VILLAGES=638588Population Density=312
12-15 Feb 08 Bali: India Presentation 3
Pri
mar
y H
ealt
h C
are
Sys
tem
In In
dia
CHC3346
30 BeddedReferral Unit
For 4 PHC2.21 lakh population
4 Spl. & 21 staff
PRIMARY HEALTH CENTRE (PHC)
23236A Referral care unit for 6 S.C.
4-6 beds 1 Medical Officer and
14 support staff31954 population
SUB CENTRE 146026 units
Most Peripheral Contact Point Aux. Nurse Midwife
MPW (Male)
Community Health Centers
12-15 Feb 08 Bali: India Presentation 4
Health systemS.C. 146026
PHC 23236
CHC 3346
ANM 133194
H.W. (M) 61907
HA (M) 20181
LHV 17371
NURSE MIDWIFE 28930
DOCTORS AT PHC 20308
OB AND GYN AT CHC 1215
PHYSICIAN AT CHC 884
PEDIATRICIAN AT CHC 678
SURGEONS AT CHC 1201
12-15 Feb 08 Bali: India Presentation 5
Reproductive and Child Health Program (RCH II) – Adolescent Reproductive and
Sexual Health (ARSH) StrategyOverall 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
12-15 Feb 08 Bali: India Presentation 6
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
12-15 Feb 08 Bali: India Presentation 7
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
12-15 Feb 08 Bali: India Presentation 8
Launch of National Standards and Training Package
• Launched by Secretary, Health on 9 May 2006
• Dissemination to State programme managers, CBOs, NGOs, Professionals….
12-15 Feb 08 Bali: India Presentation 9
Standard 1: Service PackageLevel of
CareService Provider
When Services
Sub-centre (SC)
•ANM During routine sub-center clinics
•Information & Provision of contraceptives Enroll newly married couples for ANC care and institutional delivery•Referrals: Complicated pregnancy, safe abortion, PPTCT, ART•RTI/STI/HIV prevention education •Nutrition counseling, anemia prevention and treatment•T.T. immunization
Primary Health Centre
Community Health Centre (CHC)
•Health Assistant (F)/LHV•Medical Officer
During Routine Hours
Once a week Teen Clinic will be organized for 2 hrs
•Information & Provision of contraceptives•Management of menstrual disorders•RTI/STI/HIV preventive education and management•Counselling and services for pregnancy termination•Nutritional counseling, anemia prevention and treatment•Counselling for sexual problems•T.T. immunization
12-15 Feb 08 Bali: India Presentation 10
Implementing approved national standards
Regional Workshops: Covered 28 states so far Objectives:
• Orientation of the state managers to National ARSH Strategy and Operational Guidelines
• Sharing the steps in implementation of providing good quality adolescent-friendly health services as proposed in the ‘Implementation Guide’
• Understand the stakes and role of the health sector in promoting Inter-sectoral collaboration
• Review / draft State implementation Plan for ARSH and developing an action plan for operationalization of adolescent friendly health services
12-15 Feb 08 Bali: India Presentation 11
Planning Matrix 1: Service PackageIn reference to the Menu of Services detailed in the
Implementation Guide
Level / Providers
Essential Package (As given in the
Implementation Guide, P 11-17)
Proposed State SpecificAdditions, if any
Remarks / Reasons
District Hospital, Medical College
1.2.3.
CHC 1.2.3.
PHC 1.2.3.
Sub-Center 1.2.3.
Whether plan to involve:•Private providers: YES / NO•NGOs: YES / NO
12-15 Feb 08 Bali: India Presentation 12
Regional WorkshopsOutcomes
• Better understanding of the strategy, approved standards and operational guidelines
• Realize the importance of demand generation for the proposed services and promoting inter-sectoral co-ordination
• Decided to implement ARSH in only a few (2-5) districts in the first phase
Better Quality of Plans for implementation
12-15 Feb 08 Bali: India Presentation 13
Standard 4: Training Package
12-15 Feb 08 Bali: India Presentation 14
Training of Health ProvidersNational level Training:• Five batches completed: 125 Trainers
availableState level Trainings:• Goa,Maharashtra, Rajasthan, Madhya
Pradesh, OrissaInvolving private sector through professional
associations: IAP, FOGSI– Contribution in capacity building of
healthcare providers– Provision of adolescent friendly health
services from private clinics (Public Private Mix)
Distance education (IGNOU): Strengthen adolescent health component in existing PG Diploma in Maternal & Child Health
12-15 Feb 08 Bali: India Presentation 15
Standard 2, 5, 6Developing IEC Material on
Adolescent Issues
• Wall posters
• Pamphlets
• Media messages
12-15 Feb 08 Bali: India Presentation 16
Monitoring & Evaluation (Standard 7)
• Incorporating ARSH in routine MIS• Incorporating ‘M & E Guide’ Indicators in
National AIDS Control Program• Piloting tools for assessment of cost and
quality of services: Pilot completed at three adolescent friendly sites
National / Sub-national Surveys• Secondary analysis of national survey data
Obtaining age disaggregating data from National Family Health Survey and District Level Household Survey: 15-19 years and 20-24 years
• YP Behaviour survey: 6 States
12-15 Feb 08 Bali: India Presentation 17
Facilitating factors• Supportive policy environment: National
Population Policy, National Youth Policy, Recognition of rights of young people in RCH programme
• Infrastructure strengthening: National Rural Health Mission
Hindrances• Competing priorities• Variable system capacity at state and district
level
12-15 Feb 08 Bali: India Presentation 18
Lessons• Participatory process: Involve all key stakeholders /
sectors:– Consensus building among stakeholders– Ownership– Take cultural sensitivity into account– Partnership in implementation
• Assess local needs and system’s capacity• Provide handholding for down stream facilitation of
implementation:– New programme: Closer monitoring is needed– Supportive supervision – problem solving
12-15 Feb 08 Bali: India Presentation 19
Supporting District Level Implementation
12-15 Feb 08 Bali: India Presentation 20
Implementation at district level
• Identification of districts for implementation in the first phase
• Orientation of district managers in state planning meetings
• Facilitation of developing district action plans to implement services under ARSH
12-15 Feb 08 Bali: India Presentation 21
District level training plan• State level training of trainers by
national facilitators
• District level trainings by state trainers supported by at least one national trainer
• Translation and printing of Health Worker (ANM) OP
• Monitoring quality of training
12-15 Feb 08 Bali: India Presentation 22
Plan for State TOT: For training State level Facilitators: One batch=24, Duration: 4 days
Venue: State HQ, State training Instt
Facilitators: 4 from National PoolParticipants (Prospective State Level Facilitators): Desirable attributes:1. Interested in training and committed to do subsequent trainings2. Positive attitude towards adolescents / young people3. Experience of working with adolescents (May have to look at NGOs active in the field of providing adolescent services)4. Good communication skills‘ and Flair for training’5. Pediatrician, Physicians, Obstetrician to strengthen technical elementsProposed Dates: 1. 2. 3.
Plan for District level Trainings for MOs and ANMsDuration: MOs: 3 Days, Others: 5 Days,
Venue: Distt Training Centers
Personnel to be trained:Number of personnel to be trained at all identified SDPs (Consult SDP Matrix - 2)
M O ANMs, LHVs, PHNs, S/N (i)
MPW-M, BEE(ii)
Counselors(iii)
Other Staff(iv)
Numbers
No of Batches (of 24): Total Numbers (i + ii + iii + iv):No of Batches (of 24 each):
Training Calendar:
District MOs: Dates Others: Dates
1.
Monitor Quality of Training:
Follow up after training: (indicative)1. Self assessment of competence and comfort: (Checklist): After 3 months and after 6 months: Problem identification and solution: Supervisory Visits: Every 6 months:
12-15 Feb 08 Bali: India Presentation 23
Support for Implementation of approved standards
• State MOH and District management
• Mentoring:– NGOs: Haryana– Medical College: West Bengal– Development partners/Donors
• WHO: – Technical assistance: planning matrices– Financial assistance for piloting
12-15 Feb 08 Bali: India Presentation 24
Quality Assurance Manual(Under development)
• Process: problem solving• Manual and tools / checklists• Field test• Institutionalization within the
public health system
12-15 Feb 08 Bali: India Presentation 25
Operationalization of AFHS using ARSH Implementation Guide
Pilots supported in 2 rural districts• Haryana: Ambala
• West Bengal: Midnapur
Objectives:• Gaining experience from the ground
• Promote local innovations
• To demonstrate ‘do-ability’
12-15 Feb 08 Bali: India Presentation 26
Objectives a) Increasing the use of services
through awareness generation
b) Improving the quality of services rendered at multiple facilities using RCH-ARSH Implementation Guide
12-15 Feb 08 Bali: India Presentation 27
Baseline assessment of health facilities
11 PHCs, 8 private facilities,16 sub-centers and 62 AWW centers
In more than 90% facilities mapped,• No provider trained in AFHS, no training
material available• Supplies (IFA, contraceptives) available but
not provided to adolescents • No provisions for privacy and confidentiality• Records available but no disaggregated data • No special clinics for adolescents
12-15 Feb 08 Bali: India Presentation 28
Description of the selected location
• Covers 2 PHCs and 16 subcenters and 72 villages with about 70,000 population in district Ambala, Haryana
• Project implemented within the scope of national and state policy framework (RCH-ARSH)
• Used locally applicable innovations
• Duration 1 year
12-15 Feb 08 Bali: India Presentation 29
Interventions and innovations • Capacity development through a model
of ongoing training – staggered, modular training
• Reaching the un-reached adolescents through peer educators and providers from other sectors (AWW)
• Branding of AFHS • Assessment of outputs • Review of lessons learnt and challenges
ahead
12-15 Feb 08 Bali: India Presentation 30
AFHS Packaging and Branding
I Card for a ‘Friendly Provider’Logo for the Clinic
12-15 Feb 08 Bali: India Presentation 31
Criteria for designating a facility as adolescent friendly
• At least one provider trained on AFHS• Training material and IEC material available
in the facility • Display of signboard indicating that AFHS
norms are being practiced• Clinic held regularly at least once a week for
adolescents • Supplies are available and adolescents are
given the supplies according to needs• Records are maintained (age and sex
disaggregated)
12-15 Feb 08 Bali: India Presentation 32
AFHS-Use of services S.No. Health Center April-June
2006April-June
2007
1. PHC Shahzadpur 164 289
2. PHC Patreri 152 234
3. SC Banondi 37 140
4. SC Patreri 70 270
5. SC Bari Bassi 52 285
6. SC Pilkhani 47 297
7. SC Korwa Khurd 33 275
Total 555 1790
12-15 Feb 08 Bali: India Presentation 33
Reasons for increased utilization of services by adolescents
• Increased capacity of providers and supportive attitudes of staff
• Awareness generation by PGEs, AWWs and ANMs
• An enabling environment relating to AFHS• Referral by PGEs, AWWs, ANMs• Availability of services e.g TT, IFA,
contraceptives • Provision of AFHS through ‘Special clinics’
12-15 Feb 08 Bali: India Presentation 34
AFHS- Peer Group Educators
December 2006-August 2007
Total: 68
Active: 50
Males: 16
Females: 34
Total number of adolescents who contacted PGEs for problems and concerns 1507
12-15 Feb 08 Bali: India Presentation 35
Problems and concerns reported to PGEs
Body image (Pimples, Hair, circles): 310
Menstrual (Pain, excess, scant, nil): 253
Psycho social concerns: 191(tension, frustration, school, financial…)
Nutrition (Anaemia, Height, Weight): 172
Sexual (Nightfall, Masturbation, vaginal: 129
discharge)
General health and others: 442
12-15 Feb 08 Bali: India Presentation 36
Challenges ahead • Sustaining training, capacity development
and motivation of providers• Increased collaboration within health sector-
RCH, HIV/AIDS, Nutrition• Inter-sectoral collaboration- education,
women and child development, youth groups, village health and sanitation committees
• Sustaining PGEs, especially males • Un-interrupted adolescent-specific supplies • Age and sex disaggregated data in routine
MIS
12-15 Feb 08 Bali: India Presentation 37
So Far……• Supportive Policies:
– Adolescent Health & Development Strategy under RCH-II– National Standards and Guidelines: ‘Implementation Guide’– Support States in Planning for Implementation
• Strategic Information: – Using existing mechanisms and available data– Monitoring: Quality, Coverage and Cost assessment– QA Process: under development
• Adolescent Friendly Services:– Capacity Building of providers– IEC Materials– Demonstration models in districts
• Strengthening other Sectors:– HIV/AIDS and Young People initiative– Deptt. of Women and Child Development, Youth, Education
12-15 Feb 08 Bali: India Presentation 38
THANK YOU
