Establishing Urban Primary Facilities as Adolescent-Friendly Health Clinics to Meet the Health Needs of Adolescents and Youth
Purpose: This tool is a guide on establishing urban primary health facilities as adolescent-friendly health clinics (AFHCs) to provide accessible, equitable, comprehensive and high-quality health services, including sexual reproductive health (SRH) services, to adolescents and youth (AY). This tool codifies the learnings from layering of adolescent-friendly services to urban primary health centers’ (UPHCs’) service offerings.
Audience:
- Additional Director/Joint Director/Divisional Program Manager
- General Manager (GM)/Deputy GM, Rashtriya Kishor Swasthya Karyakram (RKSK)
- Chief Medical Officers (CMO)
- Divisional Urban Health Consultant
- District RKSK Consultant
- RKSK Nodal Officers/Managers
- Nodal Officers - Urban Health, Family Planning, National Urban Health Mission (NUHM)
- Urban Health Coordinator/Assistant Program Manager, NUHM
- Medical Superintendent of Urban Community Health Centres
- Medical Officer-In-Charge (MoIC) and Staff Nurse of UPHC
- District RKSK Counsellor
Background: Adolescents are stereotypically perceived as the healthiest population and often marginalized from mainstream healthcare services. An increase in the age of marriage coupled with the fact that the age at first sex has remained unchanged means that India now has a large and increasing cohort of unmarried sexually active adolescents, with low access to sexual and reproductive health services. Close to 20% of adolescents live in urban slums and are one of the more vulnerable populations within the target group of all adolescents between the ages of 10 and 19 years.
While analyzing the health management information system (HMIS) data on service delivery, it is evident that the common problem faced by most health facilities in India is the underutilization of health services by adolescents due to many reasons, such as lack of knowledge on the part of adolescents; legal, cultural and logistical barriers; high costs; and most prominently, poor quality of clinical services and unwelcoming facility environment. The recognition that adolescents have specific health needs and face various barriers in seeking and receiving healthcare has led the Rashtriya Kishore Swath Karyikram (RKSK), Government of India’s flagship program on adolescent health, to introduce criteria for initiating adolescent-friendly health services (AFHS) in both primary and higher-order facilities. As per RKSK’s mandate, AFHS are delivered through trained MoIC, ANM and counselors located at Primary Health Centers, Community Health Centers, District Hospitals and Medical Colleges.
In urban areas, AFHCs were nestled in higher-order facilities, which are well-equipped with a multidisciplinary team, more staff available than other facilities and a dedicated adolescent counsellor. However, the distance and crowding of these sites from the slums often limit young adolescent girls and boys from accessing the services. Adolescent services must be made accessible, closer to the area where this vulnerable population lives and works, specifically primary health care facilities in urban areas should offer AFHS.
Evidence of Impact
Data reported in the Government of India’s HMIS portal for adolescent-friendly health services revealed increased footfall (i.e., adolescent clients availing services) for the three-year period among the 96 UPHCs in the five TCI-supported cities of Uttar Pradesh, where UPHCs had started offering adolescent-friendly services with TCI’s coaching support. The footfalls were examined using three different indicators—number of adolescents registered, number received counseling and number received clinical services captured separately for adolescent boys and girls. With AFHS being offered at UPHCs, there is a marked improvement in the adolescent health services data being recorded and uploaded from the 96 UPHCs into the HMIS from the five demonstration cities (Firozabad, Varanasi, Gorakhpur, Allahabad, and Saharanpur). This reporting of adolescent health services in HMIS started in July 2018. Before the start of the program implementation among unmarried adolescents, only 43 boys and 319 girls were registered for AFHS in the five demonstration cities. However, the number of adolescents registered greatly improved during the program implementation period. A total of 6,369 boys and 10,059 girls were registered for AFHS in the first year of implementation, i.e., from April 2019 to March 2020. This further increased by 7% (6,788 boys) and 19% (11,970 girls) in the second year of implementation from April 2020 to March 2021. Out of the total registered, 94.5% of boys and 92.2% of girls reported having received clinical services. Data also reflected an increase in adolescents seeking counseling services (89% out of total 18,758 adolescent registrants).
Later, TCI supported government in scaling AFHS to 238 UPHCs in 10 additional cities of Uttar Pradesh. The number of adolescents visiting the UPHCs across the 10 additional cities and registering themselves for services increased by 288% from 5,240 in April-September 2020 to 20,307 registrations in April-September 2021 according to HMIS data. Among the 20,307 registered adolescents, 89% voluntarily sought counselling services on nutrition, SRH and hygiene, while 91% of them also availed clinical services, for example , haemoglobin and body mass index (BMI) screenings and/or availed iron and folic acid supplements (WIFS) and albendazole pills. The evidence from these 15 cities provided a chronology of steps, which could transform an UPHC into a adolescent-friendly health clinic. The guidance steps are listed below.
Guidance on Establishing Urban Primary Health Centers as AFHCs
The following steps lead to transforming UPHCs into AFHCs and increasing AY access and utilization of health/SRH services:
Select ready-to-start UPHCs for layering AFHS
To demonstrate, initially RKSK and CMO/NUHM team identifies ready-to-start UPHCs, where adolescent services can be quickly layered on. These selected facilities are equipped with essential human resources, commodities and equipment to provide AY services in an appealing and friendly manner. The visiting area or outpatient department (OPD) is made lively by displaying available posters from RKSK or getting the walls painted with RKSK messages. The infrastructure should be clean, bright and must have a private space for counselling AYs. Also, these points pertaining to adolescent services should be reflected in the citizen charter of the UPHC. The following steps equips a UPHC for layering AFHS:
- Capacity Building of Service Providers to offer AY-friendly services
From each of the selected UPHCs, at least one clinical service provider, i.e., MoIC and/or staff nurse, should be trained on AY services so that they impart quality counselling and preventive services on the six RKSK’s domains, ranging from sexual and reproductive health (SRH) to nutrition, substance abuse, injuries and violence (including gender-based violence), non-communicable diseases and mental health, and encourage future health seeking behavior among AYs visiting the facilities. The training of MoIC and staff nurse is conducted by a certified RKSK trainer and RKSK counsellor from the district hospital on RKSK’s AFHS module for medical officer and counsellor. The training focuses on building competencies of service providers to communicate with AYs on SRH issues in a non-judgmental and friendly manner and providing the full range of contraceptive options regardless of their age/marital status, while maintaining privacy and confidentiality.
- Whole-site Orientation (WSO) of UPHC staff on AFHS
WSO for AFHS is an effective approach to assure AY’s right to information, privacy, confidentiality, respect, non-discrimination and non-judgmental attitude. The coached MoICs/staff nurse and RKSK team facilitate WSO to equip all UPHC staff with AFHS knowledge and tools, negate their biases and misconceptions, orient them on the barriers and SRH needs of unmarried AYs. Irrespective of cadre, the entire clinical and non-clinical staff of UPHC is sensitized through WSO sessions. This includes staff from all levels, including the staff nurse, lady health visitor (LHV), lab technician, pharmacist, auxiliary nurse midwife (ANM), accredited social health activist (ASHA), data entry operators, ward boy, support staff, etc. The WSO sessions should be conducted at the UPHC itself to ensure no disruption in services. RKSK’s interactive game, Kranti Bhranti, and TCI developed WSO slides can be utilized during WSO sessions.
- Ensure Provision of Supplies & Equipment
A wide range of adolescent-friendly commodities must be ensured. This includes albendazole pills, WIFS, multivitamin tablets and sanitary pads along with supplies required for contraceptive services, like oral contraceptive pills, emergency contraceptive pills, condoms and pregnancy test kits. The equipment required for screening tests are blood test machine, stethoscope, BP machine, weighing machine and BMI chart. The RKSK team can utilize city coordination committee (CCC) platform for arranging WIFS and albendazole pills with the support of RKSK nodal or any development partner working on AY issues.
Designate Facility Adolescent Health Day (F-AHD)
After the AFHS training of service providers, WSO of UPHC staff and arranging for adolescent-friendly commodities, city officials, including RKSK nodal officer and CMO, should be coached to release all necessary directives related to organizing monthly F-AHD at equipped UPHCs. Meanwhile, the following key steps ensure a successful F-AHD.
- Pre-Facility Adolescent Health Days
Coordination with relevant departments: The CCC platform is utilized to converge with stakeholders from other departments, such as RKSK manager and coordinator, district RKSK counsellor and doctor, Integrated Child Development Services (ICDS) department, Education Department (Basic Shiksha Adhikari), National Urban Livelihoods Mission (NULM), elected representative of the municipal ward, local youth-based non-governmental organizations (NGOs), and youth champions, to jointly plan for effective F-AHDs. Liaising is required in advance of these CCC meetings and during the meeting, each department is assigned specified tasks to ensure effective use of resources and accountability. The decision regarding the timing of F-AHD is critical as it should be feasible for the AY population in that area. For example, the morning time is reserved for school/college for most of the AY population and, thus, a UPHC should consider providing AY services post-lunch time.
- Event Day
- Setting up kiosks: This includes setting up five types of spaces/ kiosks at the UPHC: a) Space for registration; b) Separate counselling corner/space for boys and girls with audio-visual privacy; c) Mobile pathology space for screening tests; d) Game/IEC zone, having interactive tools and all six thematic posters of RKSK (nutrition, substance abuse, mental health, gender based violence, SRH and non-communicable disease); and e) Nutrition corner, displaying specimens of locally available low-cost, nutritious grains/fruits/vegetables to create awareness of healthy and balanced diet.
- Execution of AY-friendly tools: This is a crucial step to break the ice between service providers and AYs. Tools serve as hooks to connect participants with the decided topic and establish an open and comfortable environment to discuss the desired subject matter. The tools/job aids developed by RKSK and development partners must utilized. For instance, tools developed under the TCI initiative were adopted by RKSK. These include:
Tool 1 shows safety tools that build recognition of the risk of unprotected sex and unwanted pregnancy and the availability of contraception as safety tool. Tool 2 is an emergency preparedness game that highlights the availability of the emergency contraceptive (EC) pill as a tool for preventing pregnancy in the event of unprotected sex. Tool 3 is a flipbook with a story that builds recognition of the importance of consent in a sexual relationship and self-efficacy to negotiate on contraceptive usage. Tool 4 is a contraception "match the cards" game with messaging on different methods of contraception and their availability.
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- Talk show with trained service provider: The talk show with the AFHS-trained MoIC/staff nurse inculcates candidness and confidence among AYs to clear their doubts on SRH issues (e.g., puberty, mensuration, sex, physical changes, etc.), mental health, violence, abuse, etc.
- Service delivery: Ensure each participating AY is screened for haemoglobin and BMI, receives sanitary pads, WIFS and albendazole pills and voluntary counselling services are offered to them. Privacy should be maintained by dedicating a place for counselling or establishing a counselling corner using curtains. In cases requiring further investigation and treatment, referrals should be made to appropriate higher order facilities/speciality clinics.
- Record keeping: UPHCs must keep a proper record of registered participants, counselling and screening services provided, and commodities distributed in the AFHC reporting formats (), developed by RKSK. MoICs must validate the data required to be reported on the HMIS portal and ensure complete and timely reporting of the same by a person designated to do so at the UPHC.
Coach and mentor ANM for strengthening demand generation activities
Once F-AHD is ready to be initiated, efforts should be made to create buzz for F-AHD and aggregate demand for AY services provided on F-AHD days and otherwise at the now adolescent-friendly UPHCs. Community-AHD (C-AHD), a group activity (ideally 25 participants in a group) conducted in slums for girls and boys, respectively drives AYs to avail these services.The district RKSK Counsellor/doctor, RKSK Nodal Officer and MoIC coach and mentor ANMs on facilitating C-AHD sessions. This coaching covers aspects on how to encourage discussion on SRH issues with the use of interactive games and how to devise a priority list of unmarried AY population. The trained ANMs coach ASHAs on updating the ‘adolescent survey section’ in urban health index register (UHIR)/ASHA diary, who devise a priority list of 15-19 years unmarried girls and boys from their survey records. The ASHA with the support of Anganwadi Workers (AWWs) of ICDS invite adolescents for C-AHD by keeping parents and guardians in loop. These field-level workers propagate about F-AHD in their door-to-door visits and during group meetings.
Prior to or on the day of C-AHD, the ANM also interacts with parents and guardians and make them aware about the contents of the C-AHD sessions and encourage them to let their wards participate in these sessions and further avail desired health services from the UPHC.
Continuous quality improvement to make UPHC a preferred place for AY population
Ensure facility assessment of UPHCs is part of government’s periodic evaluation so as to ensure continuous quality improvement. The facilities must be assessed biannually using . It helps to measure characteristics of facilities, service providers and the status of AY program. Based on assessment findings, an action plan should guide the UPHC to make improvements.
Roles and Responsibilities
Monitoring & Evaluation
The CMO, state and district officials of RKSK, NUHM officials and DQAC members while visiting UPHCs must monitor and evaluate service provisions for adolescents. The AY data of UPHCs can be monitored as a regular agenda item for discussion in the district and divisional level meetings and monthly meetings of MoICs convened by CMOs. The following indicators should be reviewed:
- Number of UPHCs established and functional as AFHCs
- Number of Medical Officers (MOs) and staff nurses of UPHCs trained on AFHS
- Carder wise number of UPHC’s clinical and non-clinical staff trained through AFHS WSO
- Number of ANMs trained on executing C-AHD
- Number of C-AHD organized by ANMs
- Number of F-AHD organized by UPHCs
- Number of girls and boys participated in UPHC’s F-AHDs (refer HMIS section- 12.1.1.a and 12.1.1.b girls and boys registered in AFHC)
- Percentage of girls and boys received clinical services out of the total number of registration (refer HMIS section- 12.1.2.a and 12.1.2.b girls and boys received clinical services out of total number registered in AFHC)
- Percentage of girls and boys received counselling services out of the total number of registration (refer HMIS section- 12.1.3.a and 12.1.3.b girls and boys received counselling services out of total number registered in AFHC)
Cost Elements
The elements required for ‘establishing UPHCs as AFHCs’ are mentioned in the table along with their PIP codes for easy reference. They may be covered under existing budget line items, but if not, they should be incorporated through the PIP in the next cycle. Besides, any additional support can also be sought from the flexi-pool.
Source: Approved activity under RKSK guideline FY 2019-2020
*Note: The table above is indicative and illustrates the manner in which cost elements are provided in a government PIP, thus giving guidance on where to look for elements related to a particular task.
Sustainability
This approach can be sustained by ensuring trained and sensitized providers of UPHCs provide AFHS to AYs, irrespective of their age, gender and marital status. Moreover, the rising demand among unmarried AYs for health/SRH services will indicate sustenance of this approach.
Also, analyze and present the AY data in national and state level meetings and advocate for provisioning adequate funds in Program Implementation Plan (PIP) for urban adolescent program. Apart from the data review, ensuring facility assessment of UPHCs as part of government’s periodic evaluation ensure continuous quality improvement and ensures sustenance of these services.
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Government of India Resources
RKSK Training Materials
- RKSK Facilitators Guide for Medical Officer
- RKSK Facilitators Guide for Counsellor
- RKSK Facilitators Guide for ANM & LHV
- RKSK Resource Book for Medical Officer
- RKSK Resource Book for Counsellor
- RKSK Resource Book for ANM & LHV
- RKSK Kranti Bhranti -Interactive Game
TCI Interactive Tools Adopted by RKSK
- Tool 1
- Safety Game
- Safety Games Cards
Boys | Girls
- Tool 2
- Tool 3
- Tool 4
Other Materials
- RKSK’s IEC/BCC Material
- RKSK Games
- RKSK Flash cards
- RKSK Wall painting
- RKSK Hoarding
- RKSK Poster and leaflet
- Advocacy booklet
- RKSK Video and Audio
- Manual and Formats for AFHS
- RKSK AFHS Register
- RAFHS Reporting Format
- RKSK AFHC Checklist
- TCI AFHS WSO Presentation
- TCI Poster on COVID guidelines for RKSK
Other India Program Areas
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