Advances in Applied Sociology
2012. Vol.2, No.4, 320-324
Published Online December 2012 in SciRes (http://www.SciRP.org/journal/aasoci) http://dx.doi.org/10.4236/aasoci.2012.24042
Copyright © 2012 SciRes . 320
Adolescent Health in India: Still at Crossroads
Mona Gupta1, K. V. Ramani2, Werner Soor s3
1MSG Strategic Consulting, New Delhi, Indi a
2Indian Institute of Management, Ahmedabad, India
3Prince Leopold Institute of Tropica l Medicine, A n twerp, Belgium
Email: mona . hrd @gmail. com; rama ni@ii mahd.ernet.in; email@example.com
Received August 16th, 2012; revised Septembe r 18th, 2012; accepted Septem ber 30th, 2012
Internationally, Adolescent Reproductive and Sexual Health (ARSH) has become a priority programme
approach to help the future generations have a safe, healthy and satisfactory life. India is yet to develop a
comprehensive policy on ARSH mainly due to lack of inter-ministerial collaboration, socio-cultural and
politico-religious factors, even though evidence from surveys and non- governmental organization pro-
jects has corroborated the case for ARSH since late 1980s. Fortunately, recent evidence provided by
Sample Registration Survey (SRS) 1999, Census 2001, National Family Health Survey (NFHS)-II and
District Level Household Survey (DLHS) 2004 particularly on early marriage, teen pregnancy, anaemia
and unmet need for contraception has led GoI to recognize the importance of adolescent health. However,
a comprehensive ARSH policy is yet to emerge, since components of adolescent health are being ad-
dressed by separate ministries and departments. Adolescent health in India is still in an infant stage and at
the risk of infanticide. From “health for the adolescents” to “health with the adolescents”, it is still a long
way to go.
Keywords: Adolescents; Reproductive and Sexual Health; Policy; Qualitative Study; Intersectoral
Adolescents have always remained in a dilemma, as they are
neither considered children nor adults. A similar fate seems to
follow the development of a comprehensive policy on Adoles-
cent Reproductive and Sexual Health (ARSH) in India mainly
due to lack of inter-ministerial collaboration, socio-cultural and
politico-religious factors. India has about 230 million adolescents
in the age group 10 - 19 years, with females comprising about 47%
of the total adolescent population (GoI, 2001). It is this adolescent
population which will enter the workforce in the next 5 - 15 years,
and play a vital role in India’s socio-economic development.
Internationally, ARSH1 has become a priority programme
approach to help the future generations have a safe, healthy and
satisfactory life. In this paper2, we briefly trace the history of
ARSH in India to understand its present situation and deliberate
on problems coming in way of a comprehensive ARSH policy.
It builds upon research undertaken on ARSH in India through-
out the HEPVIC (Health Policy-making in Vietnam, India and
China) project between 2006 and 2009. This research project3
explored the nature of health policy process and more specifi-
cally how the policy processes used evidence, handled the con-
sideration and integration of different policy aspects, and in-
volved a range of different actors4. Three case studies were
selected from each country to understand the policy process in
maternal health. The case studies in India focused on skilled
birth attendance, medical termination of pregnancy (abortion)
and ARSH. Within the wider HEPVIC scope, we report here on
the Indian case study on ARSH and focus on the contribution
(or lack of it) of actors in the policy process5.
4The HEPVIC study conceived policy processes as “the formal and infor-
mal mechanisms through which policies are developed (policy development
and its subsequent implementation (policy implementation)”, and actors as
“individuals or institutions who are associated with, and either involved or
not involved in, policy processes”.
5This study, the main data were collected through in-depth interviews with
key stakeholders. Non-random, purposive sampling and snowballing was
used to select respondents. Separate open-ended questionnaires were de-
veloped for each group of respondents, e.g. government policy-makers and
civil society representatives. During the interview, care was taken to ensure
that respondents were able to speak freely on topics/issues not covered by
the questionnaire but what they thought to be relevant. All interviews were
conducted between March 2007 and October 2008. Out of a total of 34
interviews, 9 were exclusively for the ARSH case study. Politicians though
very impor tant actor cou ld not be int erviewed becaus e of sensitiv ity issues.
All interviews but one were audio recorded with informant’s consent and
transcribed verbatim. One respondent did not permit recording of the inter-
view so extensive notes were taken. Each interview lasted between 45-120
minutes. Secondary data were obtained from literature. NVivo 7.0 was used
as primary aid to organize, index, chart and map the data. After a first round
of interviews, triangulation and analysis, preliminary study results were
resented in a participatory stakeholder workshop (International Workshop
on Maternal Health Policy Process, IIMA, 25-26 October 2007) to allow
feedback from the stakeholders. A second round of interviews and analysis
concluded in the presentation and discussion of the final study results in
another Stakeholder s ’ Wo rkshop (I IMA, 18 Febr uary 2009).
1Internationally, Adolescent Sexual and Reproductive Health (ASRH) is
more widely accep ted ter m. I n a r ig hts -bas ed p ersp ecti ve, “ sex ual heal th ”is
more comprehensive and thus precedes “reproductive health”. In India
however, Adolescent Reproductive and Sexual Health (ARSH) was used
for a long time. Since 2011, GoI has started using the term adolescent
health whic h i n cludes ARSH, school health, mens t ru al hygiene and others.
2This paper briefs on core findings from the study done in India on ARSH
as a part of the HEPVIC (Health Policy-making in Vietnam, India and
China) research project supported by the European CommunitySixth
Framework Programme (INCO-CT- 2005-517746).
3The HEPVIC project involved a consortium of eight partners: University
of Leeds, UK (coordinator); Hanoi School of Public Health, Vietnam;
Indian Institute of Management Ahmedabad (IIMA), India; Fudan Univer-
sity, China; Liverpool School of Tropical Medicine, UK; Prince Leopold
Institute of Tropical Medicine (ITM), Belgium; Royal Tropical Institute,
etherlands; and University of Bologna, Italy. This study was carried out
by IIMA in association with ITM.
M. GUPTA ET AL.
ARSH Policy Process: A Brief History
In India, evidence from surveys and Non Governmental Or-
ganization (NGO) projects has corroborated the case for ARSH
since the late 1980s6. The reports of some of their studies sug-
gest that communities must be involved if gains are to be made
in changing the social norms that discourage youth from ac-
cessing the reproductive and sexual health information they
need (Pande, 2006). Though ARSH at that time had been ac-
cepted in many countries as an important intervention, it started
getting some attention from the Government of India (GoI)
only after the International Conference on Population and De-
velopment (ICPD) in 1994. ICPD emphasized the need to focus
on the reproductive health needs of adolescents as a separate
group (RFSU, 2004).
As a signatory to the ICPD declaration, the Government of
India initiated the development of an ARSH policy. While the
RCH-I (Reproductive and Child Health) Program (1998-2004)
did not make any direct mention of adolescent health needs in
the objectives or beneficiaries, NACP II (National AIDS Con-
trol Program II, 1999-2006) took the challenge seriously and
introduced the School AIDS Education Programme (SAEP) in
the 9th and 11th grades on a voluntary basis throughout India.
Less explicit mention of adolescents was also because RCH-I
was mainly concerned with structures and institutional capaci-
ties that would be utilized in RCH-II (2005-2010), where a
specific focus on adolescent health was planned (UN 2008). As
the overarching National health goals are to attain significant
decline in the TFR, MMR, and IMR, and efforts are on to limit
the HIV spread, reproductive and sexual health became the
entry point of adolescent health also. The RCH-II Program
recognized ARSH as one among the four strategies (besides
Maternal Health, Child Health, and Family Planning) to reduce
MMR, IMR and TFR.
Evidence provided by SRS 1999, Census 2001, NFHS-II and
DLHS-RCH 2004 particularly on early marriage, teen preg-
nancy, anaemia and unmet need for contraception led GoI to
recognize the importance of adolescent health. In India, more
than 50% of the illiterate girls get married before they reach the
legal age of 18 years (ibid). Nearly 27% of married female
adolescents have reported an unmet need for contraception
(MoHFW, 2006). Projections estimated significant increase in
adolescent pregnancies and births. In 2000 there were an esti-
mated 20.2 million adolescent pregnancies which was projected
to increase in subsequent years (Gupta, 2003). According to
National Family Health Survey III (IIPS, 2007), 16% of women
between 15 - 19 years were already mothers or pregnant at the
time of the survey. Adolescent mothers are at a higher risk of
miscarriages, maternal mortality, and morbidity. If a mother is
under the age of 18, her infant's risk of dying in its first year of
life is 60% greater than that of an infant born to a mother older
than 19 (UNICEF, 2008). An inter-country consultation on ado-
lescent health and development (South-East Asia region) or-
ganized by WHO in collaboration with UNFPA and other UN
agencies resulted in setting up Adolescent Friendly Health
Centres (AFHC) by the GoI. The experience of AFHCs dis-
cussed in a subsequent workshop brought out the need to go
beyond clinical services offered by the Health Ministry. In
September 2005, MoHFW organized a national consultation
jointly with WHO and UNFPA on RCH-II ARSH strategy. The
ARSH strategy thus formulated and stated in the National Pro-
gram Implementation Plan (NPIP) of the RCH II (MoHFW,
2005a) program advocates the use of existing public system
infrastructure for ARSH service delivery, working towards
meeting the needs of adolescents, and the need for a delivery
strategy looking at different stages of development, needs and
problems of adolescents. The RCH-II ARSH strategy was
communicated to the states in May 2006 in a Dissemination
workshop. However a review of the state RCH plans and ex-
penditure for the year 2008-09 shows that most of the states are
yet to implement ARSH in all its districts. Fourteen of the 35
states and UTs had reported nil expenditure for ARSH in
2008-09 (MoHFW, 2009).
Multiple Actors, No Ownership
In India, components of adolescent health are being looked
after by separate ministries and departments. The Ministry of
Health and Family Welfare (MoHFW) focuses on delivering
adolescent health services. The Adolescent Education Pro-
gramme (AEP) and sex education come under the Department
of Education in the Ministry of Human Resource Development
(MoHRD), while its earlier version SAEP was administered by
National AIDS Control Organization. The program on nutrition
and counselling of adolescent girls—Kishori Shakti Yojana—is
being looked after by the Ministry of Women and Child De-
velopment (MoWCD) under its Integrated Child Development
Scheme (ICDS). The National Youth Policy 2003, of the Min-
istry of Youth Affairs and Sports (MoYaS) recognises adoles-
cents (15 - 19 years) as distinct from the youth (20 - 35 years
age), but its focus on ARSH is limited to advocacy on ARSH
and life skills (MoYaS, 2008). Thus each ministry is looking
after one component of adolescent health and therefore a com-
prehensive ARSH policy is yet t o emerge.
As a respondent from a national NGO commented:
Every department has its own concern; nobody is concerned
about the adolescents as a vulnerable group. MoYaS’s target
population is youth. Its goals are nationalism, sports and per-
sonality development. WCD is more concerned with nutrition
and empowerment of women. Ministry of Health is into service
delivery. Along with other health concerns Adolescent Repro-
ductive and Sexual Health also features in its long list.
Commenting on its multi-sectoral characteristic and the role
of the health sector, a respondent from an UN organization
There are domains in ARSH, which can be attended to by so
many actors. In addition to the civil society, education depart-
ment, youth department, social justice department, women and
child etcetera need to pitch in. Health sector has limited capac-
ity and efficiency especially in developing world. We have to
define the health sector’s role in the multi-sectoral framework.
While collaborating we should be clear that this is what the
health sector can do.
Though collaboration and coordination is essential for ARSH,
the process of implementation of the Indian ARSH strategy has
not addressed the inter-ministerial coordination satisfactorily.
The National Programme Implementation Plan (NPIP) of RCH
II says that “Department of Health and Family Welfare will
need to steer policy dialogue and partnerships with other de-
partments for inter-sectoral activities” (MoHFW, 2005b). But
6Organisations like Parivar Seva Sanstha, the International Centre for Re-
search on Women (ICRW) Ind i a o f fi ce, Swaasthaya, t h e H ealth Inst i tu t e f o r
Mother and Child (MAMTA) and Family Health International India started
adolescent health projects and provided programmatic evidence, where as
Census of India, the three rounds of the National Family Health Survey
(NFHS) and the 2006-2007 Youth Surveys provided additional quantitative
Copyright © 2012 SciRe s . 321
M. GUPTA ET AL.
the 11th five-year plan document mentions MoYaS as the nodal
ministry for youth and adolescent, though with some reserve-
tions: “The MoYaS is the nodal ministry for development and
empowerment of youth and adolescents in the country. MoYaS’
role and responsibilities in this context are still not clearly de-
fined, which affects its schemes and programmes in terms of
their monitorable deliverables and outcomes on the one hand,
and dovetailing them in an integrated framework with programs
of other ministries” (Planning Commission, 2007). Among the
stakeholders interviewed for this research there is consensus
that MoYaS lacks the power to fulfil this nodal role. The
MoYaS is not a member in the Mission Steering Group and the
Empowered Programme Committee—the highest policy mak-
ing and steering institution under the National Rural Health
Mission (NRHM), which includes ministries such as Health and
Family Welfare, Rural Development, Panchayati Raj and Hu-
man Resources Development (GoI , 2005).
Highlighting NRHM as an opportunity to initiate inter-sec-
toral collaboration in ARSH a senior government officer re-
marked: “As NRHM is the umbrella programme for all health
issues and stresses on inter-sectoral collaboration to achieve its
objectives, it may be useful to view ARSH policy development
as an important inter-sectoral activity under NRHM.”
But in the third year of NRHM (2008-09), ARSH accounted
for only 0.4% (less than 1%) of the total expenditure under
Multi-sectoral nature of adolescent health becomes even
more complicated because of the non-homogeneity of adoles-
cents as a group. Adolescents could be boys and girls, married
and unmarried, with diverse sexual preferences, in-school and
out of school, working and unemployed, migrants and those at
home, of various castes, cultures, religions and economic strata.
Programmes and schemes of most ministries and departments
cater to some, but leave out too many.
The parliamentary committee looking into what has been
termed the “sex education controversy” has expressed dissatis-
faction on the total lack of coordination amongst various agen-
cies in formulating and implementing the Adolescent Education
Programme (AEP). The Committee would like the Ministry of
HRD to oversee the process of revision of AEP under its super-
vision, direction and control (ibid). The AEP reaches only the
school children, and not the large segment of out-of-school
boys and girls8. In Gujarat, Mamta-Taruni addresses out-of-
school girls, but leaves out the out-of-school boys. MoYaS
caters to rural youth through its Nehru Yuva Kendras, but its
focus is more on nationalism and sports and not on ARSH.
Many NGOs are trying to cater to the adolescents, but their
reach is limited in scope and coverage.
The policies at both federal and state levels either belong to
specific sectors like health, education, population, nutrition,
HIV/AIDS etc. or the policies address specific population seg-
ments like youth, women, and children, and therefore the em-
phasis on adolescents gets diluted (MAMTA, 2001).
The Context Trap
Complexity of socio-cultural and politico-religious factors
adds on to the complicated interplay of actors. To start with, the
concept of “adolescent” has not been a common one in India,
where traditionally childhood has been seen as leading directly
to adult life. As one of the respondents voiced, “Problem is
more serious for people who are illiterate and their children
who do not go to school. When the children turn 13 or 14 years
their parents think that they are into adulthood, and they should
work. By 18 they must get married”.
An INGO respondent synthesized: “A child suddenly be-
comes adult after marriage”.
Government services delivery fails to recognize the transition
through adolescence, particularly in the case of married teenag-
ers. As an INGO respondent commented “A married adolescent
for a provider is quite like an adult, in the adult role. Whether
the communication capacity of the client has evolved or not,
whether the decision-making capacity of the adolescent client is
of adult level or not, the provider is not aware”.
Socially, married girls are most vulnerable. Within a patriar-
chal family structure, women have relatively little power, but
young and newly married women are particularly powerless,
secluded, and voiceless. As one of the respondents from an
INGO who has worked extensively in the field of adolescent
They (married girls) are more at risk. They are less likely to
be allowed out of house and so less likely to access services.
They have very little decision-making power. They probably
don’t have much communication with their husbands, nor does
any health care provider even worry about them until they have
a child. An adolescent married girl is socially isolated and has
very little contact with her parental home.
As argued by several of our respondents, there is tremendous
societal pressure on girls for marrying early and having a child
early. In fact, there are strong pressures on women to prove
their fertility as soon as possible after marriage: social accep-
tance and economic security in the marital home are established
largely through fertility, and particularly through the birth of a
son (Jejeebhoy, 1998). Adolescent girls have little choice about
whom and when to marry, whether or not to have sexual rela-
tions, and when to bear children. A proposal that was intro-
duced to reduce the legal age at marriage for boys from 21
years to 18 years probably would have put still more pressure
on girls, but has been rejected (UNI, 2009).
In India, the politico-religious context has played a very sig-
nificant role in determining policy and the content of education
to be provided to the youth. While parents articulate a need to
provide reproductive and sexual health education to their chil-
dren, political and religious leaders have tended to decide what
is good for the youth. Those who apparently have the least say
are the key stakeholders: the adolescents themselves. Adoles-
cents have found it difficult to voice their needs. When it comes
to reproductive and sexual needs it becomes all the more diffi-
cult: sex is a taboo subject. Even the subdued adolescents’ de-
mand seems to be only marginally taken into account in the
policy process. As stated by a policy-maker the government
does not pay much attention to the adolescents’ perspective in
formulating ARSH policy:
The formal approval of any government policy (central or
state government) requires that the policy draft document is
tabled in the parliament (or the state legislature) for debate and
discussion, or taken to the cabinet for its approval when the
parliament (or the state legislature) is not in session. It is up to
the parliamentarians (legislators) to get inputs from their con-
7With increased focus the expenditure on Adolescent health has increased
to 2.5% in 2011-12 of the total expenditure under RCH/NRH M.
8School dropout rates for girls are 19% and 66% in the age groups 11 - 14
years and 1 5 - 19 year s resp ectively ( IIPS, 1999). Th e corresp onding statis-
tics for boys are 20% and 51% respectively. In addition to school dropouts,
an average of 22% of girls and 7% of boys in the age group 15 - 19 years
never atte n ded school.
Copyright © 2012 SciRe s .
M. GUPTA ET AL.
stituencies and stakeholders for discussions during the delibera-
tions of the policy. Yet, an average youth doesn’t even know
what the whole youth policy is about. Efforts are made in
workshops and seminars to give the adolescents and youth a
platform to raise their voice. But such efforts are very few.
At times, lack of attention comes close to plain negation:
“Because of the potential political backlash and the whole cul-
tural milieu, I think nobody wants to have any major impetus
on it. ‘Our youth don’t have sex’—this attitude still exists”:
said a respondent from an INGO working with adolescents. Yet,
population-level data (Population Council and IIPS, 2007) re-
veal that premarital sex among female and male youth is a real-
ity. At the same time, a very marginal percentage of the respon-
dents in the IIPS study is engaged in discussions on sexual and
reproductive systems, including pregnancy, with their parents.
Lack of health awareness among adolescents is another is-
sue9 which is more widely recognised. One of the government
policy-makers, quoting an opinion poll conducted by one of the
leading fortnightly magazine, indicated that “There is an utter
lack of awareness and knowledge about sex and sexuality, ways
to use contraceptive methods among the youth”.
But lack of knowledge does not equal lack of demand. As
one NGO respondent indicated:
Parents of adolescents would like their children—both boys
and girls—to receive reproductive health and sex education.
Even the adolescents and youth themselves have voiced their
needs for sex education. Further, the youth want to know and
learn about sex education from a formal source such as school,
or college and taught by a teacher or a health provider. Parents
do not feel comfortable talking about sex to their children and
therefore prefer that their children receive such information
from schools from their teachers.
In spite of the fact that both adolescents and their parents
have expressed a need for sex education, and government offi-
cials recognizing that adolescents lack awareness about sex and
sexuality, efforts to provide sex education through the SAEP
came under attack (some termed it as cultural hijack) and were
discontinued in several states because of political pressure. A
political leader had argued that the attempt to impart sex educa-
tion is a ploy of the multinational companies that are keen on
promoting the sale of condoms and other sex devices. Some
religious leaders even argued that “sex education would make
adolescents promiscuous”. In a country where Valentine’s Day
celebrations and vibrating condoms are viewed as capable of
unsettling the nation, there is no novelty in these arguments.
One is only too familiar with them. But their efficacy in stalling
sex education in schools is a matter for worry (Anandhi, 2007).
The report from the Rajya Sabha committee on petitions
(Rajya Sabha, 2009) officializes the plea for scaling down sex
education. The committee appears satisfied with the revision of
the AEP by a commission led by the chairman of the Central
Board of Secondary Education. But it also advises that chapters
like “Physical and Mental Development in Adolescents” and
“HIV/AIDS and other Sexually Transmitted Diseases” should
be removed from the present curriculum and included in the
books of biology, not before the 10 + 2 stage.
Adolescent health in India is still in an infant stage, and at
risk of infanticide. If we want to deliver a comprehensive ser-
vices package to our adolescents, then we have first to over-
come a range of obstacles: traditional society, cultural restrict-
tions—especially for girls—and the political-religious context.
Only government action can put these hindrances aside.
But government actors are far from steering in the same di-
rection. Improved coordination should be a first step. Coordina-
tion of policy processes amongst different departments and
different ministries—especially the need to identify a lead
agency which has the mandate and power to coordinate—is the
key to any government policy. In ARSH, shattered by many
and buried in complexity, coordination and steering becomes
imperative. However, this can only be a first step. From ‘health
for the adolescents’ to ‘health with the adolescents’, there is
still a long way to go.
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9The recently conducted Youth Surveys in six 6 states (Jharkhand, Bihar,
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