ADOLESCENT HEALTH
Item
- Title
- ADOLESCENT HEALTH
- extracted text
-
%
RF_WH_.11.5_SUDHA
Sexual and reproductive health of
young people, India
Shireen Jejeebhoy
Population Council, New Delhi
Definitions
Adolescence
0
19
10
—4-
-H-
-4-
15
—H
24
Years
of age
Youth
Young people
1
9
Adolescence and youth
Adolescence
has
both
biological
(physical
psychological) and socio-cultural dimensions
&
■
“Adolescence” is a phase rather than a fixed age group
and can be perceived differently in different cultures
■
Gender differentials are important
■
Stages in adolescence (10-13,14-16,17-19 years)
Why focus on young people?
4^
Adolescent risk behaviours and implications for
adult health
Behaviours formed in adolescence have lasting implications
for individual and public health.
Most adults who smoke started during their adolescence
Young people who start drinking before age 15 are four
times more likely to become alcoholics than those who
start at age 21 or later
HIV+ women more likely than others to report forced sex
in adolescence
Why focus on young people?
■ >300 million population aged 10-24: India’s health, mortality,
morbidity scenarios depend heavily on the experiences of
this population
■ Current thinking not informed by the unique needs and
vulnerabilities of young people - and continues to
Serve married adolescents in the same way as married
adults
r- Exclude unmarried adolescents from the network of
contraceptive supplies
> Focus on nutritional supplementation and other noncontroversial services
3
Why focus on young people?
• With new thrust towards youth programming (e.g. RCH-2),
need to have benchmarks, enable us to track the situation
of youth
• Above all, understanding young people's transitions to
adulthood, the life choices they face, the factors that
facilitate expansion of these choices or limit their
attainment will enable the design of more integrated and
realistic programming.
RyitoiCw
Context of young people’s lives
4
Young people not a homogeneous group: Youth transitions
■ Schooling: % attending school:
ages
80% of boys and 67% of girls
ages 15-17: 58% of boys and 40% of girls
■ Work: % 15-19 year olds working (1991):
Females:
26
Males:
44
■ Marriage: % 15-19 year olds ever married:
Females:
34
Males:
6
■ Family building: % women 15-19 with 1+ children:
All women:
16
Married women:
48
■ Mortality rates generally low; gender disparities apparent
What % are sexually experienced?
5
Unsafe, unwanted sexual relations
Majority of sexually active females are active
within marriage
Percentage ofyoung women married by age 13, 15, 18 years
Women currently aged:
20-24
25-29
Proportion ever married
78.8
94.5
Percentage married by age 13
8.9
12.1
Percentage married by age 15
23.5
29.2
Percentage married by age 18
50.0
58.9
Percentage married in adolescence
(by age 20)
67.1
74.9
Source: UPS and ORC Macro 2000
6
Sexual initiation within marriage
■ Large proportions of adolescent girls experience sexual
initiation within marriage
* Age at marriage remains low, and wide regional variation
■ Often the adolescent herself is excluded from the choice
of whom and when to marry
■ Married adolescents are a neglected population in terms
ofSRH
Premarital sexual activity observed among youth
30
26
26
20
20 15
55
15 10 -
5
0
6
4
3
Ki
Slum resettlement
colonv
College students
Low-income
A do 1 esc en t s y o un g
adults,
opportunist icallv
selected
Delhi
Chandigarh
Mum bai
1 6 cities
El Fem ale
Bi Male
Source: Abraham and Kumar 1999 for Mumbai; Kaur et al.. 1996 for Chandigarh;
Mehra, Savithri and Coutinho 2002 for Delhi; Watsa 1993 for the 16 city study
7
Sexual relations are not always safe
■ Multiple partners, casual and sex worker relations, relations with
“aunties"
10% rural males 15-19 reported a casual encounter in last 12
months (NACO and UNICEF, 2001)
r >20% in other studies
■ Non-use of condoms
Among unmarried males: large proportions report non-use, and
inconsistent use (>85%)
r- Among those reporting a casual contact, > 60% report
use (NACO and UNICEF 2001)
inconsistent
■ Non- use of contraception
r- Among the married, 8% report use and 27% report unmet need for
contraception (NFHS)
.
Sexual relations are not always wanted
Percentage of females and males aged 16-17 reporting nonconsensual sexual experiences, Goa
1
Forced sex f
7
6
j
Forced to touch [
abuser
[
Touched without
permission
10
6
'
.
:
'J— 13
-
- -- -
1
Brushed private
10
IP?
parts
0
5
10
□ Females
a Males
15
20
Source: Patel and Andrew (2001)
8
Non-consensual sexual relations are reported by
married females
“I decided to stop it since I used to feel uneasy while
having sex with a big abdomen. But my husband used to
get angry if I told him that I did not want to have sex. He
used to tell me that he would remarry if I refused to have
sex with him. I tried to explain to him, but he did not want
to listen. He used to get angry if I refused and we had
some tiffs on this issue. I had to give in to his demands
after a few days and our tiffs were resolved. We continued
in this manner till my ninth month. I had feelings of
discomfort but I had to accept my husband’s wishes”
(18 year old, recently delivered mother, Santhya et al., 2001).
Adverse consequences of unsafe or unwanted
sexual relations
9
Pregnancy related consequences
■
19% of TFR contributed by 15-19 year olds
■
Early pregnancy: >1 in 5 by age 17
■
Nearly 15% stunted and 20% anaemic
■
High rates of maternal morbidity and mortality
■
1-10% abortion seekers are adolescent
■
Neonatal mortality (63 vs 21) and low birth weight
Unintended Pregnancy
■ Large minorities of married
unintended pregnancy
and
unmarried
report
■ Often resolved by abortion
■ Young abortion seekers - particularly the unmarried - are
more likely than adults to delay abortion, opt for unsafe
providers and experience complications
io
Adolescent births are often unplanned
Ghana
Zimbabwe
Bolivia
Bangladesh
Egypt
60
80
RTIs, STIs and HIV
■
STIs observed: married young females aged 18-22 often
considered “low risk” : 18%
■
Significant percentages of youth with HIV/AIDS:
■ Females 14-24: 0.96%-0.46% (high & low prevalence
sites)
■ Males 14-24: 0.46%-0.20% (high & low prevalence
sites)
Sources: Joseph et al., 2003; UNICEF, UNAIDS, WHO, 2002
11
HIV/AIDS among youth, selected Asian countries: % of
youth living with HIV/AIDS
Females
Males
Adults
2il
I
% oJ
c ]
ir
.2
■u
c
a
Q.
Z
c
ca
o
a
c
a
2
22
0
Q.
5
o
8
c
- S
lo
a*
o
c
■O
5
'5i
«
rfTI
o
c
a
<3
Ecj
c
o
w
Z
£
F
Q.
ffl
Source: UNICEF, UNAIDS, WHO (2002)
Life expectancy at birth in 29 African countries
with and without AIDS
Without AIDS
E With AIDS
65 -i
60.4
2n
58.4
o 60 -1
>
o
c
56.4
54.1
55 4
0
o 50 o
a
x
©
45 -
51.7
50-249.2
52.6
-
■
47.5
47.4
■ ‘i £
’J .
V
’ -
40
1985-90
1990-95
1995-2000
2000-05
2005-10
2010-15
12
Underlying risk factors
and promising practices
CAN WE IDENTIFY THEM?
Postal Gxiim
Underlying risk factors
and promising practices
1. Lack of awareness
|| ftpitoiCcMia
13
Lack of awareness: % of adolescents aged 15-19 who have heard of
AIDS and who know about transmission routes
10°
_,
93.2
89.6
90
82.7
n
80
72.3
70 60
60
as
50
40
55.6
I
54.1
1
44.5
30.3
30
20
10
0
ill
21.8
18.7
15
9|1
al
f
20.2
13
81
MALE
FEMALE
URBAN, 15-19
MALE
FEMALE
RURAL, 15-19
□ Have heard of HIV/AIDS
□ Aware of at least 2 important methods of prevention
a Correctty aware of 3 common misconceptions on transmission
□ Aware of Unk of STI and HfV
Source: NACO and UNICEF 2002.
Superficial awareness and widespread misperceptions
■ % women aged <25 who have heard of AIDS: 37
■ % of these who reported:
57
multiple partner sex as a risk factor:
58
Consistent condom use as protective:
A healthy looking person could be HIV+: 26
■ “One does not require much information on these ages in
the adolescent age. More information, no doubt, tempts
them to do wrong things.” (father’s group, Mehra et al.,
2002, Delhi).
14
Interventions can overcome lack of awareness and
misperceptions:
BEFORE
ADOLESCENT GIRLS, ALLAHABAD
- Could name a STI:
- Knew how pregnancy occurs
ADOLESCENT BOYS, LUCKNOW
- Aware of multiple types of STIs
- Know that STIs can
be asymptomatic
AFTER
67
44
94
98
66
83
30-40
80
Sources: Sebastian, 2002 personal communication; Awasthi et al., 2000.
||
Underlying risk factors
and promising practices
2. Gender double standards and power imbalances
15
Gender roles and power imbalances
■ Priority on preserving young women’s virginity before marriage
but condoning sexual activity among young men
■ Supervision of the movements of daughters and relative freedom
to sons
■ Friendships between girls and boys are unacceptable
Girls, low-income setting, Delhi: 80%
Boys, low-income setting, Delhi: 25%
• Boys do not respect girls who have engaged in pre marital sex:
>66%
• Girls who engage in pre-marital sex always regret it: 80%
■ Limited decision making autonomy of adolescent females in sexual
and reproductive matters
Sources: Mehra et al„ 2002; Sodhi et al., 2002
ftpdfeClW
Gender roles and power imbalances
Many feel that society condones premarital sexual
activity among boys and even puts social pressures on
boys to become sexually active at an early age"... And if
the girl says no then boys defame her in her gali (lane)
and colony. Because there is no effect on boy’s
character” [19 year-old male student]
“[Boyfriend] kissed me forcefully...he gets angry if I talk
to anyone in the lane. One day he saw me talking to my
brother...he... beat me up. He was saying that boy was
my boyfriend... he beat me so much even then I did not
say anything to him because I love him so much” [indepth interview, 15 year-old girl, slum setting, Delhi]
Source: Sod hi, 2005 forthcoming.
16
Gender roles and power imbalances
■
% women aged 19-24 who had a say in marriage
decisions
rural Uttar Pradesh:
10-12
rural Tamil Nadu:
37-53
■
“Did I get the chance to say anything? Could I say
anything after my parents took the decision? What could
I have done? [in-depth interview, 18 year old recently
delivered mother in Kolkata]”
Sources: Jejeebhoy and Halli, 2002; Santhya et al., 2001.
Emerging evidence of self-efficacy, autonomy,
negotiation skills
Follow-up of a cohort of out-of-school adolescent girls two to five years
after exposure to a comprehensive education and service intervention:
□ Control Q Intervention
80
68
70
52
60
50
%
42
35
40
25
30
20
10
0
8
I
Economically
Active
7
25
21
US'*
■
■•L
'
6
■ .ik-z
Participates
in marriage
decision
Decides on
going to the
market
Decides on
how to
spend money
Travelled
outside
village alone
Has gone to
a health
centre alone j
Source: Levitt-Dayal et al., 2002
17
Emerging evidence of self-efficacy and autonomy
Follow-up of girls aged 14-19 who participated in a
reproductive health education and vocational skills training
programme:
□ Base-line (2001) m Endline (2003)
90
78
80
70
60
50
40
30
20
10
0
63
26
Can make self
understood to
others
26
25
15
13
Woman is not
inferior to men
Husband should
decide on
spending income
ii
Agree’’boys
preferred in
education over
girls"
Source: Sebastian et al., 2004
Underlying risk factors
and promising practices
3. Interaction, communication, supportiveness missing
4^ RyufatotCouMa
is
Interaction with parents and other adults
■
Limited communication: sex and reproduction are taboo
subjects; belief that talking about sex leads to sexual
activity
■
Supervision of the movements of daughters and relative
freedom to sons
Parental counselling and supportiveness limited
Teachers ambivalent: stress biological information over
broader issues of sexuality
Parental interaction: policing may not safeguard
against risky behaviour
“There are a lot of constraints on girls’ movements. But
they continue to meet their male friends stealthily. When
parents leam of these cases they generally forcibly get
them married off elsewhere after an abortion or agree to get
them married to the same boy.” (Adolescent girls, 17-19,
slum)
“There are some cases of pregnancies among unmarried
girls, we do have girls of this kind in our area. We do not
know them well and do not interact with them” (Adolescent
girls, 15-17, resettlement colony)
Source: Mehra et al., 2002
19
Interaction with parents: what young people want
■ We need more attention, care and support from all. We
feel we do not have the right to make our own choices,
even after learning about all the alternatives and choices
related to our careers, friends, movements and life
partners. We greatly lack proper and correct information
and guidance, especially related to our bodies’
physiological and psychological changes.
■ We are not allowed to express our emotions and our
thoughts. To our parents, we say that we need you to
listen to us, to our dreams, our experiences, our
explanations. Give us your time. Don’t hide things from
us, especially when they are related to us. Give us the
privacy and the space to grow. Guide us; don’t drive us.
Source: Singh. 2002, statement made at the UNFPA South Asia
Conference on Adolescents, New Delhi,1998
Pyyfafavj
Underlying risk factors
and promising practices
4. Lack of an available, accessible, acceptable service
environment
20
Limited use of services
49% of married young women experiencing gynaecological
problem in rural Maharashtra
9% of married 16-22 year olds experiencing
symptoms in rural Tamil Nadu
RTI/STI
About as likely as older women to seek pregnancy related
care
Unmarried adolescent abortion-seekers more likely than
other women to seek second trimester abortion, choose
home remedies and unqualified providers
Sources: Barua and Kurz, 2001; Joseph et al., 2002; Santhya and Jejeebhoy, 2002;
Ganatra and Hirve. 2002
Service environment and obstacles to care
■
Lack of autonomy
■
Lack of affordability
■
Long distances, waiting times
■
Poor quality of care
■
Lack of privacy, confidentiality
■
Providers lack counselling skills, are judgmental and
disrespectful.
■
Providers reluctant to providing services -notably
contraception - to unmarried youth
21
Making the service environment “youth friendly”
■ Accommodating young people’s stated priorities:
“a welcoming facility, where I can drop in and be
attended to quickly”
r
“...where thee is privacy and confidentiality,”
“where staff treat us with respect and do not judge
us,”
“where we can get a range of services so that we do
not have to be referred to different places for
treatment”
Source: Godinho, Dias-Saxena, Divan et al., 2002
Key SR rights of adolescents
22
India’s commitment to SRHR of Adolescents
■ ICPD and ICPD+5 Plans of Action and made a commitment
to “protect and promote the right of adolescents to the
enjoyment of the highest attainable standard of health,
provide appropriate, specific, user-friendly and accessible
services to address effectively their reproductive and
sexual health needs, including reproductive health
education, information, counselling and health promotion
strategies.”
■ Convention on the Rights of the Child (CRC, 1989) and its
general comment No. 4 (2003) on the main “human rights
that need to be promoted and protected in order to ensure
that adolescents
are adequately prepared to enter
adulthood and assume a constructive role in their
communities and in society at large.”
■ MDG goals cannot be achieved without attention to SRH of
adolescents
t
.
nlplwliffl Qwi
Key SR Rights of Adolescents
■ Protection from all harmful traditional practices notably
early marriage
■ Access to information
■ Access to health services, including counselling and health
services for sexual and reproductive health of appropriate
quality and sensitive to adolescents’ concerns
■ Opportunities to acquire life skills
■ A safe and supportive environment
Sources: CRC 2003, ICPD
23
Meeting these rights
■ How far have we come in aligning our own policies and
programmes with the commitments articulated in the CRC
and ICPD
■ To what extent have these rights been realised in terms of
the reality of young people’s lives?
■ Way forward
Protection from all harmful traditional practices
notably early marriage
24
Protection from all harmful traditional practices
such as early marriage
- CRC:
o State parties must [fulfil their] obligation to protect
adolescents from all harmful traditional practices, such
as early marriages... (para 39g)
o need to review and reform legislation and practice to
increase the minimum age for marriage with and without
parental consent to 18 years (para 20)
■ NPP (2000) and NYP (2003):
o special programmatic attention to delay marital age and
enforce the Child Marriage Restraint Act
Going further: Delay marriage and recognize the
vulnerability of married female adolescents
- REAL J IA ?
■ Secular trend towards increased marriage age: but at this rate,
by 2015 1/3 girls will marry in adolescence
o education for girls, programmes for parents, addressing
community norms and enforcing existing laws - to accelerate the
pace of change
o raise awareness of the negative impact of early marriage
o enhance married girls’ autonomy within marital homes: education,
life and livelihood skills and opportunities.
0
train providers to recognize married adolescent girls as a special
group
25
Access to information
Access to information
■ CRC:
o ensure that adolescents have access to the information that is
essential for their health and development (para 39b)
o including on family planning and contraceptives, the dangers
of early pregnancy, the prevention of HIV/AIDS and the
prevention and treatment of STIs regardless of marital status
and whether their parents or guardians consent. (Para 28)
■ICPD+5:
■ Ensure that adolescents, both in and out of school, receive the
necessary information, counselling and services to enable
them to make informed choices and decisions (para 73e)
26
Access to information
■NPP:
o ensure for adolescents access to SRH information
• NYP:
o information and education activities; incorporate sexuality
education within the school curriculum
•NAIDSP:
o generate greater awareness about nature of its transmission
|| RipufaCcwa
Going further: Attention to content and quality
• REAM I ¥?
■ As larger proportions of adolescents remain in school, larger
proportions will be exposed to school based sexuality
education programmes.
0
attention to content and quality of information
o reaching the out-of school
o Lessons from small scale innovative sexuality education strategies
o Sensitise trainers, counselors
o dispelling fears and misconceptions — no evidence that in-depth
awareness encourages risk taking
FbpdfltoGwid
27
Availability, Accessibility, Acceptability and Quality:
of sexual and reproductive health services and counselling
Access to SRH services
CRC:
o availability,
services
accessibility,
acceptability
and
quality
o effective prevention programmes
o address cultural and
adolescent sexuality...
other
taboos
surrounding
o remove barriers hindering the access of adolescents to
information,
preventive measures such as condoms,
and care.
o privacy and confidentiality...
o counselling and health services of appropriate quality
and sensitive to adolescents’ concerns
Source: paras 41, 33
28
Access to SRH services
ICPD+5
■ Ensure services that safeguard the rights of adolescents to
privacy, confidentiality and informed consent
■ Train all who are in positions to provide guidance to
adolescents, particularly parents and families, but also
communities, religious institutions, schools, the mass
media and peer groups
■ Ensure that attitudes of health care providers do not restrict
the access of adolescents to appropriate services and
information
■ Remove legal, regulatory and social barriers to reproductive
health information and care for adolescents
Source: ICPD+5 see paras 73b, e, f
Policies and programme commitments
■ NPP:
o ensure “access to... counselling and services, including RH
services, that are affordable and accessible;
o “strengthen PHCs and SCs to provide counselling, both to
adolescents and also to newly weds"
■ NYP:
o establish “adolescent clinics” for counselling and treatment
and Youth Health Associations at grass root level for family
welfare and counselling services
■ RCH-2 (proposed)
o Weekly adolescent health clinics at PHC, CHC and higher levels
29
Going further:
Integrate young people’s concerns into programmes
■REALITY? Ambiguities remain: Unmarried not eligible for
contraceptive services; married report unmet need for contraception
and lack pregnancy related care; Poor quality of care, lack of
confidentiality and privacy
o HW to provide SRH services including contraceptives to
unmarried females and males
o Providers to give
confidential services
sensitive,
non-judgmental,
private
and
o Redefine male health worker role to include SRH counselling and
services to young men
o Engage newly married young women and their husbands
(contraception, delaying pregnancy, appropriate care)
o Two-pronged effort: establish adolescent health clinics; supplies
and counselling also through other acceptable outlets, youth
clubs etc
Opportunities to acquire life skills and
address unbalanced gender role attitudes
30
Life skills development, redress gender imbalances
CRC, ICPD
■ ensure that adolescents...have opportunities... to acquire life
skills, to obtain adequate and age appropriate information, and to
make appropriate health behaviour choices. (CRC Para 39b)
• develop and implement awareness-raising campaigns, education
programmes and legislation aimed at changing prevailing
attitudes, and address gender roles and stereotypes(CRC Para 24).
■ Develop action plans, based on gender equity and equality that
cover education, professional and vocational training and income
generating activities, and incorporate mechanisms for education
and counselling in the areas of gender relations and equality,
violence, responsible sexual behaviour including contraception
and infection (ICPD+5, para?3c).
NPP, NYP:
■ not addressed but mentioned in RCH-2
Address life skills and gender role attitudes
•
REALITY?
■ Few programmes address life or livelihood skills, gender
double standards;
■ existing programmes are small-scale NGO efforts
■ Going further:
■ Expand life and livelihood skills programmes for youth, for
females but also males
■ Review, adapt and up-scale lessons learned from successful
demonstration projects that impart non-formaI, life skills, family
life, livelihood or vocational skills - for both females and males.
31
A safe and supportive environment
|| MtoiCw
Safe and supportive environment
CRC:
■ Creating a safe and supportive environment entails addressing
attitudes and actions of both the immediate environment of the
adolescent - family, peers, schools and services - as well as the
wider environment... (Para 14; 39a)
■
promote the health and development of adolescents by (a)
providing parents (or legal guardians) with appropriate
assistance.... (b) providing adequate information and parental
support to facilitate the development of a relationship of trust and
confidence in which issues regarding, for example, sexuality and
sexual behaviour and risky lifestyles can be openly discussed and
acceptable solutions found that respect the adolescent’s rights....
(CRC Para 16).
Cont...
32
Safe and supportive environment
ICPD:
■ ensure that parents and others responsible for rearing children are
educated about and involved in providing sexual and reproductive
health information in a manner consistent with the evolving
capacities of adolescents (para 73d)
NPP, NYP, RCH-2 (proposed):
■ Not addressed
Safe and supportive environment
• Parents unwilling to discuss & uncomfortable about
discussing sexual matters with adolescents & young
people
■ Going further: Sensitise parents and other adults to
provide more supportive environments for youth
■ Programmes for parents/adult gatekeepers
• about sexual and reproductive issues
■ breakdown inhibitions/discomfort
•improve communication skills
•address misperceptions: that talking about sex leads
adolescents to engage in risky sex
33
Last thoughts
■ No “best practices” models available
s feasibility, effectiveness and acceptability will
continue to remain poorly understood unless they are
rigorously and regularly monitored and assessed.
• Need to address sustainability and up-scaling
importance of inter-sectoral collaboration & public
private partnerships: Health and Family Welfare,
Education, Youth, NGOs...
o
*
34
I
4 Special articles
Long-Tenn Population Projections
for Major States, 1991-2101
The authors decompose the prospective population growth in 16 major states between
1991 and 2101 into three components to estimate the contribution of each of
them individually. The decomposition of population growth in different states seeks to
estimate the impact of growth momentum built into the age distribution of population and
the share ofprospective growth attributable to (a) the unmet need for family
planning and (b) high wanted fertility.
Leela Visaria, Pravin Visaria
In 1996, a decomposition ofthe projected long-term population
growth in India as a whole and an exploration of its policy
implications had elicited considerable interest among the plan
iven the scale and diversity of India’s population, a ners and policy-makers [Visaria and Visaria 1996].1 A similar
u
—woman in 1970, to analysis at the sub-national level for the major states of the
| ^decline
from around six children per
almost
half
that
level
in
a
span
of
30
years is a significant country was recommended as potentiaHy useful and instructive,
VJt___
j country, albeitt The case for such an exercise rested on the regional diversity
achievement. Fertility has declined throughout the
...
in
states in the level and pace of decline in fertility as well as in mortality
at varying pace in rural and urban areas or L.different
---------------^fiTKeSa^dTamilNadualready reaching replacement level, during the past several years and also on the fact that the onset
Fertility
Fertility in
in India
India has
has fallen
fallen under
under aa wide
wide range
range of
of socio-economic
socio-economic and the course of demographic transition m the Indian states
and cultural conditions. The rising levels of education, influence have varied. The 16 major states are at different stages of demoofthe media, economic changes, continuing urbanisation, decline graphic transition; and therefore, the analysis of interstate yanain infant and child mortality all have contributed to fertility tions in the role of different factors m long-run population
decline. The diffusion of new ideas and enhanced aspirations for growth was expected to highlight the appropnate state-specific
children has led even the uneducated parents to limit their family policy options.
size [Bhat 2002]. Fertility has fallen at all ages; at younger ages
This paperpresents long-term state level projections up to 2101.
due to rise in the age at marriage and at older ages due to control We decompose the prospective growth in each state in a manner
of fertility within mairiage through the adoption of family plan- similar to that followed for the national projections prepared m
ning (mainly sterilisation).
1996.2 The procedure relies on a series of population projections
Population projections made by the United Nations, the World with alternative assumptions about the rate of decline m fertility
Bank and demographers all indicate that India as a whole will and a likely course of mortality decline. The projections use:
attain replacement level fertility or complete the fertility tran (a) the state level base population and its five-year age distri
sition in the next 20 years [Visaria and Visana 1996, United bution available from the 1991 Census; (b) life expectancy at
Nations 2001, World Bank 2000, Natarajan and Jayachandran birth (separately for males and females), based on the Sample
2001, Dyson 2003]. However, the population size will continue Registration System (SRS) life tables for 1991-95; and (c) the
to rise for 50 to 60 years due to the recent history of high fertility SRS-based age-specific fertility rates for the period 1992-94.
that has resulted in young age structure and because, despite the In the different variants of projections, future trends in fertility
decline, the total fertility rate (TFR) for the country as a whole are assumed to vary, whereas only one pattern ofmortality regime
is still well above replacement level of TFR of 2.1. On the other is envisaged.
Decomposition of the future population growth in
hand, the welcome decline in mortality that began around 1921
m different
and accelerated since 1951 has caused substantial population states seeks to estimate the impact ofthe growth momentum built
growth in the past. However, since a significant proportion of into the young age distribution of population and the share of
deaths in India continue to be due to communicable diseases, prospective growth attributable to (a) the unmet need for family
their control will bring mortality levels further down in the planning and (b) high wanted fertility. A ‘standard’ population
’
L
coming decades. It is important to understand why population projection, which corresponds to the ‘medium’ projections m
most
such
exercises,
is
made
for
all
the
major
states.
The
second
will continue to grow in the years to come and the relative
contribution of the factors causing growth. An exercise in de- set ofprojections is based on the assumption that the replacement
composition of population growth would enable us to devise level fertility will be attained with immediate effect by all the
appropriate policy measures to affect growth.
states
states regardless
i
of their present actual levels. A third set ot
I
IntzoducticQ
..................................................
Economic and Political Weekly
November 8, 2003
’
’
4763
projections is based on the assumption (unrealistic, of course)
that the unwanted fertility will be eliminated within the next fiveyear period (or with almost immediate effect). In addition, a fourth
projection illustrates the implications of below replacement level
of fertility, such as has been observed in Kerala since 1988.
Assuming that this process will spread to the rest of India as
well, this fourth projection is essentially an extension of the
standard projection, in which the TFR is assumed to decline to
1.8 in each state and then remain stable at that level.
The expected absolute growth of population in each state
between 1996 and 2101 according to the standard projection is
decomposed to estimate and analyse the contribution to growth
of unwanted fertility, high desired fertility and population
momentum. Population growth resulting from unwanted fertility
will require identification of measures that would assist the
couples to achieve their reproductive goals in a manner that is
safe, affordable and accessible. The government-sponsored
family welfare programme needs to be responsive to individual
needs while offering good quality comprehensive services.
Population growth resulting from a desired family size or wanted
fertility that is higher than the replacement level of fertility will
require efforts to modify the preferences of couples about their
family size. To address this issue, a socio-economic environment
favouring small families will need to be created. Population
growth attributable to momentum can be reduced by measures
such as a later age at marriage among females, raising their age
at first birth (which would increase the length of generation),
and elongation of the inter-birth intervals.
The long-term projections have been prepared for 16 major
states with the 1991 Census population above five million.
Although 18 states had a population of more than five million
in 1991, we have not considered Delhi with a population of
9.4 million, of which nearly 90 per cent is urban, because
migration is a major factor influencing its population
growth. Jammu and Kashmir has not been considered because
the 1991 Census could not be conducted, and as a result, we do
not have an age distribution for the base period. Its population
was 6.0 million in 1981 and an estimated 7.7 million in 1991
[Office of the Registrar General 1998a: 4]. The all-India
projections, however, cover all the states and union territories
of the country.
I
The Indian states vaiy widely in terms oftheir total population.
Among the 18 major states with the 1991 Census population
exceeding five million, Uttar Pradesh had 139.1 million people,
nearly 27 times the population in Himachal Pradesh (5.2 million).
The other two populous states of Bihar and Maharashtra had a
population of 86 and 79 million, respectively. Together, the three
most populous states accounted for 36 per cent of the total
population ofthe country. In three other states ofAndhra Pradesh,
Madhya Pradesh and West Bengal, population ranged between
66 and 68 million and the six states included almost 60 per cent
ofIndia’s population (505 out of846 million) in 1991. Population
of Gujarat, Karnataka and Rajasthan ranged between 41 and 45
million, whereas that of Tamil Nadu was close to 56 million.
Except for Himachal Pradesh, the 1991 population in the remain
ing five states ranged between 16 and 31 million (Table I).4
TrendsinMzrtality
The Indian states have varied in their mortality levels and in
the pace of mortality decline. As shown in Table 2, we have
chosen the expectation of life at birth (e (0)) as the indicator of
mortality during 1971-75 and 1991-95 to illustrate the differ
entials in the level ofmortality and the level ofinterstate diversity
in India over time. The estimates are shown separately for males
and females. During 1971-75, the difference between the highest
e (0) value of Kerala (62 years) and the lowest e (0) value of
Uttar Pradesh (43 years) was 19 years for both sexes together.
In 1991-95, among the major states, Madhya Pradesh reported
the lowest e (0) of 55 years, 18 years lower than that in Kerala
(73 years). The interstate difference of 15 years for males and
21 years for females reflected the uneven progress in the avail
ability of health care services and infrastructural facilities in
different parts of the country. During 1991-95, life expectancy
Table 1: Papulation Statistics for 16 Mtjar States of India, 1571-2001
State
1971
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tami 1 Nadu
Uttar Pradesh
West Bengal
Alllhia
43.5
14.6
56.4
26.7
10.0
3.5
29.3
21.3
41.7
50.4
21.9
13.6
25.8
41.2
88.3
44.3
548.2
Rjpulatdcn (inmi 11 i<~n)
1981
1991
2001
2001
53.6
69.9
34.1
12.9
4.3
37.1
25.5
52.2
62.8
26.4
16.8
34.3
48.4
110.9
54.6
683.3
66.5
22.4
86.4
41.3
16.5
5.2
45.0
29.1
66.2
78.9
31.7
20.3
44.0
55.9
139.1
68.1
846.3
75.7
26.6
109.8
50.6
21.1
6.1
52.7
31.8
81.2
96.8
36.7
24.3
56.5
62.1
174.5
80.2
1027.4
1971-1981
1971-1981
Interoensal Growth (Per Cent)
1971-1991
1981-1991 1991-2001
23.1
24.2
24.1
27.7
28.8
23.7
26.7
19.2
25.3
24.5
20.2
23.9
33.0
17.5
25.5
23.2
24.7
23.5
21.2
27.4
20.8
21.1
14.3
26.8
25.7
20.1
20.8
28.4
15.4
25.5
24.7
23.8
13.9
18.9
33.6
22.5
28.1
17.5
17.3
9-4
22.7
22.6
15.9
19.8
28.3
11.2
25.5
17.8
21.3
52.9
53.4
53.2
54.7
65.0
48.6
53.6
36.6
58.8
56.5
44.7
49.3
70.5
35.7
57.3
53.7
54.4
1971-2001
74.0
82.2
94.7
89.5
111.0
74.3
79.9
49.3
94.7
92.1
67.6
78.7
119.0
50.7
97.6
81.0
87.4
NDtea:
Census was not conducted in Assam in 1981 and in Jammu and Kashmir in 1991 due to disturbed conditions.
The 2002 Census figures far the bifurcated states of Bihar, Madhya Pradesh and Uttar Pradesh are included in the respective states.
Souzres: Census of India, 1971, 1981 and 1991. Series I, India, Final Itpulaticn Tables, New Delhi, Office of the Registrar General: Census of India 2001
Series 1, India, Provisicnal Papulation Ibtals, Raper 1 of 2001, New Delhi, Office of the Registrar General.
4764
Economic and Political Weekly
November 8, 2003
was below 60 years in all the four large north Indian states (Bihar,
Madhya Pradesh, Rajasthan and Uttar Pradesh) as well as in
Assam and Orissa.
In India as a whole, the female life expectancy at birth in 1991 95 exceeded the male life expectancy by a mere 1.2 years (a much
lower figure than is observed in the developed countries in
northern and western Europe, North America and Japan).5 In
fact, until 1976-80, the SRS reported a lower life expectancy for
females than for males in the country as a whole. The reversal
of this pattern became visible in the national estimates as female
life chances started improving throughout the country, more so
in all the four southern states and in Punjab and Maharashtra.
In all these states, according to the 1991-95 estimates, female
life expectancy was higher than that of males by more than
2 years. However, the anomaly of female disadvantage in life
expectancy has continued in the most populous states of Uttar
Pradesh and Bihar and to a small extent also in Orissa and Madhya
Pradesh. The gender gap in life expectancy was the highest in
Bihar (2.1 years), relatively moderate in Uttar Pradesh (1.3 years)
and less than halfa year in Orissa and Madhya Pradesh. In Assam
and Rajasthan, the female life expectancy has improved signifi
cantly, and as in India as a whole, the male life expectancy is
no longer higher than that of females.
A further examination of the data suggests that the anomaly
of lower life expectancy among females, wherever it is evident,
mainly reflects the sex-differentials in their chances of survival
in rural areas; in urban areas, the females enjoy a higher life
expectancy at birth than males in all the states.6 As for the future,
our mortality assumptions envisage a faster rise in female life
expectancy and the disadvantage ofwomen in chances ofsurvival
is presumed to disappear gradually over time.
By 1971, the regional differentials in fertility had begun to
appear in India. In 1970-72 the TFR in the southern states of
Kerala and Tamil Nadu was around 4, whereas in the northern
states of Uttar Pradesh, Haryana and Rajasthan, it was above 6.7
By 1988, Kerala had attained a TFR below the replacement level
(2.0); and since 1993, Tamil Nadu has also attained the replace
ment level of fertility (a TFR of 2.1). During 1995-97, total
fertility rate in the other two southern states of Andhra Pradesh
and Karnataka had dropped to 2.9 and 2.7, respectively, from
around 3.9 and 3.6 reported in the mid-1980s.8 According to
the results of the National Family Health Surveys (NFHS) of
1992-93 and 1998-99, the small western state of Goa with a
population of only 1.2 million in 1991 also had a TFR below
replacement level of 2.1 during the three years preceding the
survey.9 Because of its very small size, we have not done any
projection exercise for Goa.
On the other hand, fertility in some northern states has con
tinued to be quite high. Despite the evidence of some decline
in recent years, TFR ranged between 4.5 and 5.0 in Bihar,
Rajasthan and Uttar Pradesh according to the SRS data for 199597. Evidently, the pace of decline has varied, such that the gap
between the low-fertility states and high-fertility states has widened
Table 3: Absolute and Percentage Change in Total Fertility
Rate, 1982-84 to 1992-94 in thaMajor States of Tnrtia
State
IttalFfertilityffete
1982-84
1992-94
TUI India
Kerala
Tamil Nadu
Andhra Pradesh
Karnataka
Maharashtra
Group 1 mean
Punjab
West Bengal
Gujarat
Orissa
Assam
Haryana
Group 2 Mean
Madhya Pradesh
Bihar
Rajasthan
Uttar Pradesh
Group 3 Mean
4.5
2.6
3.3
3.9
3.7
3.8
3.5
3.9
4.0
4.1
4.4
4.2
4.9
4.3
5.2
5.7
5.6
5.8
5.6
3.5
1.7
2.1
2.7
2.9
2.9
2.5
3.0
3.0
3.2
3.2
3.5
3.7
3.3
4.3
4.6
4.5
5.2
4.6
Deel i ne in the 10-Year Period
Absolute
Itercentage
Decline
Dy] ine
21.5
35.4
35.4
30.5
22.5
23.p
29.4
23.7
26.4
23.4
27.5
17.3
23.8
23.7
17.9
18.8
21.0
10.9
17.0
1.0
0.9
1.2
1.2
0.8
0.9
1.0
0.9
1.0
1.2
0.7
1.2
1.0
0.9
1.1
1.1
0.6
1.0
Table 2: Eetimates of Life Expectancy1 at Birth by Sex for the 16 Major States of India for 1971-75 and 1991-95
State
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
Alllrdia
e(0) in 1991-95
e(0) in 1971-75
Male
Female
Male
Fetrale
48.4
46.2
49.3
44.8
48.8
56.7
54.8
55.4
60.8
47.6
53.3
46.0
59.0
49.2
49.6
45.4
48.8
52.5
50.9
55.1
63.3
46.3
54.5
45.3
56.8
47.5
49.5
40.5
50.5
49.0
60.3
55.6
60.1
60.2
63.0
64.1
60.6
69.9
54.7
63.5
56.6
66.1
58.3
62.3
57.3
61.5
59.7
62.8
56.1
58.0
62.0
64.0
64.7
63.9
75.6
54.6
65.8
56.2
68.4
59.4
64.4
56.0
62.8
60.9
Increase in Years ine (0)
between 1971-75 and 1991-95
Male
Female
11.9
9.4
13.5
11.3
11.4
6.3
9.3
5.2
9.1
7.1
10.2
10.6
9.1
12.7
11.9
13.2
11.5
13.8
8.8
12.3
8.3
11.3
10.9
11.6
11.9
14.9
15.5
9.2
11.9
Years in Viiiche(O) will Reach
__________ Highest Levels___________
Nfale (79years)
Female (85 Years)
2056-61
2066-71
2056-61
2056-61
2051-56
2056-61
2056-61
2031-36
2071-76
2051-56
2066-71
2041-46
2061-66
2051-56
2066-71
2056-61
2061-66
2056-61
2071-76
2071-76
2061-66
2051-56
2056-61
2056-61
2026-31
2076-81
2056-61
2071-76
2046-51
2066-71
2051-56
2071-76
2056-61
2066-71
bbte:
Estimates for Bihar and West Bengal for the initial period are not available.
Sources: Registrar General, India, Occasional Papers No 1 of 1985, SRSBasedAbridgedLife Tables 1975-80. New Delhi.
Registrar General, India, SRS Analytical Studies, Report No 1 of 1998, SRSBasedAbridgedLife Tables, 1990-94 and1991-95, New Del hi.
Economic and Political Weekly
November 8, 2003
4765
from about 2 to 2.5 children in the 1970s to 2.5 to 3.2 children
in the 1990s. The 16 states fall in three distinct categories in terms
of fertility decline during 1982-84 and 1992-94: (a) those having
low initial level offertility and experiencing fast decline, (b) those
with moderate fertility level and moderate decline and (c) those
with high fertility and slow decline (Table 3).
As a result ofdifferences in the initial levels and pace ofdecline
in fertility and mortality during the recent past, the Indian states
are at different stages of demographic transition. The states of
Kerala and Tamil Nadu are much ahead of the large north Indian
states along the path of transition.10 Age at marriage, literacy
level (especially female literacy), access to and use of contra
ceptive and health care services, level of urbanisation and of
industrialisation also differ among different states.
I
Assumptions Underlying Population
Projections
The state-level projections presented in this paper begin with
the life expectancy at birth as reported for 1991-95 and the TFR
estimates for 1992-94.
Mbctality-Trends
For mortality decline, we have envisaged only one pattern. It
is presumed that consistent with the international experience, the
pace of mortality decline will slow down as life expectancy at
birth rises beyond 65 years. The initial estimates of life expect
ancy are taken from the 1991-95 state-level life tables, based on
the Sample Registration System [Office of the Registrar General
1998b]. In response to the ongoing efforts to control vaccinepreventable diseases and lowering of infant and child mortality,
life expectancy at birth is assumed to increase at a relatively faster
rate (implying an annual gain in life expectancy of 0.4 years for
males and 0.5 years for females) until it reaches 65. The annual
increase in life expectancy is expected to slow down thereafter
Table 4: Hat BxtarstataMLgxatlau during 1971-81 and 1981-91 as
Par Cent of Population Enunerated in 1981 and 1991 Censuses
.q-ate
Both Sexes
1981
1991
Males
1981
1991
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
^harashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
-0.8
-0.9
-0.4
2.8
-0.8
-2.7
1.1
4.2
-3.0
2.0
-0.6
0.5
4.0
-5.8
0.3
-2.3
1.4
3.8
13
2.3
-0.3
-0.2
-1.6
7.3
0.8
4.1
0.4
-2.9
1.6
5.0
1.0
2.7
-0.7
-0.4
-2.6
8.6
-03
2.3
-22
1.7
2.8
-1.6
0.4
-2.4
1.9
3.3
N
1.4
-0.8
-0.6
-2.7
6.0
0.5
-3.6
1.9
6.1
0.8
3.1
-1.0
-0.6
-3.5
9.9
2.7
-1.0
0.6
-2.6
1.9
4.1
-0.2
1.5
-12
-0.7
-3.4
6.6
Females
1981
1991
-0.7
1.9
-1.3
1.3
2.9
0.2
-2.1
1.9
2.6
0.3
1.3
-0.4
-0.4
-2.0
5.2
The estimates are based cn a definition of migrant as a perscn
reporting a 1 nnul -j t-ydi fferent from the place of enuneraticnas the
place of his previous or last usual residence.
N: ItegligibLe.
Sbtazxff.' Census of India, GecyraphicDiet^ributicn of Internal Migration in
India: 1971-81, New Delhi, 1989.
Census of India, 1991, State Profile, NewDelhi, 1998.
jNOteS:
4766
to 0.3 years for males and 0.4 years for females, until the life
expectancy reaches 70 years for both sexes. Thereafter, the annual
gain in the length of life is expected to slow down even further
to 025 years for males and 0.3 years for females.
We have assumed that the gain in life expectancy for females
will be faster than for males throughout the period. The peak
value in life expectancy reached by males is 79 years, and for
females it is 85 years. The age-specific mortality rates or
survivorship ratios, based on the SRS life tables, are assumed
to converge linearly to the pattern implicit in the ‘west’ model
life tables of Coale and Demeny when the e (0) attains its
maximum value.11
Given the different initial levels of life expectancy in 199195, the states are expected to attain the highest level of life
expectancy assumed by us in different years. Both men and
women in Kerala will attain the maximum level of e (0) within
the next 30 years. Except for Punjab in the case of both males
and females and Himachal Pradesh in the case of men only,
women in all the other states will take at least 30 more years
and men 20 more years to catch up with Kerala with respect to
the highest life expectancy.12
The future trends in fertility are difficult to predict. Recently,
a surprising plateauing or stagnation in the national TFR had been
evident since 1991. The TFR was 3.6 during 1991 -92,3.5 during
1993-95 and 3.4 during 1996-97. Therefore, our assumptions
about fertility decline in different states, including those'about
the year ofattainment ofreplacement level offertility, seem rather
arbitrary. The experience of Kerala since 1988 suggests that the
TFR can fall below the replacement level and continue at that
level; but it may either rise or fall further in the years to come.
The base period values of fertility for each state used in our
projections are the averages ofthe SRS age specific fertility rates
and total fertility rates estimated for 1992-94.
One variant of our projections (called standard projection)
assumes that in all the states, TFR would remain stable after it
reaches the replacement level. Another variant of the projection
assumes that unwanted fertility will be eliminated with immediate
effect and after that fertility will decline following the standard
path. In the third variant, fertility is assumed to drop to the
replacement level with immediate effect and continue at that level
in the future. In the fourth variant, we have assumed that in all
the major states, total fertility will drop below the replacement
level to 1.8, as has happened in the state of Kerala and is likely
to happen in Tamil Nadu.
Effect cfMigration
Prima facie, projections for different states of India seem more
difficult than the national projections because interstate migration
can be quite important and therefore estimates of the future
interstate net migration (inmigration minus outmigration) are
needed. At the national level, the volume of net international
migration has been unimportant in the past several decades and
can be ignored. Further, the census data for 1981 and 1991,
presented in Table 4, confirm that the net interstate migration
(measured in terms of persons reporting a place of last residence
different from the place of enumeration) accounted for only
about 3 to 6 per cent of the population even in Maharashtra and
Economic and Political Weekly
November 8, 2003
Therefore, for these two states, our standard projection and the
projection with below replacement level fertility are the same.
Table
‘ ‘ 5 shows the .period when **the major states will attain
.
replacement level of fertility. As noted above, Kerala and Tamil
Nadu had already attained the replacement level offertility (RLE)
by 1988 and 1993, respectively. The other two southern states
of Andhra Pradesh and Karnataka are expected to attain RLE
by 2008. Fertility has declined rather rapidly in recent years in
the small mountainous state of Himachal Pradesh and in
.
Maharashtra, where TFR had dropped below 3 during 1992-94.
StandardProjecticns
However, according to our standard proj ections, these two states
The standard projections have assumed that fertility in each will take five years longer to reach the replacement level fertility
state will decline at the same annual rate as was observed during than Andhra Pradesh and Karnataka,
At the other end of the spectrum are the four large north Indian
the 10-year period between 1982-84 and 1992-94 in the state.
As shown earlier in Table 3, the states fell rather neatly into three states, and Haryana, where the TFR during 1991-95 was above 4.
groups. In
1 one group of stetes, which included the four southern If fertility in these states continues to decline at the slow pace
.
of
states < Kerala, Tamil Nadu, Karnataka and Andhra Pradesh, observed in recent years, they would take 35 to 40 years to reach
amid Maharashtra, fertility had declined at an average annual rate the replacement level fertility. In between these two extremes
“
are a number of states both in Western and in Eastern India, such
of2.9 percent. In the second group ofsix states including Gujarat,
Haryana, Punjab, Orissa,?Assam and West Bengal, fertility had as Gujarat, Punjab, Assam, Orissa and West Bengal, where the
declined at an average rate of 2.4 per cent per annum. In the prevailing level of TFR during 1991-95 was between 3 and 3.5.
third group of four large north Indian states of Bihar, Uttar Their fertility transition is expected to be very similar to that
Pradesh, Rajasthan and Madhya Pradesh, the pace of fertility of Maharashtra and Himachal Pradesh. At the current pace of
decline during 1983-93 was the slowest at 1.7 per cent per annum. fertility decline, most of these states can expect to attain
These are also the states where the initial level of fertility was the replacement level fertility by 2013; only Assam will attain
it in 2018.
higher than that observed in the rest of the country.
In the standard population projection, in all the states except
Kerala and Tamil Nadu, once fertility reaches the replacement Projections BasedcnAssumedElimination
level of 2.1, it is assumed to stay at that level until the end of ofit^nntedFertility
the projection period. In the case of Tamil Nadu, if we assume
that fertility would continue to decline at the rate of 3.5 per cent
In the second set ofprojections, unwanted fertility is eliminated
per annum (the rate at which it declined between 1982-84 and with immediate effect. These projections attempt to bring out
1992-94), it would drop significantly below 2.1 to about 1.4 in the implications of meeting the unmet need for contraception or
a short span of 10 years. In Kerala also fertility declined at an eliminating the unwanted fertility ofcouples so that women have
annual rate of 3.5 per cent between 1882-84 and 1992-94 and only the children they want. The initial level of unmet need for
reached the below replacement level of 1.7 by 1993.13 Instead family planning or unwanted fertility in each state is assumed
of envisaging a reversal of the trend and a rise in fertility to the to be the same as the state-specific estimates of the extent of
replacement level in these two states, for the standard projection unwanted fertility estimated by the National Family Health Survey
we have assumed that the TFR will continue at the below conductedin 1992-93[IIPS 1995].Infourstates(AndhraPradesh,
replacement level of 1.8 until the end of the 21st century.14 Maharashtra, Punjab, West Bengal), if unwanted fertility is
West Bengal, where it was more important. Interstate migration
has been important in Delhi, the two north-eastern states of
Arunachal Pradesh and Tripura, and in the union territories of
Chandigarh, Pondicherry and Andaman and Nicobar Islands as
well as in Lakshadweep. However, we have not prepared separate
projections for these relatively small territories. Given the small
volume of migration even in major states, we have assumed it
to be an unimportant factor influencing population growth.
VA.
AV***
—-----------------------
—
Z
---- ---------------------------------------------
w
—
Table 5« Total Fertility Rate 1111991-95, Year Mme It Will ftwrihRaplaomMct Level CRL) acoording to Standard Projecticn
St^e
TFR below 3
Ksrala
Tamil Nadu
Andhra Pradesh
Himachal Pradesh
Karnataka
Maharashtra
TFUbetMsenJ. 0and4. 0
Punjab
West Bengal
Gujarat
Or-iRm
Assam
All India
TFR above 4. 0
Haryana
Madhya Pradesh
Bihar
Rajasthan
Uttaar Pradesh
TFR in 1996-2000
1991-95
2001-05
2006-10
2021-25
2026-31
Year WhenTFR Years Needed
Reaches RL
to Reach RL
2.1
NA
5
15
20
15
20
22
22
23
23
2.4
2.5
2.1
2.1
2.1
2.1
2.2
2.3
2.1
2.1
2013
2013
2013
2013
2018
2018
20
20
20
20
25
25
3.1
3.1
3.1
2.8
2.8
2.7
2.8
3.1
2.6
2.5
2.5
2.6
2.8
2033
2028
2028
2028
2033
40
35
35
35
40
2.1
2.5
2.7
2.6
2.7
2.3
2.4
2.3
2.4
2.1
22
2.1
22
3.0
3.0
3.2
3.2
3.5
3.6
2.7
2.7
2.8
2.9
3.1
3.2
2.4
2.4
2.6
2.6
2.7
2.8
4.2
4.3
4.5
4.5
5.1
3.8
3.8
4.0
4.0
4.5
3.4
3.4
3.5
3.5
3.9
November 8, 2003
2016-20
NA
1998
2008
2013
2008
2013
1.7
2.2
2.8
2.9
2.9
2.9
Economic and Political Weekly
2011-15
32
3.5
2.1
2.4
2.3
22
2.3
2.5
22
2.1
2.1
2.1
22
4767
eliminated, TFR level would drop very close to die replacement
level. In Himachal Pradesh, the gap between the prevailing total
fertility rate and wanted fertility was the highest in the country;
31 per cent of the current fertility was reported as unwanted.
Elimination ofunwanted fertility would lower the TFR in Himachal
Pradesh slightly below the replacement level. Surprisingly, even
in die states ofKerala and Tamil Nadu, where the estimated TFR
was close to or below the replacement level, 12 and 15 per cent
oftotal fertility was reported as unwanted, respectively.15 Wanted
fertility was significantly above the national average of TFR of
2.6 in all the four large north Indian states and also in Haryana
in north India; it ranged between 2.8 in Haryana and Rajasthan
and 3.8 in Uttar Pradesh.
In the states, where TFR was above the replacement level after
the unmet need or the unwanted fertility was eliminated, we have
assumed that the TFR would gradually decrease during successive five-year periods until it reaches the replacement level of
2.1. The year when that would happen will vary between the
states and would depend on the existing or initial level of fertility,
the extent of unwanted fertility (reported in the NFHS survey),
and the pace of decline in fertility observed in each state during
1982-84 and 1992-94.
The information on the extent of unwanted fertility, estimated
by the NFHS, is shown in Table 6. Admittedly, unwanted fertility
is unlikely to be eliminated suddenly. But the assumption of its
elimination is made in order to estimate the effect of unwanted
Tabla 61 Tbtal FertilityRata, MtaitedFertillty Rate aodtkMKxtad
Fertility aa Per Oent of TFRby State, 1992-93 (NFBSData)
State
TFR in
Wanted
Wanted
Unwanted UMrtedlfertility
ferala
Tamil Nadu
Andhra Pradesh
Himachal Pradesh
Karnataka
Maharashtra
Punjab
West Bengal
Gi^arat
Cirima
Assam
Alllrdia
Haryana
Madhya Pradesh
Bihar
Rajasthan
Uttar Pradesh
1992-93
Rrtility
RTtilfry
Rrtitity
as Per Cent of TFR
2.00
2.48
1.82
1.76
2.09
2.04
2.18
0.18
0.72
0.50
0.93
0.67
0.73
0.77
0.70
0.66
0.60
1.01
0.75
1.18
0.69
09.0
29.0
2.59
2.97
2.85
2.86
2.92
2.92
2.99
2.92
3.53
3.39
3.99
3.90
4.00
3.63
4.82
2.13
2.15
2.20
2.33
2.32
2.52
2.64
2.81
3.21
3.18
2.78
3.82
0.82
0.85
1.00
19.3
31.3
Projections BasedcnAssunption ofAttainment
In the third set of hypothetical population projections, fertility
is assumed to reach the replacement level in all the states with
immediate effect, regardless of the prevailing fertility levels in
each of the states. The TFR is assumed to drop to 2.1 during
the five-year period 1996-2001 and is assumed to stay at that
level until the end of the 21st century. In reality, fertility cannot
drop so drastically from a relatively high level, but the projections
based on this assumption help to estimate the contribution of
the momentum of population growth. The momentum is in
part due to a young age structure of population and in part
due to future improvements in mortality that are envisaged in
the country and built into the mortality regime assumed for
the projections. Again, we have not carried out this set of
projections for Kerala and Tamil Nadu, because it would
require raising their TFR from below replacement level to the
replacement level.
BelowReplaoementLevel fertilityProjections
The fourth set of projections is an extension of the standard
projections. Instead of assuming that fertility will stabilise at the
replacement level, with a TFR of 2.1, this set of projections
envisages that fertility would decline below the replacement level
up to a TFR level of 1.8. Under this projection, all the states
are assumed to maintain a TFR of 1.8 through the rest of the
21 st century after it is attained. Given the different levels ofinitial
fertility in the Indian states, and the variations in the pace at which
fertility has declined in recent years, the below replacement level
fertility will also be reached in different time periods.
23.5
25.5
26.4
24.7
22.1
20.5
28.6
22.1
29.6
17.7
20.5
23.4
20.7
Nttee: - Ffertilityrates are calculated cn the basisof births Airing the 0-36
rrenths before the interview of women aged 15-49.
- A birth was ccnsidered unwanted if the nuntoer of living children at
the time of conception was greater than or equal to the current ideal
nurber of children, as reported by the respondent. By subtracting
was derived,
- timet need for familyplanning includes need for spacing as well as
for limiting fertility, tlxret need for spacing is estimatedbytaking
account of the pregnant women whose pregnancy was mistimed,
women whose last birth was mistimed and those women who wanted
to wait two or more years before their next birth but were not using
any method of family planning, timet need for limiting is estinated
by taking into account of the pregnant women whose pregnancy was
unwanted, wcxnen whose last child was unwanted and who did not
want any children but were not using any family planning to avoid
beconing pregnant.
Source: Internaticnal Institute fcrKpulatirxiScienoes (UPS), 1995, National
FamilyJtfealth Survey, 1992-93, Bootoay, UPS.
4768
fertility on the long-term growth of population expected under
the standard projection in different states.
Population Growth According to Alternative
Proj actions
The population projections for 1991-2101 for all-India are
shown as Figures 1. Additionally, figures for one state from each
of the three groups are also given.16,17 For all the major states
and for India, the expected population in years 2051 and 2101
according to the standard projections is shown in Table 7 along
with the base population of 1991. The population of India is
expected to nearly double in a 60-year period during 1991-2051
from 846 million to 1620 million. However, the state-level
differences in the population growth would be quite large. By
2051, population is expected to more than double or increase
by nearly one and a half times in the large north Indian states
including Haryana from 352 million to 820 million. Thus, these
five states between them would contain more than half the
population of India in 2051.18 The population will increase by
about 75 per cent in most of the other states of the country. The
only two exceptions are Tamil Nadu and Kerala, where popu
lation growth over the next 60 years is expected to be less than
30 per cent.
Apart from the northern states of Bihar, Madhya Pradesh,
Rajasthan and Uttar Pradesh, where population will range be
tween 106 and 337 million by 2051, the other states with a
Economic and Political Weekly
November 8, 2003
the states after reaching a peak in different years. This is evident
in the Figures 1 to 4 for all-India and the three states of Andhra
Pradesh, Guj arat and Madhya Pradesh. For the country as a whole,
2000
the population in 2101 with a below replacement level of
fertility would be 25 per cent smaller (1.36 billion as against 1.81
1800
billion) than if it is assumed to remain stable at the replacement
level. As might be expected, the extent of decline in total
population by 2101 would differ between the states, according
1600
to the year when the replacement level of fertility is expected
J
to be reached. The difference would be of the order of 30
J 1400
per cent in the six states of Andhra Pradesh, Himachal Pradesh,
Karnataka, Maharashtra, Punjab and West Bengal. In the
1200
four large north Indian states and Haryana, the expected popu
lation size in 2101 with a below replacement level of fertility
1000
would be about 20 per cent smaller than under the standard
projection.
800
If unwanted fertility were to be eliminated with immediate
effect, India’s population in the year 2101 would be about 13
per cent (240 million) smaller than is expected under the standard
600
’
1991 2001 2011 2021 2031 2041 2051 2061 2071 2081 2091 2101 projection(1.57billion as against 1.81 billion). As can be expected,
Year
the effect of this factor on the population size would be greater
RLFby 1998
RLFby 2018
in those states (Himachal Pradesh, Haryana, Assam) where nearly
TFR of 1.8 by 2028
NSinerted fertility
30 per cent of the TFR was reported as unwanted fertility
population exceeding 100 million would be Andhra Pradesh, according to the 1992-93 NFHS data.
For India as a whole, the assumed immediate attainment of
Maharashtra and West Bengal. These seven states between them
will contain more than a billion people or 65 per cent of India’s a replacement level fertility would lower the 2101 population
by only 16percentbelowthestandardprojection(to 1.52billion).
estimated population of 1.6 billion.
The effect of attainment of replacement level fertility in all Relative to the projection envisaging an immediate elimination of
the states will be evident in the quantum of increase in unwanted fertility; total population with an immediate attainment
the population during the next 50-year period between 2051 and ofreplacement level of fertility would be only 3 per cent smaller.
2101. Although the net increase in population will continue In the demographically backward states such as Bihar, Madhya
to be positive in all the states, except Tamil Nadu and Pradesh, Rajasthan and Uttar Pradesh, population with an im
Kerala, the absolute increase in the country as a whole will mediate attainment of replacement level of fertility would be 30
be about 193 million, or 12 per cent above the figure reached per cent smaller than under the standard projection. In fact, in
these four states, the population size in the year 2101 would be
in 2051.
If fertility declines below the replacement level to a TFR of smaller under this assumption than ifthe below replacement level
1.8, the absolute size of population will begin to decline in all TFR of 1.8 is reached after the standard path of fertility decline.
FLgmlt Bopulafclcnof Ibdl&aoaaDdhvtoAltKxiafcivB
Aasuaptlcns, 1991*2101
Table 7: PryiinHcnnf
State
Kerala
Tamil Nadu
Andhra Pradesh
Himachal Pradesh
Karnataka
Maharashtra
Si±total
Per cent of total pcpulaticn
Punjab
West Bengal
Gujarat
Orissa
Assam
SLfctotal
Per cent of total pcpulaticn
All India
Haryana
Madhya Pradesh
Bitar
Rajasthan
Uttar Pradesh
Sctfcotal
Per cent of total pcpulaticn
In 1991. 2051 rad 2101 acxxodHagto Standard Projection, by State
1991
2051
2101
29.1
55.9
66.5
5.2
45.0
78.9
280.6
31.2
20.3
68.1
41.3
31.7
22.4
183.8
21.3
846.3
16.5
66.2
86.4
44.0
139.1
352.2
41.6
36.0
72.0
119.9
9.5
78.0
147.4
462.8
28.2
35.7
121.9
73.0
53.9
42.0
326.5
19.9
1619.5
41.1
148.0
188.0
106.1
337.0
820.2
50.0
25.2
57.0
130.5
10.3
85.0
159.6
467.6
25.4
37.9
132.0
80.2
59.5
47.0
356.6
19.4
1812.2
48.8
175.3
216.7
125.9
405.0
971.7
52.9
Economic and Political Weekly
November 8, 2003
Jteolute Difference
between 1991-2051
Absolute Difference
between 1991-2101
Per Cent Increase
djring 1991-2051
Ffer Cent Increase
during 1991-2101
-3.9
-13.4
2.0
96.2
98.1
88.9
102.3
66.6
6.9
16.1
45.4
4.3
33.0
68.5
182.2
64.0
5.1
40.0
80.7
187.0
23.7
28.8
68.3
82.7
73.3
86.8
64.9
15.4
53.8
31.7
22.2
19.6
142.7
17.6
63.9
38.9
27.8
24.6
172.8
75.9
79.0
76.8
70.0
87.5
77.6
86.7
93.8
94.2
87.7
109.8
94.0
773.2
24.6
81.8
101.6
62.1
197.9
468.0
965.9
32.3
109.1
130.3
81.9
265.9
619.5
91.4
149.1
123.6
117.6
141.1
142.3
132.9
114.1
195.8
164.8
150.8
186.1
191.2
175.9
4769
Figure 2: Population of Andhra Pradeah according
toAltaxnativeAasuaptlxxia, 1991-2101
V
Decomposition of Population Growth
140
The absolute growth of population between 1996 and 2101
according to the standard projection for each state is decomposed
to estimate the contribution of unwanted fertility, high desired
fertility and population momentum. The share of each of these
three factors, shown in Table 8, varies a great deal between
the states of the Indian union, thereby highlighting the fact that
the regional diversities within the country require distinct
policy responses within the framework of the overall national
population policy.
The share ofunwanted fertility in the total expected population
growth varies between a low of 10 per cent in Andhra Pradesh
and 15 per cent in the other southern state of Karnataka to above
40 per cent in Haryana and Uttar Pradesh. In Bihar, Rajasthan
and Madhya Pradesh also, where the initial levels of fertility have
been high and the decline in recent years has been slow, the share
of unwanted fertility in expected population growth was higher
than the national average of 24 per cent. If the family planning
programme in these states can be strengthened and the unmet
needs of couples can be met by giving them access to a wide
range of methods, the prevention ofunwanted pregnancies would
significantly reduce fertility as well as population growth in these
’
large
states.
On the other hand, the share of high desired fertility in the
total expected population growth is quite low in a majority of
the states in India; for the country as a whole it was estimated
to be only 5.5 per cent. Again, the only exceptions are the large
north Indian states, where the share ofthis factor ranged between
15 and 22 per cent. In all the other states, it was in single digit
numbers or even negative. The very low or negative share implies
that if the couples’ unmet needs for family planning are met;
their desired fertility would reach very near or below the replacement level. In other words, couples in states like Karnataka,
Maharashtra, Punjab and West Bengal want even fewer children
than the number needed for the replacement level of fertility or
a TFR of 2.1. This is a revolutionary change in a country where
earlier findings have indicated that throughout the country, the
preference for sons had kept the wanted fertility high, and the
sons are much more valued than are daughters. Evidently, the
son preference has become rather weak in all the four southern
130
120
110
J
80
70
60
50
40
------ T------ T-------T------ T------ T------ T------ T------ T------ T------ T------ T------ I------ T------ T------ T-------T------ T-------T------ ,------- T-------:------- >
1991 2001 2011 2021 2031 2041 2051 2061 2071 2081 2091 2101
Year
RLFby 1998
TFR of 1.8 by 2018
RLFby 2008
ft>\x*ented fertility
states of India and the desire for more than one son has rapidly
dropped in many other parts of the country as well. On the other
hand, wanted fertility is somewhat high in the northern belt of
the country,
country, where
where the
the unmet
unmet need
need isis also
also relatively
relatively high.
high. The
The
the
desire for large families is very likely related to the higher infant
and child mortality levels in these states.
According
to Table 8, 70 _per cent of the _population
growth
j
_
in India as a whole is due to the momentum built into the young
age distribution of the population.19 The share of high desired
fertility in the total growth is less than 6 per cent The balance
24 per cent of the growth is due to high-unwanted fertility. In
the
southern states of India as well as in Maharashtra, Gujarat,
t___________________________
West Bengal and Orissa, momentum accounts for more than 80
per cent ofthe prospective population growth. On the other hand,
in the four northern states and in Haryana, momentum accounts
for only about 43 to 53 per cent of the population growth.
The estimates of the share of high desired fertility, unwanted
fertility and growth momentum in the total expected population
growth obtained for the country as a whole in the present exercise
are somewhat different from those obtained when a similar
exercise was done a few years ago [Visaria and Visaria 1996: 8].
Table 8: Factors tbderlydixj Papulation Qro»»th •coording to the Standard Projection for Major States of India, 1991-2101
State
Kerala
Tamil Nadu
Andhra Pradesh
Himachal Pradesh
Karnataka
Maharashtra
Punjab
West Bengal
Gujarat
Orissa
Assam
All India
Haryana
Madhya Pradesh
Bihar
Rajasthan
Uttar Pradesh
4770
Total Expected Pjpulation Growth
Absolute
Percent
1.1
64.0
5.1
40.0
80.7
17.6
63.9
38.9
27.8
24.6
971.7
32.3
109.1
130.3
81.9
265.9
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
limantedFertility
Absolute
Percent
6.6
1.1
5.9
14.0
3.4
10.4
7.9
5.3
6.5
237.4
14.0
29.2
39.0
27.7
107.0
10.3
21.6
14.8
17.3
19.3
16.3
20.3
19.1
26.4
24.4
43.3
26.8
29.9
33.8
40.2
HictiEBsixedfertility
Absolute
Percent-
0.2
0.3
-1.0
-1.9
-0.4
0.2
0.7
-0.3
57.0
2.5
24.7
22.4
12.4
43.4
Momentum of Growth_
Absolute
Percent
0.3
5.1
-2.5
-2.4
-2.3
-3.0
0.5
2.5
-1J2
5.9
7.7
22.6
17.2
15.1
16.3
Economic and Political Weekly
57.2
4.3
35.1
68.6
14.6
55.4
30.8
21.8
18.4
677.3
15.8
55.2
68.9
41.8
115.5
89.4
84.3
87.8
85.0
83.0
86.7
79.2
78.4
74.8
69.7
48.9
50.6
52.9
51.0
43.4
November 8, 2003
toMtanoatlveAMUiptdjCDa, 1991-2101
JlSMSpdOC** 1991-2101
200
90
180
80
160
3 70
5 140
i 120
50
100
40
80
30
60
20
------ T------ T------ T------ T------ T------ r------ >------ T------ >-------T------ T------ T------ T------ T------ T------ T------ T------ T------ T------ T------ T------ ,
1991 2001 2011 2021 2031 2041 2051 2061 2071 2081 2091 2101
40 -I—^-r—r
r—r---- t
.
Year
RLF by 2013
Jbunwantedfertility
■
.
■
r-.
r
t
t-------- r------ r-
1991 2001 2011 2021 2031 2041 2051 2061 2071 2081
2091 2101
Year
RLFby 1998
TFRof 1.8 by 2023
This is mainly because the present series of projections have
used more recent estimates of total fertility rates for the period
1992-94, rather than the 1990-92 estimates that were used earlier,
The estimated pace offertility decline during the decade between
1980-82 and 1990-92 (17.8 per cent or from a TFR of 4.5 to
3.7) was slower than between 1982-84 and 1992-94 (22.2 per
cent or from a TFR of 4.5 to 3.5), in spite of the slow decline
in the early 1990s. A somewhat faster pace of fertility decline
assumed in our standard projection has raised the estimated role
of momentum and lowered that of the high desired fertility.20
IE
Demographic Consequences of Prospective
Population Growth
RLF by 2028
hbuT*ented fertility
RLF by 1998
TFRof 1.8 by 2053
old age dependency was very small. However, by 2011, die
postulated fertility decline will lower the overall dependency ratio
to below 60 per cent in all the states except in the large north
Indian states and Haryana, where it will hover around 70 per
cent. By 2051, there will be a steady increase in the share of
old age dependency to almost the same level as (or a higher level
than) child dependency ratio in all the major states except for
the five states in the northern zone.
In Kerala and Tamil Nadu, by 2051 the old-age dependency
ratio can be expected to be almost twice as high as the child
dependency ratio. These states would have to prepare themselves
from now onwards to address the health, economic and social
needs of the rising proportion of the elderly in their population.
Demographic Transition
Given the large regional disparities in the levels of fertility and
India and most of its states are presently in the third stage of
also of mortality, the long run age distribution of population, the
composition of dependents (young as well as old) and the share demographic transition where both mortality and fertility have
of the population of working ages will differ significantly be been declining for some time now. Since the initial level of
tween states. The growing pressure of population on land will fertility and the pace of fertility decline vary between the states,
also begin to influence the structure of employment in different the demographic transition is expected to be completed in difstates ofthe country. The associated policy implications will merit ferent time periods in different states. This is shown graphically
in Figures 9 to 12. As may be expected, the rate ofnatural increase
attention by the state governments.
will decline to around or below one per thousand or 0.1 per cent
by 2071 in Andhra Pradesh, Karnataka, Maharashtra, Gujarat,
DependencyRatios
Punjab, Himachal Pradesh and West Bengal. The five north
The estimated age distribution of the population and the as- Indian states of Bihar, Uttar Pradesh, Rajasthan, Madhya Pradesh
sociated dependency ratios for all-India are shown in Figure 5 and Haryana and in Assam and Orissa will take 10 to 15 years
and for three representative states from each group in Figures 6-8 longer to complete their demographic transition. On the other
according to the standard projections. The child and old age hand, the situation in Kerala and Tamil Nadu is likely to be quite
dependency ratios and total dependency ratios are shown for a different in the sense that the rate of natural increase may become
period up to 2051 only. Also, figures are shown only at 20-year negative in 30 to 40 years.
interval, i e, for the years 1991, 2011, 2031 and 2051. Depen
MI
dency ratios help us to assess the extent of economic dependence
in the population.
PoLLcy* DqplicaticDB
In the initial year of 1991, the total dependency ratio exceeded
The large differentials in the share ofunwanted fertility, desired
70 per cent in all the states of India, except for Kerala and Tamil
Nadu, where it ranged between 60 and 65 per cent. Also, the fertility and population momentum between states in a large
child dependency constituted the major share of dependency country call for very different and state-specific population
burden on the population in working age groups. The share of strategies and programmes to lower the growth of population.
Economic and Political Weekly
November 8, 2003
4771
Figure 5: Total, Child and Old Age IMpcodancy Batloe
for Sadia for SalectedTeare
FdgureGt Total, CM Id and Old Agen^pandicy Bwf-lrw
for Andhra Pradesh for Selected Tears
90
90
80
o
80
70
60
s 50
I
■8
o
s 50
&
40
I
30
20
10
0
70
60
m
1991
40
30
20
10
2031
2011
rilbtal
Year
child
0
2 051
1991
2011
□old
□ibtal
Figure 7: Total, Child and Old Age
dijarat for Selected Tears
Ratios for
80
70
-2
60
70
50
I
50
40
c
40
60
30
30
20
20 -
10
□dd
90
80
I
2 051
Figure 8: Total, CMld and Old Age
Par 4
for Madhya Pradaoh for Selected Tears
90
X
203 1
Year
□child
u
1991
10
0
nr
19 91
2011
2031
Year
□natal
□child
Qcid
rn
2011
2 051
ibtal
203 1
Year
child
2051
□old
The implications need to be spelt out and may require major women. Two, there is a need to expand the range ofcontraceptive
structural changes in the way health and family welfare funds methods available through the programme. The services for
are allocated between states and the centre. For example, the treating reproductive tract and sexually transmitted infections are
centre may consider making family welfare a state subject, just rather rudimentary in the public sector in all the states. Some
as health has been.
states like Tamil Nadu are somewhat ahead ofothers in initiating
Improving access to family
be the most measures to alleviate this major lacuna in the programme, yet
- planning
- services would
--------------------effective means of reducing high-unwanted fertility in the north it has a long way to go.21 Similarly, in spite of abortion being
Mian states as well as m the north-eastern region of the country, legal in the country since 1972, safe abortion is still not easily
There is enough evidence that access to any kind of health care, available to most women throughout the country. Training
including family planning methods; to those who need them the paramedical personnel in safe and new technique of abortion
most is severely limited in these states. One of the issues that should be viewed as a r
74iitmsii
priority.
Also, the feasibility of making
witi have to be addressedrelates to the dichotomy between health medical abortion widely available, need to be explored. The states
and family welfare and treating the. former as
a state the
subject
and and
willtraining
have toof their personnel
j assess
capacity
the latter as the centre subject. Although at the field level, the before launching such measures.
grass roots functionary provides both the health and family
The Indian government has permitted the private practitioners
planning services to the clients, there is often a disjunction as well as some non-governmental organisations to provide
between the two activities, because allocations of resources, injectible contraceptives services to their clients and charge some
monitoring of activities, etc, are different. In poorly governed fee for them. While these experiments need to be thoroughly
backward states, these problems are accentuated. A recent evaluated, the feasibility of making them available through the
exposure visit for the health ministers of some of the backward public sector, including necessary training for the providers,
states to the health facilities in Tamil Nadu state, which has needs to be explored to enhance the V11WVV
vc»
choice ofwuuaw
contraceptives
implemented the new reproductive and child health programme available to the'couples” The^'^CTt'measur7to provide taming
more successfully than most other states, was fa step in the to
...
doctors in no-scalpel vasectomy is a welcome step in increasing
right direction.
the choice and engaging the participation of men.
Nationally, the family welfare -programme
has been revamped
* I
While we have not presented the state level data on infant and
to provide more comprehensive services to women and children child mortality, there are large interstate differences in the
and also address the involvement of men in the welfare of the prevailing levels. According to the 1997 estimates, infant morfamily. Two relevant issues have been articulated in recent years tality rate (IMR) ranged between a low of 12 per 1000 live births
in the Indian context. One, along with contraceptive methods, in Kerala to 94 and 96 in Madhya Pradesh and Orissa, respecefforts will have to be made to providing easy access to good tively. In Rajasthan and Uttar Pradesh, IMR was 85, significantly
quality reproductive health, including safe abortion services, to above the national average of71. On the other hand, IMR ranged
4772
Economic and Political Weekly
November 8, 2003
Flyura 9t vital Bataa Xqpllclt dnStandtadBapulatimFroJaotlou
florUxHa, 1991-2101
Vigun 101 Vital Bataa Hillcit In Btmdta^RpilBtlQnBEcjacticn
for Andhra PradMh, 1991-2101
35 -----------------
35
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2- 20
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--- 1--- ,----.---- !---- 1--- 1--- 1----!----1--- X--- X--- X--- X--- X--- X--- 1---- 1--- T~ !— T—
Birth Rate - - - Death Rate — “Natural Increase Rate
■ Birth Rate - - - Death Rate — “Natural Increase Rate
Figure 11: Vital Bates Thplirrit In Standard Population Projection
fiorGujarat, 1991-2101
1--- r—
Period
Period
1
---- 1---- X--- X--- X--- 1---- X--- 1---- 1---- X--- X--- X--- X--- X--- 1---- X--- X--- X--- 1
1991- 2001- 2011- 2021- 2031- 2041- 2051- 2061- 2071- 2081- 209196
06
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66
76
86
96
1991- 2001- 2011- 2021- 2031- 2041- 2051- 2061- 2071- 2081- 20919606
16
2636465666
76
8696
Figure 12: Vital Rates
in Standard Population Projection
for Madhya Pradesh, 1991-2101
35 ---------------
35
30
30
§ 25
5
& 20
s
co 25
I
CL
o
20
§
®
I 15
15
tn
2
a
10
10
£
5
5
0 —.—i—i—i—i—i—<—i—i—i—<—i—i—i—>—<—-—r-r—rr1991- 2001- 2011- 2021- 2031- 2041- 2051- 2061- 2071- 2081- 20919606 16
2636465666
76
8696
Fteriod
i ■■ Birth fete - - - -Death Rate — — Natural hcrease Rate
between 53-55 in the states of Karnataka, Tamil Nadu and West
Bengal [Office ofthe Registrar General 1999]. In the states where
IMR is high, a strong effort to improve the health and nutritional
status of children and mothers must remain a top priority. This
should be viewed not only as an important goal in itself for
improving the well-being of people, but also because lowering
of infant and child mortality will also reduce wanted fertility
insofar as couples try to replace deceased children and seek to
insure against the loss of children [Bongaarts 1990].
A concerted effort to lower infant and child mortality will
require a programme ofuniversal immunisation, provision ofsafe
drinking water to reduce both morbidity and mortality resulting
from water-borne diseases, and ante-natal care and safe delivery,
In the large north Indian states, these basic minimum facilities
are not available to those who live in remote areas, belong to
backward and poor families and are not literate. Improvements
in these services will positively enhance the credibility of the
health care providers as well of the government.
In the large north Indian states and Haryana, the average age
at marriage of girls continues to be quite low and is lower than
the average for the country as a whole. Concerted efforts will
have to be made to increase the age at marriage in these regions,
Further, in this entire belt, NFHS has indicated quite a strong
son preference. As one of the authors has argued elsewhere, it
Economic and Political Weekly
November 8, 2003
0
------- ■------- ‘'------- 1------- ‘------- 1------- ■------- 1------- 1------- '------- 1-------1------- 1
1—1------ ‘-------- 1
*------ ‘—
1991- 2001- 2011- 2021- 2031- 2041- 2051- 2061- 2071- 2081- 209196
06
16
26
36
46
56
66
76
86
96
Period
...... — Birth Rate - - - -Death Rate — — Natural hcrease fete
is not easy to address culturally and socially governed norms
or preferences through policies or programmatic interventions.
Yet, efforts to educate the people about the implications of
alternative courses of behaviour can be expected to change their
actions at least in the long run [Visana, Leela 1999].
The interstate disparities in population growth evident in the
standard projection would have altered the level ofrepresentation
of different states in the national parliament over the next 25
to 30 years. However, the national population policy, announced
by the government of India during February 2000, has recommended that until 2026, the number of seats for each state in
the Indian parliament will continue to be based on the population
enumerated by the 1971 Census. To mitigate political tension
and an adverse effect on the state-centre relationships, the freeze
will presumably need to be extended beyond 2026.
w
CSosiclusion
In this paper we have decomposed the prospective population
growth in the 16 major states between 1991 and 2101 into three
components to estimate the contribution of each of them
individually. The components are: growth momentum built into
the age distribution ofthe population of each state as enumerated
4773
by the 1991 Census, the desired high fertility and the unwanted
fertility as reported by the respondents in the National Family
Health Survey, conducted in 1992-93.
The state level population projections under these alternative
scenarios have assumed that in all the states, mortality will
continue its downward trend at the pace at which it has in recent
decades. The possibility of increase in mortality at certain ages
or slowing down the pace of decline, due to relatively high
reported cases of HTV/AIDS in some states, is not built into our
projections. The loss of life due to major natural calamities is
difficult to predict.
The standard projections are based on the assumption of a
continuation of the decline in fertility in each state at the level
that was observed during a decade between 1982-84 and 1992-94.
Although all the states in India have experienced fertility decline
in recent years, the states have varied significantly both in the
initial level of fertility considered by us and in the pace of fertility
decline experienced by them in the recent years. The extent of
reported unwanted fertility has also been different among states.
These variations are reflected in the population projections and
in the estimations ofthe share ofeach ofthe contributory factors.
The resulting analysis clearly points to the state-specific policy
measures that will have to be initiated in order to meet the unmet
need for family planning, lowering desired fertility and also
slowing the momentum of growth.
Additionally, the Indian states will also have to prepare them
selves for certain other outcomes or consequences of the popu
lation growth. For example, the state level differentials in the
rate ofpopulation growth and the resulting variations in the child
and old age dependency will have very different impheations
for the expenditure and investments necessary for the education
of the children in school-going ages, for the health care of young
children and for maternal services. In Kerala, for example, a
number of primary schools, managed or run by the state, have
been slowly closing down because the absolute number ofchildren
of school-going age has been declining as a result of the fall in
fertility. There is however, a flip side to this also. With the decline
in the total number of children that couples have, the aspirations
of providing the best education that the parents can afford, have
risen and the private fee-charging schools continue to flourish.22
In less than a decade, a similar situation is likely to occur in Tamil
Nadu, where fertility has been declining and schooling at least
at the primary level has become nearly universal23 These states
can use their funds to improve the quality of education in the
government-run schools and also provide more diverse voca
tional education to the older children. The states where the school
going population will continue to increase due to both population
growth and increase in enrolment in schools in the coming decade
or so, will have to spend a large proportion of their revenues
on providing basic education by opening more primary schools
for the children. Training and hiring teachers, construction of
school buildings, etc, will continue to claim a larger share of
their revenues.
On the other hand, several states will find a steady increase
in the proportion and the number ofthe elderly in their population
and will need to initiate effective measures to safeguard their
well-being and to meet their needs for both physical and psycho
logical health care. Again, the state of Kerala has been very
well aware of the implications of the ageing of its population.
However, measures to alleviate the problems associated with
ageing are slow to evolve. The problem is not likely to be acute
4774
for a few decades in the states with relatively high fertility, but
the issue cannot be ignored for too long.
There is a likelihood of new pressures for interstate migration
because of differences in the density of population on land,
development ofinfrastructural facilities, and employment opportunities. Given the linguistic barriers and uneven economic and
social development of different states, tensions between the sons
of the soil and those who migrate in from other regions will
surface in many places in India from time to time. The situation
is likely to be accentuated in the future and appropriate policy
responses will merit serious consideration. SEI
Address for correspondence:
gidrad 1 @sanchamet. in
Notes
[Pravin and I worked on this paper during 1999-2000 and nearly finalised
it just before his untimely death His contribution to this work was immense.
Our grateful thanks are due to John Bongaarts and Mari Bhat for providing
very valuable guidance, to Jignasu Yagnik for the projections and to Shomo
Shrivastav for drawing figures for all the states.]
1 The estimated share of the three factors of momentum, unmet needs and
high wanted fertility in the expected population growth was noted in the
Ninth Five-Year Plan and also in the National Population Policy, 2000,
that was announced on February 15, 2000 by the government of India.
2 The methodology underlying the decomposition exercise has been outlineJ
by Bongaarts [Bongaarts 1990 and 1994].
3 Since the age data are not yet available from the 2001 population count,
1991 Census age distribution is used for the projections. Consequently,
fertility and mortality estimates for the period around 1991 Census are
used for the projection exercise.
Economic and Political Weekly
November 8, 2003
4 The demands from many sections of population from these states for
forming independent states is viewed as reasonable by many in the
country, because they have a large population, with considerable socio
cultural diversity. The administrative unit of state appears too big in these
large states for efficient governance. A bill introduced in the Indian
parliament has already set up (a) Uttaranchal state out of the hilly districts
of Uttar Pradesh, (b) Jharkhand state for the tribal population of Bihar
and (c) Chattisgarh state for the tribal population of Madhya Pradesh.
The total number of states in India has increased to 29 with the three
new states carved out of the three largest states. Even after Uttaranchal
state is carved out from the territories of Uttar Pradesh, the latter remains
the most populous state in India.
5 In many European countries such as Finland, Belgium, France, and
Germany and in Japan, female life expectancy at birth is estimated to
be above 80 years, which is 7 to 8 years higher than that of males. See
Population Reference Bureau (1999).
6 In urban areas, the female life expectancy at birth was higher by 1.5 to
4 years than the male e(0) even in those states where in the rural areas
the female life expectancy was lower than that of males. See Office of
the Registrar General, India (1998b).
7 The estimates are based on the Sample Registration System (SRS) data.
The SRS had not become fully operative in the initial years in the large
North Indian State of Bihar.
8 The chief minister of Andhra Pradesh has recently followed the example
set in 1993 by the then chief minister ofTamil Nadu in aspiring to achieve
a TFR of 1.5 by 2020 [Government of Andhra Pradesh 1999].
9 The total fertility rate in Goa was 1.9 according to 1992-93 NFHS and
1.77 according to 1998-99 NFHS. A long-term projection has not been
prepared for the state, where migration seemed relatively quite important.
Some 93,000Goa-bompersons had outmigrated, whereas 1,79,000 persons
bom outside the state had migrated to Goa from other states or from other
countries. The net lifetime migrants constituted 7.3 per cent of the
enumerated population of Goa in 1991 [Census of India 1991b].
10 Demographic transitions in the states of Kerala and Tamil Nadu have
been analysed the most by Indian scholars. The analyses highlight the
contribution of increase in the age at marriage and increase in female
literacy level in fertility decline. Qualitative studies undertaken in Tamil
Nadu also emphasise the changing aspirations of couples for their children
as a major factor in desiring smaller number of children [see for example,
Bhat and Rajan 1997, Kishor 1994, Ramasundaram 1995, Visaria, Leela
2000].
11 The highest levels of life expectancy had been selected in the programme,
which used the ‘west’ model life tables of Coale and Demeny [see Coale
and Demeny 1983].
12 However, it is almost impossible to predict the course the HIV/AIDS
will take in the country and its impact on mortality.
13 Like the gain in life expectancy, which tends to slow down after reaching
a certain level, the pace ofdecline in TFR would also slow down. However,
it is not the purpose of this paper to identify how low the fertility can
reach in states like Kerala and Tamil Nadu.
14 For the projections, we have allowed the TFR ofKerala to rise marginally
from the estimated value of 1.74 to 1.8.
15 Since elimination of unwanted fertility would lower fertility in the states
of Kerala and Tamil Nadu to somewhat absurdly lower levels, we have
not prepared long-term population projections for them based on this
assumption.
16 Population projection figures for the remaining major states along with
the figures on dependency ratio are available on request from the senior
author.
17 The figure for Tamil Nadu, shows only two projections - one based on
standard projection and the other based on elimination of unwanted
fertility. The projection incorporating attainment of TFR of 1.8 is the
same as standard projection. For Kerala, we have drawn the figure giving
only the standard projection, which again is the same as TFR of 1.8.
18 We have not projected the population separately for the three states that
are formed out of Uttar Pradesh, Bihar and Madhya Pradesh. Besides
a clear demarcation of their boundaries and estimates of their 1991
population, such an exercise would require estimates of fertility and
mortality as well.
19 In the earlier exercise, undertaken in 1996 [see Visaria and Visaria 1996],
we had estimated the share of population momentum in the country as
a whole to be 61 per cent. In the present exercise, the share has gone
up mainly because of the faster pace of fertility decline.
20 In both the earlier exercise and this exercise, India is expected to attain
replacement level fertility during 2016-21. However, the total population
sizein2101 was projected to be 1,75 7 mill ion as opposed to 1,812 million
now.
21 For an examination of the measures undertaken in Tamil Nadu in response
Economic and Political Weekly
November 8, 2003
to the Reproductive and Child Health Programme, see Visaria, Leela
(2000).
22 During the period 1990-93, the government of Kerala closed down 67
schools and recommended closing down of another 89 schools in which
the strength of students was below 50 students. Taking into account the
fertility decline in the two years preceding 1994, the school age population
was estimated to decline from 5.7 million enrolled in 1992-93 to 5.3
million in 2001. Continuing fertility decline will also have an effect on
the university student population with a time lag [see James 1995].
23 There is some evidence to suggest that both in Kerala and Tamil Nadu,
some fictitious names of children are entered on the school registers to
augment the number ofchildren in school, since the grant or aid to schools,
and the number of teachers provided depend on the total number of
enrolled children.
References
Bhat, P N, Mari (2002): ‘Returning a Favour Changing Relationship between
Female Education and Family Size in India’, World Development, 30(10):
1791-1804.
Bhat, P N Mari and Irudaya Rajan (1997): ‘Demographic Transition since
Independence’ in Zachariah, K C and S Irudaya Rajan (eds), Kerala’s
Demographic Transition: Determinants and Consequences, New Delhi,
Sage Publications India: 33-78.
Bongaarts, John (1990): ‘The Measurement of Wanted Fertility’, Population
and Development Review, 16(3), 487-506.
- (1994): ‘Population Policy Options in the Developing World’, Science,
Vol 263, February 11, 771-76.
Census of India (1971): Final Population Totals, New Delhi, Office of the
Registrar General.
- (1981a): Final Population Totals, New Delhi, Office of the Registrar
General.
-(1981b): Geographic Distribution ofInternal Migration in India: 1971-81,
New Delhi, 1989.
- (1991): Final Population Tables, New Delhi, Office of the Registrar
General.
Coale, Ansley J and Paul Demeny (1983): Regional Model Life Tables and
Stable Populations, Second Edition, New York, Academic Press.
Dyson, Tim (2003): ‘India’s Population - the Future’ in T Dyson, Robert
Cassen and Leela Visaria (eds), 21st Century India: Population,
Environment and Human Development, Oxford University Press
(forthcoming).
Government of Andhra Pradesh (1999): Andhra Pradesh: Vision 2020, State
Secretariat, Hyderabad.
International Institute for Population Sciences (UPS) (1995): National Family
Health Survey, 1992-93, Bombay, UPS.
International Institute for Population Sciences (UPS) and ORC Macro (2000):
National Family Health Survey (NFHS-2), 1998-99, Mumbai, IIPS.
James, K S (1995): ‘Demographic Transition and Education in Kerala*,
Economic and Political Weekly, Vol 30, No 51, December 23, pp 3274-76.
Kishor, S (1994): ‘Fertility Decline in Tamil Nadu, India’ in B Egero and
M Hammarskjold (eds). Understanding Reproductive Change: Kenya,
Tamil Nadu, Punjab, Costa Rica. Lund: Lund University Press, 66-100.
Natarajan, K S and V Jayachandran (2001): ‘Population Growth in 21st
Century India’ in SrinivasanandM Vlassoff(eds),Population-Development
Nexus in India, New Delhi: Tata McGraw-Hill, 35-57.
Office of Registrar General (1998a): State Profile 1991, India, New Delhi,
Controller of Publications.
- (1998b): SRS Based Abridged Life-Tables, 1991-95, New Delhi.
- (1999): Sample Registration System, Statistical Report, 1997, New Delhi,
Controller of Publications.
Population Reference Bureau (1999): World Population Data Sheet.
Ramasundaram, S (1995): ‘Causes for the Rapid Fertility Decline in Tamil
Nadu: A Policy Planner’s Perspective’, Demography India 24(1): 13-21.
Registrar General, India, Occasional Papers No 1 of 1985, SRS Based
Abridged Life Tables 1975-80, New Delhi.
Registrar General, India, SRS Analytical Studies, Report No 1 of 1998, SRS
Based Abridged Life Tables, 1990-94 and 1991-95, New Delhi.
United Nations (2001): WorldPopulation Prospects: The2000Revision, New
York, United Nations.
Visaria, Leela (1999): ‘Deficit of Women in India: Magnitude, Trends,
Regional Variations and Determinants’ in Ray, Bharati and Apama Basu
(eds), From Independence Towards Freedom, Oxford University Press,
New Delhi, pp 80-99.
- (2000): ‘Innovations in Tamil Nadu’, Seminar, Issue No 489, May, pp 49-55.
Visaria, Leela and Pravin Visaria (1996): Prospective Population Growth
and Policy Options for India, 1991-2101, The Population Council,
New York.
4775
Policies
Page 1 of 12
NATIONAL YOUTH POLICY 2003
II
1.
II
II
II
PREAMBLE
1.1. The National Youth Policy, 2003 reiterates the commitment of the entire nation to the composite and all-round
development of the young sons and daughters of India and seeks to establish an All-lndia perspective to fulfill their
legitimate aspirations so that they are all strong of heart and strong of body and mind in successfully accomplishing the
challenging tasks of national reconstruction and social changes that lie ahead.
1.2.
The earlier National Youth Policy was formulated in 1988. The socio-economic conditions in the country have
since undergone a significant change and have been shaped by wide-ranging technological advancement. The National
Youth Policy - 2003 is designed to galvanize the youth to rise up to the new challenges, keeping in view the global
scenario, and aims at motivating them to be active and committed participants in the exciting task of National
Development.
1.3. The Policy is based on recognition of the contribution that the youth can, and should, make to the growth and well
being of the community and endeavours to ensure effective co-ordination between the policies, programmes and delivery
systems of the various Ministries, Departments and other Agencies. The thrust of the Policy centres around "Youth
Empowerment" in different spheres of national life.
1.4.
For India to occupy her rightful place in the Comity of Nations and to meaningfully discharge the manifold
obligations thereto, it would be imperative to ensure the effective pursuit of youth development programmes which
promote personality development and Qualities of Citizenship and enhance commitment to Community Service, Social
Justice, Self-reliance, National Integration and Humanism, an inclusive view of the entire universe as enshrined in our
ancient scriptures. The Policy, therefore, recognizes these inter-related values and principles as its basic premise.
2.
RATIONALE
Since our national progress depends, crucially, on the ways and means through which the youth are encouraged
and nurtured as a positive force for national progress and are enabled to contribute to socio-economic development, it is
essential for an appropriate policy framework to be in place to harness the energies of the youth in this task.
2.2
Recognizing, further, that youth development is a multi-faceted concept, it is equally necessary that all the
relevant agencies, including the Ministries and Departments of the Central and State Governments, and local self
Government bodies and Panchayati Raj institutions devise their plans and programmes bearing these aspects and
features in mind. The Policy will facilitate a multi-dimensional and integrated approach in this behalf, with the State
Agencies striving to accelerate the formulation and implementation of programmes.
An important indicator of the success of such programmes being the stake of the beneficiaries in the results of the
same, this Policy also stresses that the youth of the country should enjoy greater participation in the processes of
decision-making and execution at local and higher levels. Such participation would be facilitated by identifiable structures,
transparent procedures and wider representation of the youth in appropriate bodies, with the emphasis being more on
v/orking with the youth than for the youth.
3.
THE DEFINITION OF YOUTH
This Policy will cover all the youth in the country in the age group of 13 to 35 years. It is acknowledged that since
all the persons within this age group are unlikely to be one homogenous group, but rather a conglomeration of sub-groups
with differing^social roles^and requirements, the age group may, therefore, be divided into two broad sub-groups viz.~13-i9
years and 20-35 years. The youth belonging to the age group 13-19, which is a major part of the adolescent age group,
will be regarded as a separate constituency.
3.2
The number of youth in the age group of 13-35 years, as per the 1991 Census, was estimated at about 34 crores,
□nd about 38 crores in 1997, which is anticipated to increase to about 51 crores by the year 2016. The percentage of
youth in the total population, which, according to the 1996 Census projections, is estimated to be about 37% in 1997, is
also likely to increase to about 40% by the year 2016. The availability of a human resource of such magnitude for
http://yas.nic.in/yasroot/policies/youth_policy_03.htm
9/20/2004
Policies
Page 2 of 12'
achieving socio-economic change and technological excellence needs commensurate infrastructure and suitable priorities
to maximize its contribution to National Development.
4.
OBJECTIVES OF THE NATIONAL YOUTH POLICY
The objectives of the National Youth Policy are:
4.1
to instil in the youth, at large, an abiding awareness of, and adherence to, the secular principles and values
enshrinjed in the Constitution of India, with
unswerving commitment to Patriotism, National Security, National
Integration, Non-violence and Social Justice;
4.2
to develop Qualities of Citizenship and dedication to Community Service amongst all sections of the youth;
4.3
to promote awareness, amongst the youth, in the fields of Indian history and heritage, arts and culture;
4.4
o provide the youth with proper educational and training opportunities and to facilitate access to information in
respect of employment opportunities and to other services, including entrepreneurial guidance and financial credit;
4.5
to facilitate access, for all sections of the youth, to health information and services and to promote a social
environment which strongly inhibits the use of drugs and other forms of substance abuse, wards off disease (like
HIV/AIDS), ensures measures for de-addiction and mainstreaming of the affected persons and enhances the availability
of sports and recreational facilities as constructive outlets for the abundant energy of the youthl;
4.6
to sustain and reinforce the spirit of volunteerism amongst the youth in order to build up individual character and
generate a sense of commitment to the goals of developmental programmes;
4.7
to create an international perspective in the youth and to involve them in promoting peace and understanding and
the establishment of a just global economic order;
4.8
to develop youth leadership in various socio-economic and cultural spheres and to encourage the involvement of
Non-Gqvernmental Organizations, Co-operatives and Non-formal groups of young people; and
4.9.
to promote a major participatory role for the youth in the protection and preservation of nature, including natural
resources, to channelise their abundant energies in community service so as to improve the environment and foster a
scientific, inquisitive reasoning and rational attitude in the younger generation and to encourage the youth to undertake
such travel excursions as would better acquaint them with cultural harmony, amidst diversity, in India, and overseas.
5.
THRUST AREAS OF THE POLICY
5.1
Youth empowerment: The Policy recognizes that in order for the youth to effectively participate in decision making
processes, it is essential that they are better equipped with requisite knowledge, skills and capabilities. Towards this end,
the Policy envisions the following:
Attainment of higher educational levels and expertise by the youth, in line with their abilities and aptitudes, and access to
employment opportunities accordingly;
Adequate nutrition for the full development of physical and mental potential and the creation of an environment which
promotes good health, and ensures protection from disease and unwholesome habits;
Development of youth leadership and its involvement in programmes and activities pertaining to National Development;
Equality of opportunity and respect for Human and Fundamental Rights without distinction of race, caste, creed, sex,
language, religion or geographic location and access to facilities relating to Sports, Cultural, Recreational and Adventure
activities.
5.2.
Gender Justice: The Policy recognizes the prevailing gender bias to be the main factor responsible for the poor
status of health and economic well-being of women in our society and that any discrimination on grounds of sex violates
the basic rights of the individual concerned and it, therefore, stands for the elimination of gender discrimination in every
sphere. The Policy enunciates that:
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Policie.s
(a)
Every girl child and young woman will have access to education and would also be a primary target of efforts to
spread literacy.
Women will have access to adequate health services (including reproductive health programmes) and will have
full say in defining the size of the family.
(b)
(c)
Domestic violence will be viewed not only as violation of women’s freedom but also as that of human
rights.
All necessary steps should be taken for women’s access to decision-making process, to professional positions
(d)
and to productive resources and economic opportunities.
Young men, particularly the male adolescents shall be properly oriented, through education and counseling to
(e)
respect the status and rights of women.
5.2.1
The Policy further enunciates that
(a)
Action would be pursued to eliminate all forms of discrimination in respect of the girl child, negative cultural
(a)
attitudes and practices against women, discrimination against women in education, skill development and training, and the
socio-economic exploitation of women, particularly young women;
Concerted efforts will be made to promote a family value system that nurtures a closer bond between men and
(b)
women, and ensures equality, mutual respect and sharing of responsibility between the sexes.
5.3
Inter-Sectoral Approach:
The Policy recognizes that an inter-sectoral approach is a pre-requisite for dealing
with youth-related issues. It, therefore, advocates the establishment of a coordinating mechanism among the various
Central Government Ministries and Departments and between the Central and State Governments, and the community
based organisations and youth bodies for facilitating convergence in youth related schemes, developing integrated policy
initiatjves for youth programmes and for reviewing on-going activities / schemes to fill in gaps and remove unnecessary
duplication and overlap.
5.4
Information & Research Network: Youth development efforts in India have been hampered by lack of adequate
information and research base. The Policy, therefore, suggests the establishment of a well organized Information &
Research Network in regard to various areas of concern to the youth to facilitate-the formulation of focused youth
development schemes and programmes. The Rajiv Gandhi National Institute of. Youth Development (RGNIYD) will serve
as the apex Information and Research Centre on youth development issues. The National Youth Centre and the State
Youth Centres will also serve as store houses of information for the youth. At the micro level, the Youth Development
Centres under the NYKs will be equipped to serve as information centres for the local youth.
6.
PRIVILEGES OF YOUTH
The Policy acknowledges that the youth of the country should be assured of the following:
Appropriate education and training which enables them to render themselves socially useful and economically
productive;
6.1
Gainful employment and adequate opportunities for personal development and advancement for those not
6.2
currently in employment;
6.3
Requisite shelter and a clean environment, as also basic health services of quality;
6.4
Social defence and protection from all manner of exploitation;
Suitable participation in decision-making bodies which are concerned with issues relating to the youth and with
socio-economic and cultural matters;
6.5
6.6
Sufficient allocation of public funds for youth development;
6.7
Access to Sports, Physical Education, Adventure and Recreational opportunities.
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RESPONSIBILITIES OF YOUTH
The Policy exhorts the youth to fulfill their responsibilities, as are enumerated below:
tto contribute
' ■ ' to sectoral, family and self development and to promote social and inter-generation understanding
dpr Pni
inhh/'
3
and gender
equality:
.7.1
7.2
tto extend respect to teachers and elders, parents and the family, in consonance with our cultural norms and
traditions;
7.3
Ju ur?ho!d the unity. and integrity of the Nation, maintain peace and harmony, observe Fundamental Duties and
resped: the Fundamental Rights and Freedoms guaranteed under the Constitution to all sections of the people;
7.4
t esPect...........................................
lo^
ethers
beliefs
in the
religious, oTfellow^kiz^Ind^o?;;^^^
cultural and social spheres and to different
schools of thought
and to ^either
exploit
nor Jaiths^and
be instrumental
in the
exploitation
espedat^
'women;
7.5
to promote appropriate standards of ethical conduct in individual
and social life, to maintain honesty and
integrity of character and be committed to fight against all forms of corruption, social evils and practices.
7.6
to preserve and protect the Environment; and
7.7
tto commit.......................
themselves to create a discrimination and exploitation free environment and to devote their time and
energy in nation building activities.
8.
KEY SECTORS OF YOUTH CONCERN
8.1
The Policy recognizes the following areas as key sectors of concern for the youth:
8.2
i.
Education;
ii.
Training and Employment;
iii.
Health and Family welfare;
iv.
Preservation of Environment, Ecology and Wild life;
v.
Recreation and Sports;
vi.
Arts and Culture;
vii.
Science and Technology; and
viii.
Civics and good Citizenship.
education
8.2.1. ~
•
■ •_
...................
_________________
_
acknowledges
that
the ^objective
of providing _appropriate
education, which enables the youth to
develop
into
good
citizens
of
the
country,
should
also
suitably
influence
actions of the
Government
, ,
.
~
*'
— —
w relevant uvuvixzi
iivvp11iii
ici11 and oublic
behaviour.
r
8.2.2
1
JJ*}6 ne*ed °Lthet ®ducational system to instill, in the youth, an abiding sense of patriotism and
m ,,values
oriented towards the unity and integrity
of
the country,
equally VWIIM
calls for
the <_IH
elimination
of VIVPICIIUC
violence III
in ail
all IUIIIIO,
forms,
J
w
y
-J,
iv>f lll^.
I III IQllIVPI I
adherence to good moral and ethical values and respect and reverence for India's composite culture and national
heritage
8.2.3 This Policy emphasizes that the learning process should minimise the stress and strain, which the system may
exert on students, especially in the early years. The thrust of the educational system, particularly in the early years, ought
to be on learning, rather than on merely qualifying in examinations and memory-based tests. The Policy lays emphasis
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on outdoor learning as an integral part of the educational process and on
Adventure activities.
8.2.4
Physical Education, Sports, Games and
Academic institutions should be equipped with adequate sports and recreational facilities.
82 5
Education above the secondary level, should have a high degree of vocationalisation so as to enable the^youth to
acauire such requisite skills as would augment avenues of employment for them, technical institutions need to be
strengthened and their number increased keeping an eye on our country's emergence as a major force
mformatio
technology.
8.2.6
There needs to be greater uniformity in the educational system and standards in various parts of the country.
827
Closer links should be developed between the educational system and prospective employers, on ari institutional
basis and career counselling should be' a part of the educational system, from the secondary level onwards. P-g ammes
need to be undertaken for proper dissemination of information, amongst young men and women, in respect
options.
828
Programmes should be undertaken to upgrade the existing skills of young artisans^of
^"XeTrural
other products and for those who may wish to take up the same as a vocation. Education system should also have
orientation to address the varied needs of agriculture, agro - processing and other areas of rural economy.
8.2.9
Educational curriculum in schools should include information on health issues, including reproductive health, HIVAIDS and also on population issues.
8 2 10 Youth clubs and Mahila Mandals should be encouraged to involve their members in Pro9r3^®®
"Sarv^
Shiksha Abhiyan" and Total Literacy Campaign for universalisation of primary education, and spread of literacy
organize activities to promote book reading habits among the youth.
8.3
Training and employment
8.3.1.
and that several social issues arise out of widespread
,n,s Policy further acknowledges that the incidence of unemployment is more pronounced in the rural areas and
8.3.2. This Policy further acknowledges that the incidence of unemployment is
and calls for appropriate strategies and commensurate efforts to deal with it.
in urban slums
l,_..
833
The current trends suggest that the growth rate of the labour force has been higher than the growth rate of
population and that the growth rate of employment has not been in proportion to GDP growth.
8 3 4 The critical issues in this area include a mis-match between skills-requirement and employment opportunities low
technology levef low wages and low productivity, occupational shifts in employment, under-employment owing to
seasonal Actors excess labour supply in relation to demand, migration of the labour force from the rurai to urban areas
and limited participation of women in the work force, especially in the organized sector.
8 3 5 The incidence of unemployment has been accentuated by advances in technology and communications, to tackle
which oppoZides for seremployment need to be created. Schemes to provide "seed money' to assist viable
enterprises initiated by the youth need to be drawn up. A network of youth skill training centres wou n
established to build up the capacities of the young people for income generation activities.
836
Adequate funding for both pre-job and on-the-job training for youth by governmentt as well as other stake holders
should be ensured. For proper vocational guidance and career counselling,
c—"!nC schools
«^™i* and colleges should pay adequate
attention to this aspect as part of their co-curricular activities.
837
Government in conjunction with youth organisations, will develop training programmes for young People ini the
rural areas based on heir needs. Special schemes would also be developed for young women, youth with disabiht es
and for young people returning from the urban to the rural areas, alongside flexibility in training systems and collaboration
between training institutions and potential employers.
8.3.8.
Co-operative schemes involving Self Help Groups of young people in the production and marketing of goods and
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services would be encouraged and strengthened, with government support. Banks and Co-operatives would be advised
to make identifiable allocations of soft credit to young people and their Self Help Groups and micro-credit adopted as a
strategy to enable young women and men, in the rural areas, to undertake fruitful economic ventures.
8.3.9.
A Data Bank will be created to keep abreast of the employment opportunities being generated, as also the
availability of young people, with the requisite skills, for the same;
8.4
Health
8.4.1 The policy recognises that a holistic approach towards health, mental, physical and spiritual, needs to be adopted
after careful assessment of the health needs of the youth.
8.4.2 As per the youth population projections (based on the 1991- Census), about 21.4% of the total population in 1996
was estimated to be in the age group of 10-19 years; of these, about 78.4% lived in the rural and the remaining ( 21.6% )
in the urban areas. The mean age of marriage in the rural areas was 21.56 years for males and 16.67 years for females.
In the urban areas, the mean age for marriage was 24.32 years for males and 19.92 years for females. In other words,
most women in India are married during the age of adolescence.
8.4.3 The areas of focus of this Policy, in so far as health of the youth is concerned, are:
a.
General Health;
b.
Mental Health;
c. Spiritual Health;
d.
AIDS, Sexually Transmitted Diseases, Substance Abuse; and
e. Population Education.
(a)
General Health
8.4.4
Nutrition : The policy recognises an urgent need for greater concentration on nutritional studies on the youth particularly the young women and the adolescents and advocates all measures to lessen the differences between their
daily average intake of energy and proteins and the recommended daily intake allowances ( PDA). The Policy particularly
emphasises on reduction of this gap, which is wider among the children of growing age as per Indian National Nutritional
Profile, 1998.
8.4.5 The growth rate standard of Indian adolescents, measured in terms of Body Mass Index ( BMI ) viz. ratio between
weight and height, is lower in India than in most of the industrialised nations. Iron deficiency and anemia are common,
especially in girls. The growth-related requirements of adolescents often continue beyond the teenage years and overlap
with the nutritional needs of early pregnancy, which has an impact on the health of new-born children, in addition to the
mothers. Discriminatory practices in respect of girls also lead to lack of adequate nutritional intake, which results in
malnutrition, anaemia and other micro-nutrient deficiencies in young girls which are more noticeable in the rural areas.
These concerns need to be effectively tackled through appropriate measures, including awareness-generation
programmes.
8.4.6
The Policy lays emphasis on the importance of hygiene and sanitation in promoting a healthy society. All efforts
should be made to inculcate in the youth a sense of hygiene and sanitation right from early education. The youth on their
part should be encouraged to organise mass awareness campaigns in their neighbourhood to promote better hygiene and
sanitation. Their sen/ices should also be utilised in creating better sanitation facilities for the community, both in rural
areas and urban slums.
8.4.7
Health education and health consciousness: This Policy strongly recommends introduction of health education in
the curricula of regular / formal education in higher classes of schools and colleges, in non-formal education centres and
in every other organised interaction with the youth. The policy advocates that every youth of India should clearly
understand the what, why and how of good health within his or her socio - economic parameters. A policy of minimum
physical exercise for all should be propagated.
(b)
Mental Health
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8.4.8 Lack of proper education often leads to mental depression.- In an environment that is becoming complex and
competitive by the day, the chances of young minds being afflicted with depression are ever rising. This is particularly so,
among adolescents who are showing higher incidence of suicidal traits than even before. Against this background, this
Pol'cy advocates a system of education which teaches the youth to fight back rather than give in. It also recommends
establishment of state-sponsored and free counseling services for the youth, particularly the adolescents.
8-4.9 Adolescence is a period of change and, consequently, one of stress, characterized by uncertainties in regard to
identity and position in the peer group, in society at large and in the context of one's own responsibilities as an adult. The
compulsions of parental approval often encounter the emerging aspirations of independence. Adolescents exhibit mood
swings and might even indulge in self-destructive activities, such as use of alcohol, drugs and violence; they need,
therefore, to be treated with openness, understanding and sympathy and offered creative channels to harness their
energies. This would necessitate training and capacity building of all professional groups including NGOs working with the
(c)
Spiritual Health
8.4.10. Health of the mind should be coupled with the health of the spirit. Towards this, yoga and meditation should be
propagated widely among the youth. Yoga, in particular, should be taught in the schools.
(d)
HIV/AIDS, Sexually Transmitted Diseases and Substance Abuse
8.4.11 The Policy recognizes that the percentage of young people falling prey to substance abuse, STDs and HIV / AIDS
being relatively higher, these issues need be tackled as, primarily, confronting the younger generation, particularly the
adolescents who are most affected. Being highly impressionable, and, therefore, prone to high risk behaviour, they
require proper education and awareness about reproductive health issues, including safe sexual behaviour. The Policy,
therefore, advocates a two-pronged approach of education and awareness for prevention and proper treatment and
counselling for cure and rehabilitation. It further enjoins that information in respect of the reproductive health system
should form part of the educational curriculum. The Policy also stresses the need for establishment of adolescent clinics
in large hospitals and similar projects in rural areas to address the health needs of the young adults.
(e)
Population Education
8.4.12 The Policy recognises that a growing population is a serious national problem that has negated many of our
achievements in the field of development. The youth have an important role to play in this sphere and can create greater
awareness in this regard through community programmes.
8.4.13 Responsible sexual behaviour can be promoted through education in family-life issues and control of population.
Pregnancy and childbirth, in the adolescent period, particularly for young women below 17 years of age who are living in
unhealthy conditions and without adequate access to health services, has been a serious bio-medical hazard. The
adolescent age-group has to be sensitised in regard to the correct age for marriage and for the first pregnancy, sufficient
spacing between births and limiting the size of the family. It is conceded that in spite of several initiatives taken by the
Government, the social climate enjoins the young couple to produce their first child soon after marriage. This scenario is
unlikely to change in the nearer medium term. Entering into matrimony at the right age assumes critical importance in this
c° xt’ apart from its Wealthy impact in checking the high rate of population growth. It is equally imperative that younq
adu ts be sensitised to their role and responsibilities as responsible parents. Ante-natal, natal and post-natal services of
quality are also necessary for young women.
8.4.14
The following strategies should be adopted to provide better health services to the youth :
a.
Government , in co-operation with the Youth Organisations and NGOs, would promote the
establishment of Youth Health Associations, at the grass-root level, to ensure proper sanitation,
health and hygiene and would, in cooperation with Youth Organisations, develop Family Welfare
Services for young people and provide counselling services;
b.
Programmes would be instituted, with the support of Youth Organisations and NGOs, to sensitise
medical and para-medic students on the issues of health and hygiene and also in the IEC component
of various disease control programmes; and
c. Young people will be recognised as “Health Promoters".
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8.4.15 The youth will also be involved in a structured manner in the following health-related activities:
a.
Construction of lavatories, water points, dispensaries and wells; cleaning of public places and related
environment protection activities; community surveys and research on health-related matters;
b.
Safe blood donation, nutrition and food production projects;
c. Information, education and prevention campaigns in respect of health concerns, such as malaria,
malnutrition, STD (including HIV / AIDS), teenage pregnancy and abuse of alcohol and other harmful
substances;
d.
Peer Education will be an important element in promoting health services.
8.4.16 This Policy urges upon universal accessibility of an acceptable, affordable and quality health care service to the
youth throughout the length and breadth of this country to be made available in close proximity to their places of
residence. The youth should have this accessibility for themselves as well as for other vulnerable age groups whom they
could help out.
.
8.5
ENVIRONMENT
‘The Policy recognises that children and ....
______________
______________________________
young people are
particularly vulnerable
to the ill effects of environmental
degradation. Unplanned industrialisation, which leads to pollution and to degradation of rivers, forests and land, adversely
affects the young who have a vital stake in a healthy environment.
8.5.1
8.5.2 C
..........................
Considering
the importance of community involvement in preservation of the environment, the Policy exhorts
r
j
young people to play an increasingly significant
role in mobilising the public, at large,
in this national endeavour. The
Policy also advocates motivating the youth to develop respect for Nature and to lead lifestyle which are less resource
consumptive and more source conservationist.
8.5.3
'The Policy recognises that women are seriously affected by environmental degradation resulting, inter-alia, in lack
of potable water and scarcity of fuel wood, The migration of men to cities to seek employment often isolates the
womenfolk who are left to fend for themselves.
8.5.4
Having regard to the above, the Policy highlights the following lines of concrete action:
a.
Greater emphasis should be placed on environmental education in school curricula and training
programmes should be arranged to inform teachers on environmental issues so as to enable them to
instruct the youth suitably. Environmental education should also be a part of the outdoor learning
process;
b. The participation of Youth Organisations in gathering environmental data and in understanding
environmental issues would be encouraged as a means of improving their knowledge of immediate
surroundings and accentuating personal concern towards proper environmental management;
c. Motivating the youth to establish nature and adventure clubs in villages and towns with a view to
creating mass awareness towards protection of the country’s bio - diversity, and to work with local
bodies and NGOs in planning and management of our forests, rural water bodies, common land and
natural resources through active local participation.
d.
Vocational training, in recycling of materials and managing waste materials, would be promoted so as
to ensure that more young people may find a local source of livelihood and, at the same time, arrest
degradation of the environment; and
e. Youth Organisations, at the grass root level, would be assisted in provision of training in agro
forestry, agriculture and traditional agricultural practices.
f. Promotion of both traditional and alternative technologies for water conservation and water harvesting
through Youth organisations.
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8.6
Sports and Recreation
8.6.1 Having recognised that the overall objective of the Policy is the all-round development of personality of the youth
and noting that Sports, Physical Education, Adventure, Recreation and related activities might often be overlooked, this
Policy strongly supports these activities as important areas of human resource development. No system of education
could be considered successful, unless it addresses the urges and aspirations of the youth to be creative and
appreciative of the manifold facets of nature and of social life.
8.6.2 The Policy, accordingly, enunciates that:
a.
Sports and games be promoted as a mass movement by making it a way of life;
b.
Sports, Games and Physical Education including Yoga, should be compulsory in all Educational
Institutions;
c. Every educational institution should have adequate facilities for recreation, adventure and sports
activities, including playgrounds;
d.
Provision be made for common play grounds in the master plans of all civic and municipal areas;
e.
At least one-fifth of the time spent by a student in an educational institution should be earmarked for
outdoor activities;
f. Geographically disadvantaged areas would be extended additional support for the promotion of
Sports and Games;
9- Rural, traditional and indigenous sports would be accorded special attention and it would be the
responsibility of the Panchayat Institutions with the help of local youth organisations to develop and
maintain infrastructure for this purpose. The involvement of organised youth bodies such as youth
clubs under the NYKS, the volunteers of the NSS and the Scouts & Guides in the creation and
maintenance of sports infrastructure will go a long way in reducing the high cost of such
infrastructure;
h.
A National Youth Festival will be held each year, starting at‘the Block level and culminating at the
National Level;
i.
Youth Hostels would be constructed in as many places of historical and cultural interest as possible,
to promote youth tourism;
j- Youth Organizations devoted to such activities will be encouraged; and
k. Adventure activities among the youth be promoted to inculcate qualities of leadership, resilience,
courage, discipline and love for nature and the environment.
8.7
Arts and Culture
8.7.1 Activities connected with Arts and Culture provide recreation to individuals, sharpen their sensitivities and afford a
vehicle to inculcate desirable ideals and values. The Policy recognizes the importance of Arts and Culture in a holistic
approach to youth development and that Young People need to be sensitised to the great heritage of our country and
provided with opportunities to understand and follow pluralistic forms of culture.
8.7.2 This Policy, therefore, enunciates the following:
a. The youth should be better enabled to imbibe the rich traditions and culture of India and sensitised to
the need to preserve and enrich this extraordinary heritage. This will be sought to be achieved interalia through
i. inclusion of learning and appreciation of the country's rich heritage in art, architecture, music
and dance etc. in the educational curricula at the school level;
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ii.
encouraging and facilitating through financial assistance in association with concerned State
Govt./PRIs etc., visits to ancient monuments/heritage sites during which attempt would be
made to impress upon the young people the need for preservation of our ancient heritage by
involving them in voluntary work for cleaning up the sites and surroundings and educating and
motivating the local youth to protect such monuments against vandalism etc. The Ministry of
Railways and State STUs will be persuded to offer concessional fares for such organised
educational trips and for organising special services to such places, particularly during
holidays;
iii.
Encouraging and facilitating the visits of well known artists to educational institutions to impart
lessons in appreciation through demonstrations/workshops/performances;
iv.
Encouraging and facilitating in association with State Govts./PRIs/NGOs attendance of young
persons at performances by well known artistes in their respective areas.
b. A National Youth Centre would be established to provide young people with a common platform
where they can express their opinions and views on various issues concerning them. Such a Youth
Centre will also provide them with ample scope to give exposure to their creative genius and abilities
in the fields of various cultural expressions like fine arts, music, theatre, film etc. State Youth Centres
would be established, on similar lines, in the various States.
8.8
Science and Technology
8.8.1 As the adaptation of scientific and technological principles and developments, to maximise the use of local
.resources,
co^m.'ccg, are
are central to empowerment in the quality of life, the Policy recognises the importance of emerging, modern
technologies, particularly in the field of information technology and electronic media, in enabling the youth to perform and
achieve in all sectors of their interest.
8.8.2 The Policy also recognises that young scientists and technologists should be extended adequate facilities for
research and that the contribution-of the private sector in this field should be encouraged.
8.8.3 The National Youth Policy, therefore, provides for:
a.
Review of policies in respect of the School Curriculum and the non-formal education sector so that
Science may be popularised amongst all sections of the youth;
b.
Support to providing exposure to the youth to the scientific temper and way of life;
c. Development of mechanisms within the system to identify and train gifted youth, as early as possible,
in the fields of science and, technology;
d.
The best and the most positive use of information and communications technology, as well as all
forms of media, including the electronic media, for youth development as well as for promoting and
protecting the richness of our culture;
e.
Promoting a multi-sectoral approach involving, inter-alia, the private sector and NGOs, to orient the
youth towards scientific and technological studies and research;
f. Ensuring co-ordination between the various Government Ministries/Departments and Scientific
Organisations/lnstitutions dealing with youth development programmes;
g-
Upgrading science curricula in institutions of learning to inculcate the scientific approach amongst all
sections of the younger generation;
h.
Linking the projects of the young scientists to the problems of the people and ensuring better
interaction between labs and the industry;
i.
Documentation of the large repository of physical and knowledge based resources within the country
to prevent their piracy by vested interests.
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8.9
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Civics and Citizenship
8.9.1 Human behaviour is significantly shaped by norms and values, which are a basis for attitudinal growth. The
ominant features in the Indian Society, which impinge on the cultural and other values of young people, include areas
such as family life, education, work and occupational activities, gender, class and ethnic relations, religion, mass
communication, artistic and creative expression, sports, recreation, politics and the economic environment.
8-9;2 Antisocial behaviour is a manifestation of the absence of well-accepted values, attitudes and norms in the
individual and in society which can reflect itself in crime, violent action, breakdown of parental authority in family life
workplace PUb 'C ' obscenity in the media’ '"discipline in schools and in.sporting activities and low productivity at the
8.9.3 The Policy, therefore, envisages the following strategies:
a.
Embodying instruction in the values like respect for teachers and parents, adolescent and the aged
besides religious tolerance, and compassion towards the poor and the needy. The concept of family
as the basic and most important asset of Indian Society will be strengthened
b.
To motivate the youth to resist fragmentation of society on the basis of caste, religion, language and
ethnicity and for promotion of democratic values enshrined in our constitution.
c. To mobilise the youth to create local pressure groups within the community to fight corruption at all
levels and to ensure that the benefits of development reach those for whom they are intended and
are not siphoned of by middlemen and the powerful.
d.
9.
Laying emphasis on the economic and social security of the youth belonging to underprivileged
sections of our society and those who are mentally and physically challenged.
PRIORITY TARGET GROUPS
This Policy will accord priority to the following groups of young people:
a.
Rural and Tribal Youth;
b.
Out-of-school Youth;
c. Adolescents particularly female adolescents;
d.
Youth with disabilities;
e. Youth under specially difficult circumstances like victims of trafficking; orphans and street children.
10.
IMPLEMENTATION MECHANISM
The Policy envisions the following implementation mechanism:
a.
All Ministries/Departments of the Union Government and the State Governments, particularly in the
social sector will strive to make identifiable allocations in their budgets for youth development
programmes;
b. A broad based National Committee on Youth Policy and Programmes is contemplated to review and
assess various programmes and schemes focusing on youth. It will also advise the Government on
measures for implementation of the Plan of Action of the National Youth Policy;
c.
The Union Ministry of Youth Affairs & Sports (with the guidance of this Committee) will be.the Nodal
Ministry for all such programmes and schemes and will oversee the implementation of the provisions
of this Policy;
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Policies
11.
d.
An effective mechanism to coordinate the activities of the Central Ministries/Departments, the State
Governments and Community and Youth Organisations, would be evolved in order to facilitate timely
execution of youth development programmes; and
e.
A National Youth Development Fund will be created through contributions, including from NonGovernmental Organisations, which would be utilised for youth development activities. Income Tax
exemption would be sought for contribution to the Fund.
REVIEW
The National Youth Policy, 2003 would be reviewed after 5 years from the date of commencement of
implementation.
.BACKTQ±OL!CIES_IN.DEX II Tq><
http://yas.nic.in/yasroot/policies/youthjpolicy_03.htm
9/20/2004
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February 2004 -March 2004 : Vol. 29 No. 6
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Publisher's Note
/I?
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Over decades, the State has played a significant role in health sector. With the
growing process of Globalization and the influence of New Economic Policy, there
is tremendous pressure to replace this arrangement, and put the social sector in
market place. There can be little doubt that the greatest economic force now
sweeping through the health care system worldwide is that of the market. Health
is a vital human good and Medicare plays a key role in promoting it. Totally
commercializing it even for the sake of choice and efficiency runs a potent risk
of submitting it to the market-forces. The integrity of medicine itself is at stake.
Thankfully for the poor in most developing countries the State still remain principal
provider in Health Sector. We need to appreciate the importance of advocacy
for people-centered health from this backdrop.
JfSPJICcuisjSes
its readers a
Health policies need to grow, develop and be continually creative to meet the
changing needs of the situation. Unfortunately, most States lack the sensitivity,
and dynamism to quickly respond to these challenges. This underlines the
importance of sustained advocacy on health policy, to ensure that they are
sustainable, people-oriented and relevant. This is particularly true for the
developing world, where a large section of the population does not have welldefined and strong enough platform to air their frustration against inadequate
social policies.
I
I
<
I
"Very Jfappy
and dfeaftdiy
cyCe(v year
The importance of urgent and sustained global advocacy for restoration of
fundamental values of Alma Ata - people-centered, holistic and sustainable health
care can not be overstressed. The challenge to health in the new millenium will
be to recognize that in no country in the world, the private sector has been the
answer to health problem of the population. Even in the United States, forty seven
per cent of the population is without health insurance coverage. Secondly, there
is an imperative need to acknowledge that health improvement is less an outcome
of medical technology than of living standards. Health improvements based on
narrow technical interventions are bound to be chimerical. Thirdly, the macroeconomic policies of globalization, liberalization and privatization, which are
increasing the exploitation of low-income countries and communities around the
globe, have had profoundly deleterious effects. Finally, it is simply not true that
we do not have resources to pay for health for all. It is estimated that the cost
of providing basic health care to the world's population will amount to 25 billion
dollars. This is about what Western Europe spends on cosmetics, and a fraction
of the 400 billion dollars, that the world spends on armaments annually.
We obviously need a new paradigm of health care far removed from the current
bio-medical model and closer to a socio-political and spiritual model. Currently,
health care has become a commodity that can be bought and sold in the market;
it is no longer an organic part of community care as it once was in traditional
society. The 'germ theory' needs to be replaced by a model, where the human
being is regarded as central and helped to regenerate a sense of well-being, and
fitness in his or her life situation. Interestingly, most of the traditional systems
approach health from this holistic perspective.
It is with sadness that I have to
inform the readers of HFM
about Tejal's leaving VHAI, as
she has moved to Mumbai. In
her tenure as Editor of HFM,
Tejal showed immense spirit
and motivation.
HFM's new editor is Ms.
Neetu Kapasi. She brings with
herself years of experience in
the field of health, nutrition
and communication. Being an
UGC lecturer, Neetu has also
spent good few years in
teaching and writing on health
. ..z
hope. that she will
continue to,,,receive, the.
support .qf our ■ readers;
#;S£esp-cially<at a^tage^yhenshe^^.
.^i^earninfethet^ingstiof ..
We need to urgently revive the spirit of Alma Ata otherwise we the public health
practitioners can be blamed by the posterity of suffering from collective amnesia.
■■ ■
' ■ "'sJ.
s':><
*
i?-
Editorial
Our country is witnessing rapid strides in economic growth.
Manifested through jet speed industrialization and urbanization.
Vision to see India, as the fastest growing country and counted
amopg the ranks ot developed nations, is the moving force behind
all this. We are even, wanting to see Indi.i free ot poverty, illiteracy,
religion, caste system, gender disparity - equipped with modern
physical and social infrastructure - in a healthy and sustainable
environment. But problems staring at our faces, on the dawn of this
new era, apart from many others, as a sequel to the aforementioned
processes is the neglect of our young generation's health. There
lies a huge gap between dreams and reality, and its the roadmap
for our youngsters to follow.
India being the youngest of all nations on the
an added
the globe
globe has
has an
added
advantage, these young minds are its wealth. Adolescents so called
'Young Adults' account for 22.8% of our population. This implies
that about 230 million Indians are adolescents in the age group of
10 to 19 years. To our further surprise, this percentage of India's
adolescent population makes 2/3r<l of the world's total adolescent
population.
HEALTH FOR THE MILLIONS
February -March 2004, Volume No.29 No. 6
Publisher
Alok Mukhopadhyay
Editor
Neetu Kapasi
Editorial Advisory Committee
Mira Shiva, P.C. Bhatnagar,
Bhavna Mukhopadhyay,
Taposh Roy
Creative Team
Bhavna Mukhopadhyay
Tama! Basu
Subhash Bhaskar
Their education and health status, their readiness to take on adult
roles and responsibilities, and the support they receive from family,
community and government will determine their own future and fate
of our country. The significant role of this population in enabling India
to achieve its developmental goal of population stabilization is
something; we all can't overlook. Depicting the importance of their
reproductive health and in turn the progress of our nation.
But reality lies in the fact, that none of the existing health policies
or programmes are specifically targeted towards them! Millions of
adolescents are unaware of their own rights, incapable of
recognizing their own creativity, they are living under hazardous
conditions, carrying risks, which could directly impact their as well
as India's physical, emotional and mental well-being.
A huge percentage of adolescents and young people in India are
faced with the prospects of early marriage and children-bearing,
childJlabour, incomplete education, and the threat of HIV/AIDS.
Majority of girls gets married much before the age of sensibility.
Giving birth to children, even before they realize the meaning of
'motherhood'. Many of the low-birth weight babies born to teenage
mothers don't even see their first birthday. One usually finds child
workers catapulted from childhood straight into adulthood. They
grow into adults without adolescence touching them and youth
reaching them.
HFM Trustees
V.V. Dongre
Dr S. N. Simha
S. Santiago
Rami Chhabra
Managing Trustee
Alok Mukhopadhyay
HFM subscription rate
Year(s)
Rs
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Address for Correspondence
Despite of growing with diverse experiences, they have a common
thread running through all of their lives, and that is the hope for a
better future. By addressing their needs one would not only be
contributing to the socio-economic development of the country but
also to other societal concerns like social harmony, gender justice,
population issues, and improving the quality of life of our people.
Failing to act, on the other hand, will incur tremendous costs to
individuals, societies and the country at large, leading us to shame
for the mere lack of will, direction and determination. This generation
will not forgive us for the opportunities lost.
Adolescents need help, to help us in turning our dreams of successful
India, into reality. But are we equipped to provide this young
generation with the opportunity to realize its creative potential? Will
we be able to do justice to them? Will timely investment in this age
group be able to add wings to the flight of our future imagination?
Health for the Millions Trust
C/o VHAI
B-40 Qutab Institutional Area
New Delhi 110 016
Phones: 26518071,26518072,26965871, 26962953
Fax:
26853708
Email:
vhai@vsnl.com
< 5
vhai@sify.com
The views expressed by the autho^ i^hdr write-ups do
not necessarily reflect^h^iews^^tlfe HEM Trust.
Reproduction' adaptatibn'br trarillatTo^are a Jthorized
worldwide for non-profit, educational purposes, provided
that c°Ple5 c^^iT^di^lif^r^ltQre sent to
A: the HFMJrust^^^^^^^^^..,
.
i
t
*
Page 5
Population and Social Developmental Policies
Dr. Francois M. Farah
Page 7
Overview of adolescent life
Neetu Kapasi
Page 19
Do the National Policies in India address adolescent health ?
Dr. Mridula Seth
Page 31
Status of adolescents: Glimpses from states of India
Shrabanti Sen
Page 33
Adolescence in urban India
Dr. Peggy Mohan
Page 39
Reality in Shivpuri
Dr. S. K. Singh
Page 42
Adolescents on the fringe in urban poor India
Dr. Sunil Mehra and Dr. Deepti Aggarwal
Page 50
Voices from Kashmir
Page 55
Africa isn't dying of AIDS
Rain Malan, Cape Town
REGULAR FEATURES
Publisher's note
Editorial
Page 54
Population Scan
Page 57
HFM News
Page 60
Health issues in the Parliament
Page 62
News from State VHAs
Erratum
In the HFM issue of October-November
2003 & December 2003-January 2004,
there was a printing error in volume
number. Volume No. 30 of the issue
should read Volume No. 29.
•J
Population and
Social Developmental Policies
I
Dr. Francois M. Farah
oluntary Health Association of India
(VHAI) celebrated its 29,r' Annual
General Body Meeting (AGBM) at IIFT,
Ni?w Delhi on 9"‘ \ 10"' October 2003. The
meeting started with keynote address on
Reproductive Child Health and Population
Issues by Dr. Francois M. Farah, Country
Representative, UNFPA. This article complied
by Neetu Kapasi is a brief of his presentation. *
Dr. Farah's paper gave us inspiration to take
out this month issue of HFM "Adolescents".
The issue is an effort to put some light on
their lives and highlight the status of this
generation. Adolescents are not only our
future, but they are our present, our strength
and our direction.
Population is not about numbers. It is about
people. It is not only about statistics and figures.
Population and development in totality are
about a large perspective of the right
conditions and environment for people,
individual men and women to grow as healthy
citizens, and live a decent life. It is about
ensuring equal access to basic social services
including education and health/reproductive
health. From the time of life in mother's womb
to birth, passing through infancy, childhood,
adolescence, adulthood and ending with old
age, population is all about the right to live with
dignity at all phases.
The whole spectrum of life cycle in
population can be covered through
population and social policies. The prime
goal of a population policy is to improve the
general well-being of population in harmony
with the physical and social environment,
beyond improving per capita income. Thus,
a population policy must form an integral
part of over-all social development policy,
and be explicitly related to such goals as
better education, better health care, full
employment,
and rationalization of
reproductive behavior.
Concepts and approaches towards defining
population and social development policies
have gone through significant change in
1950s, 1960s, and subsequent decades.
Today's policy issues are better defined
compared to what they were earlier, posing
unique challenges. It's time for us to grab
these opport unities and take immediate
action.
Most
population policies prevailing
throughout 60s and 70s were premised on
economic development theories and defined
human beings from a consumers and
producers perspective. The number was thus
perceived as a burden first and policies were
suggested to reduce the number of
consumers through systematic family
planning programmes. Quality of life was
considered as dividend of producers in the
numerator
over
consumers in
the
denominator. Reducing the number of
consumers
would
therefore optimize
The prime goal of a
use
of
available
i esources
and
population policy is to
produce a higher
improve the general well
output. A number of
policy provisions were
being of population in
proposed to control
the population growth harmony with the physical
through a smaller
and social environment,
family size or a onechild policy,
This
beyond improving per
emphasis
on
the
capita income.
reduction in numbers,
especially of those
who produce less, yet consume equally was
to a large extent at the genesis of the
population control concept for curbing
growth.
Two decades later, population policies
witnessed an interesting development and
were redefined from a human development
perspective, with a strong emphasis on the
human development component i.e.
increasing qualifications of producers or
investment in producers to increase quality
dividend. It was during 1980s, that the
debate on social development policy
gathered a significant momentum with stress
on health, education, and investment in the
economy as a whole. That was the time
when the human development index came
about parallel to increased discussions and
acknowledgment
of
the
women's
empowerment concept. It was realized at
HEALTH FOR THE MILLIONS / February - March 2004
■ 5
Il
this point that women's (‘ducation and
empowerment could meet population
stabilization goals.
Fhu human development approach ot
population policies further evolved into a
social policy thinking from a equal rights,
human rights and social equity perspec tiveredetining the goals of developmrmt, and
making it not only human and sustainable? but
also humane and freedom premised. The
series of the 1990s UN Conferences clearly
redefined population and social development
policies from human rights, social equity
perspective,
and
recommended
a
comprehensive approach to social and
economic development.
i
I
Dr. Francois M. Farah is
Country RepresentativeIndia, UNFPA.
Such policies would of necessity include the
poor and the under-served and the
marginalized sections of society such as
women, children, aged and disabled people.
These policies would focus on social
development as an ultimate goal and would be
articulated around the four major functions of
a social policy. They are summarized as follows:
First, putting people at the same starting point
in life and providing equal access to basic social
services including health/reproductive health,
education, shelter, water, and sanitation etc.
Second, provide equal access to social,
economic and other opportunities by removing
all discrimination hurdles, and creating an
environment of equal opportunity by instituting
regulatory mechanisms. Third, to ensure the
same, instituting the social and legal regulatory
instruments to < het k sot i.d abuses and
disc rimination. Last, but not the least, enabling
the margin.ilized groups who have been left
behind, to catch up with the mainstream.
It's also essential to view these policies in
light of current population growth and
dynamics realities. Irrespective of control
measures adopted so far for curbing growth,
population in India is still on the rise. A glance
at the anatomy of this growth clearly shows
a large chunk almost two thirds due to
population momentum, which implies that
existing population will continue to grow,
despite of the continuous decline in fertility
rate. Another component of the growth is
due to the unmet needs, and the lack of
access to basic reproductive services.
A particular feature of today's India's
population structure is the significant
percentage of the young people. Of these,
adolescents in the age group of 10-19
represent 22,8%, which is almost 2/3rd of
the world adolescent population. This
group, which is the future of the country,
requires immediate attention and design of
special programmes to meet their overall
health, reproductive health and social
development needs.
I
6
■ HEALTH FOR THE MILLIONS / February - March 2004
i
4
Overview of adolescent life
Neetu K.in<isi
Introduction
What happens to India's future depends, to a
larger extent, on the de( isions taken by our
adolcsc ents as they enter the phase that shapes
destiny of the world's largest democracy. 230
million adolescents in the age group of 10 to
19 years account for 22.B% of our nation's
population (Planning Commission report, 2001).
Gordon Gibbons commented "The winds and
the tides always favour the ablest navigators."
This is true for country like India, which has the
demographic advantage of having the highest
percentage of young population - the most
productive and skillful segment, and added
advantage of their demand ac ro<s the world. In
yvais to r oine, India will have the highest
number ol people in the younger age group,
.ind this will continue till >050. With additional
47 million people between 20 10 and 2030 in
the working age group, India will have an edge
over many countries like France, while they face
workforce shortages. These statistics are
beginning of a new trend. The realisation of this
opportunity will involve strong action from the
government, civil society and nation as whole.
These under-20's are our present as well as our
future. Investing in their well-being must be one
of the best and most important actions that
1
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■
HEALTH FOR THE MILLIONS / February - March 2004
a 7
can be taken today, especially actions to make
sure these young people enter adulthood with
the right kind of knowledge and information. Its
time to empower them, so they grow into
responsible adults and build India as number I
nation in the world.
Today, adolescents have diverse experiences
given the different political, social, ( ultural, and
economic realities they face in our
communities. Yet, there is a similar vision in
everyone's eyes to see a bright and shining
future. This hope is bolstered by the Millennium
Development Goals agreed to by our leaders
in the year 2000 to reduce extreme poverty
and hunger, slow the spread of HIV/AIDS,
reduce maternal and child mortality, ensure
universal primary education, and improve
sustainable development by 2015.
Within the framework of human rights
established and accepted by the global
community, certain rights are particularly
relevant
to
adolescents,
and
the
opportunities and risks they face. These
include gender equality and the right to
education and health, including reproductive
and sexual health information, and services
appropriate to their age, capacities and
circumstances.
The commitment is further strengthen by
promises of our Tenth Five Year Plan,
towards our young generation. Actions to
ensure these rights can have tremendous
practical benefits: empowering each
individual, ensuring
well-being,
The actual interpretation of their
stemming the HIV/
AIDS pandemic,
adolescence as a phase of
reducing poverty,
life remains a social
stabilizing
population, bringing
construct that differs
mortality
rate
between cultures. In India
down, improving
reproductive
there is a resistance to the
health, eradicating
concept of'adolescence'
gender disparity,
educating
the
especially for girls.
nation, fighting for
peace,
and
improving prospects for social and
economic progress. Addressing these
challenges is the need of this hour and
development priority. Failing to act, on the
other hand, will incur tremendous costs to
individuals, societies and the nation at large.
Adolescents are entitled to enjoy all basic
human rights — economic, social, political and
cultural — but their inability to exercise these
rights places the urgency on policy makers and
I
8 ■ HEALTH FOR THE MILLIONS / February - March 2004
community to implement separate measures for
ensuring their rights. Concrete and comprehensive
steps have to be taken for addressing challenges
fac ed by adolesccnts. Towards this government
and civil society have to commit themselves
strongly and then only we can achieve our
millennium developmental goals.
Defining 'adolescents'
Adolescence is generally understood as the
period of transition from childhood to
adulthood and describes both the
developments
to
sexual
maturity,
experimentation, and adult mental processes
to a move from earlier childhood socio
economic dependence towards relative
independence. The term 'Adolescence'
derives from the Latin word 'Adolescere'
which means 'to grow into maturity'. It also
means 'to emerge' or 'achieve identity.' The
most challenging and critical time of one's
life, adolescence brings novelty and
excitement of new experiences, including
taking important life decisions related to
career and a life partner enrapture, while on
the other side, growth spurts and emotional
changes often torment adolescents plunging
them into a sea of turmoil.
In addition, strong need to establish an
identity and self-image also emerge at this
stage. Wherever positive stimulation and a
congenial environment have been provided,
adolescents have risen to the occasion and
done us proud. They yearn 'to right all
wrongs', 'fight for justice' and 'do the right
thing'. They are keen to be recognised as
useful productive and participating citizens
of society. Their contribution in the struggle
for independence, the environment
movement, national literacy campaign and
campaigns against plastic bags, and
firecrackers are only some examples (Report
of the Sub-group for Tenth Five Year Plan,
2001).
The actual interpretation of adolescence as
a phase of life remains a social construct that
differs between cultures. In India there is a
resistance to the concept of 'adolescence'
especially for girls. Their vulnerability due to
poor educational and nutritional status, STDs
and HIV/AIDS infections, socialization
process and patriarchal system, gender
inequality, early marriage, early pregnancy, all
affect their normal growth and development.
Infact, the very concept of adolescence is
not valid, if viewed on a boarder spectrum.
Various factors contributing to this are - early
marriage concept, which mark the beginning
of adulthood straight after childhood.
children trapped in child-labour - maturing to
support their families, drop-outs from school
because of sex discrimination or poverty,
children holding guns rather than indulging
into play due to inc Teasing terrorism and
conflict, and lack of awareness of this age
group.
However, the viewpoints regarding the age
group that may be considered as
'adolescents' are many and varied. The
World Health Organisation (WHO) includes
individuals between 10 and 19 years of age
in its definition of adolescents. The United
Nations (UN) takes into consideration a
much larger age range by defining the age
interval of 10-24 years as youth. The
department of Women and Child
Development of the Ministry of Human
Resource Development, Government of
India, in its Integrated Child Development
Scheme (ICDS), includes all those between
the ages of 11 and 18 years as adolescents:
whereas the Constitution of India and
labour laws of the country consider people
up to the age of 14 as children and the
Reproductive and Child Health programme
mentions adolescents as being between 1019 years of age. It is observed that the age
limits of adolescents have been fixed
differently under different programmes
keeping in view the objectives of that policy/
programme. However, keeping in view the
totality of adolescents and the characteristics
of this age group, it is felt that it would be
most appropriate to consider adolescence as
the age between 10-19 years.
Being an important period of laying
foundation for adulthood in planned manner,
adolescence requires attention from policy
makers, governmental programmes, society
and families. The time has come for us, as a
nation to seriously think about providing the
right stimulus, role models and environment
for adolescents, in order for them to become
assets for nation building. They have the
potential; now is the time to provide them
with the opportunities.
Population profile
Scanning through the population distribution of
our country one finds, children between the
age group of 10-19 i.e., adolescent population
represents the largest and most rapidly
expanding segment. India's adolescents forming
22.8% of country's entire population
constitutes 23% of world's total adolescent
population. This makes 2/3rd of the worlds
most fertile and vulnerable population resides
in India.
It is estimated that over the next two decades
the number of adolescents, as well as their
share as a proportion to the total population
will be large because of the* high fertility in the
eighties, and the population momentum in the
nineties. In years to come India will have the
highest number of people in the younger age
group and this will continue till 2050. With 325
million people, representing nearly 25 per c ent
of the population by 2020, being in the 20-35
age group, gives the benefit not merely of a
young working age group but also of growing
market. Indicating a perfect mix of economic
and demographic factors depicting India in the
fast lane.
The realisation of this opportunity should call
for inculcation of skills, strengthening the
education system and major reforms in HRD.
As the most pressing challenge facing us in
the coming years will be to provide every
Indian with the opportunity to realize his or
her full creative potential. If we succeed we
achieve our goals or else create millions of
liabilities for years to come, for which our
future generations will never forgive us. We
have to make ourselves committed towards
adolescents of our country, so that their
talents and potentials are utilized for the
benefit of the nation.
The group of adolescent includes wide range
of backgrounds: they are affluent, poor,
migrants, school-going, dropouts, sexually
exploited, working adolescents, group of
special needs, besides married parents. The
specific issues related to adolescent group
thus vary on the basis of sex and age (1013, 14-16 and 17-19) representing stages of
growth and development, besides their
background.
Within this paradigm of population,
characterised by distinct physical and social
changes, the separate health, education,
economic, and employment needs of
adolescents cannot be ignored or
overlooked. But surprisingly, this group
constituting one fifth of our total population
holds not even one-health policy or
programme in their favour. They are
benefited usually as a by-product of
objectives of some other programmes. From
last many decades, the focus of health
related policies and programmes have been
on child (under five) or mother. So far
adolescents have not received the attention
they deserve because of the relatively low
morbidity and mortality rates of this age
group. However, in view of the sheer
numbers (230 million), adolescents as a
group, merit special attention.
HEALTH FOR THE MILLIONS / February - March 2004
r. 9
*
Sex ratio
The ratio of females to males, according to the
2001 Census is 9 3 3:1000 - a disturbing
indicator of gender discrimination. State-wise
sex ratios vary from 1088 in Kerala, 964 in
Karnataka, 990 in Chatisgarh to unbelievable
821 in Delhi and 861 in Haryana and 874 in
Punjab. Indicating 32 million missing women,
who would otherwise be living today, if it was
not for this inhuman practice. Out of the 12
million girls born in the country each year, 25
per cent or 3 million do not get to see their
15th birthday according to a UNICEF Report of
1995. The strong 'son preference' in India
which manifests itself in the neglect and
exploitation of girls and women has led to the
adverse sex ratio. The sex ratio for adolescents
in the 13-19 age group declined from 897.7 in
1981 to 884.2 in 1991. There is also evidence
to show a high level of female mortality in the
age group of 15 to 19 years implying high
maternal mortality amongst teenage mothers.
Age-specific mortality
Adolescents are not focussed in most of the
health policies and programmes as they are
considered a healthy group and figures of low
adolescent mortality rates supports it further,
when compared to older age groups or children
(0-4 years). However, the pervasiveness of
gender discrimination in India, lower nutritional
status of females, early marriage and high
fertility, and early child bearing (leading to
maternal mortality) contribute to a wide
difference in mortality rates in adolescent
females and males. In the older adolescent age
group, female mortality is significantly greater
than male mortality, as female adolescents
begin to experience problems of early
pregnancy, the effects of malnutrition and
anemia. About 13 per cent deaths of females
below the age of 24 years are related to
pregnancy and childbirth causes (Central
Statistics Organization, 1999). Similar trends
also prevail in the rural and urban age groups.
If this continues, it is speculated that the
number of females in future will become
shamefully low in the country, and ultimately
leading to the downfall of society, and the
downfall of civilization itself.
Policy makers must strongly address issue of
gender discrimination and high levels of female
adolescent mortality through focussed
programmes that aim to lift women's status,
and target on problems such as early marriage
and childbirth.
Education and literacy
There is a strong and positive relationship
between proper educational endeavour and the
overall growth, and development of
adolescents. The level of education is correlated
to the other social development indicators such
as fertility, lower infant and child mortality, lower
population growth and stabilization in return,
higher age of marriage, higher life expectancy,
and greater participation in work force.
The overall literacy situation of India reveals a
positive picture from 51.63% in 1991 to
65.38% in 2001. The gain by 13.75% is sign
of steady progress towards literacy and
progress. However, still a huge difference of
21.68% between males (75.96%) and females
(54.28%) prevails, depicting gender disparities.
This difference continues at regional level as
well. In Kerala for example female literacy rate
is as high as 87.86%, while in Bihar its as low
as 33.57% for females and 60.32% for males.
There are similar variations and some
inexplicable difference in other States.
While literacy rates both for males and females
have been increasing, the gender gap between
males and females in 1991 is less than 10% as
against more than 20% in earlier years. A
positive trend however is that female literacy
rose by 24 percentage points between 1981
and 1991 for girls in the age group of 10 to 14
years and by 22.5 percentage points for girls in
the age group of 15 to 19 years. The
corresponding increase for boys was only 10.2
and 9.2 per cent respectively.
As far as educational attainment is concerned.
Table 2 indicates that over half of all males aged
15-24 have completed middle school education
compared to one third of all females. The poor
attendance and high drop out rates in the
adolescent age groups are a cause of grave
TABLE 1: Percentage of literates by age and sex
Source: CSO, Youth in India, 1998
10
■ HEALTH FOR THE MILLIONS / February - March 2004
*
I
TABLE 2: Education attainment: % who
have completed:
Level
Total
Male
Female
Primary School (10-14) 43.3
48.5
37.8
Middle School (15-19)
54.1
34.8
performance tend to aspire for white
collar jobs. Thus almost 90% of the
adolescent population are therefore
perceived as 'unemployables' instead of
being an asset to the country.
In a vast majority of families economic
and socio-cultural pressures coupled with
the limited availability, and accessibility of
High School (20-24)
41.9
55.8
29.4
educational opportunities lead to the
Source: National Family Health Survey (International Institute
exclusion of adolescents, especially girls
of population Sciences, 1995)
from education. Being out of school,
boys enter the world of work and start
worrying about earning. Girls suffer .the double
burden of entering workforce and are also
concern. Lack of accessible middle schools in
confronted with matrimony and childbearing.
rural
areas,
unimaginative
curricula,
The adolescent boys contribution is measurable
dysfunctional schools, disinterested teachers;
in economic terms leading them to earn greater
early entry into the work force due to
respect, and develop an attitude of superiority
economic reasons, social attitudes, and
over their female counterparts.
expectations are some of the factors which
account for low enrolment and high drop out
In the absence of educational programmes that
rates for adolescents. For adolescent girls the
addresses their employment and self
additional reasons are - the burden of sibling
development needs, both adolescent boys and
care, early assumption of domestic
girls especially those out of school have little
responsibilities, physical and sexual insecurity,
opportunity to grow into self-confident, aware
early marriage, distance from schools,
and healthy persons. The formal school system
inadequate facilities of toilets leading to
has little to offer to the dropouts and out-of
difficulties for girl students during menstruation,
school adolescents. Dwindling non-formal
absence of female teachers, and parental
programmes, such as they are, only cater to the
educational levels. In urban settings too, the
elementary stage. There is presently nowhere
gender disparities in school enrollment and
that their real life education needs are met i.e.
completion show similar trends, though they
understanding and critically reflecting on their
are not as pronounced.
lives, exploring opportunities for employment/
self employment, skill training, confidence
There is massive attrition in the education
building etc.
system. The drop out rates in classes I to X
44.2
is around 70%, and only 40 to 60% pass
class X & XII examinations. Further there is
growing evidence to show that given the
poor quality of schools and teaching, we
have been churning out semi- literates.
Among the concerns expressed by the rural
and urban poor is that schooling also results
in little appreciation of dignity of labour.
Adolescents, irrespective of their academic
Health and nutrition
Adolescence is the phase of rapid and
significant biological changes. This is the
period of opportunities for growth and
development but also of risks to health and
well-being. The rapid growth that occurs in
adolescence demands extra nutritional
TABLE 3: Drop out rate (per cent) at different stages of school education
Year
Primary l-V classes)
Middle (I-Vlil classes)
Secondary (l-X classes)
Boys
Girls
Boys
Girls , . 2-' Boysi;.-
74.6
NA
1970-71
70.92
64.5
83.4
1980-81
62.5
56.2
1990-91
46
79.4
'65.13
; „ j37.79
40.1
35.18
....
^35^
1994-95p
,
Girls
41.22
19?8-99p IfIBsr-
<516.53
NA
^68,
59a2^^ 76^6^
50.0273.78^*.« .^7.'15fSp '
tom
p — Provisional
Source: CSO, Women and Men in India 1998; MOHRD, Selected Educational Statistics 1998-99.
HEALTH FOR THE MILLIONS / February - March 2004 ■ 11
«
*
-I
■
p
I?
-
-
S''-.
requirements, thus making nutrition as
significant indicator of adolescence health.
This is explained by the fact that it is during this
period adolescents gain up to 50% of their
adult weight, more ‘han 20% of their adult
height and 50% of their adult skeletal mass.
Most of the current programmes of
Government are focussed either on pregnant
and lactating mothers or pre-school children.
Adolescent nutrition has not been given the
attention it deserves, except for a limited
nutrition programme for adolescent girls under
the Integrated Child Development Services
Scheme run by the Department of Women and
Child Development. In fact, it is during the spurt
in growth during adolescence that malnutrition
can be remedied - a fact little recognized even
today (Report of the sub-group for the Tenth
Five Year Plan, 2001)
In under-nourished children rapid growth during
adolescence may increase the severity of
under-nutrition. Iron is deficient in almost all age
groups. Adolescent girls need additional
requirements of iron, to compensate for
physiological blood loss. Anaemia is also a
problem for adolescent boys due to rapid
growth and development of muscle mass.
Naturally the shortfalls create more vulnerability
for adolescents. This poor nutrition is often
cited as the major reason for the delay in the
onset of puberty in Indian adolescents. Pre
pregnancy anaemic status of adolescent girls is
crucial and has long-term inter- generational
consequences. Anaemic adolescent mothers
12
* HEALTH FOR THE MILLIONS / February - March 2004
are at a higher risk of miscarriages, maternal
mortality and giving birth to stillborn, and low
birth weight babies.
Within the typical gender stratified social
structure in India, adolescent girls are especially
disadvantaged. They are trapped in a viscous
cycle of poor nutrition, excessive burden of
work, early marriage, childbirth, high maternal
mortality and morbidity. In terms of food in
take, access to health care and growth patterns,
they are worse off than their brothers. If India
wishes to achieve the goals of Health for all and
adequate Nutrition for All, it must attend to the
problem of undernutrition among adolescent
girls.
Evidence also show that there has been an
increase in obesity during the last two decade''
among adolescents especially in affluent groups
both of rural and urban areas. Accompanied
with rise in problems like hypertension, diabetes,
cardiac arrest and stress. Adolescents are facing
health threats at such an early age due by
changing environment of urbanization and
globalization. Now the challenge is to combat
both undernutrition and over-nutrition.
Adolescents knowledge regarding reproductive
and sexual health is limited, more so in rural
areas. Most of the adolescent girls do not have
knowledge of puberty or menarche, till its
onset and also unaware of their physiological
changes during adolescence phase. This lack of
knowledge about reproductive health including the emerging threat of HIV/AIDS -
• may have grave consequent es for the country.
I he health related behaviours that our
adolestcnts adopt such as smoking, sexual
behaviours, alcohol, and substanc e abuse need
Urgent priority too.
in the age group of 15 to 19 years are married
and in the age group of 25 to 29 years 94 per
cent are married. File age at marriage is about
two and halt years lower in rural areas
compared to urban areas (NFHS-1998-99).
Adolescent groups are the vigour means and
(‘xtremely important producers, who will form
the main workforce of India tomorrow. Thus,
their health status, education, and awareness
will determine the economics of our country.
Early marriages are common in Madhya
Pradesh, Andhra Pradesh, Rajasthan and
Bihar, where more than 50% of young
women aged 15-19 are married. In Haryana
and Uttar Pradesh, 40-44% of young women
aged 15-19 are married. Women in Kerala,
Punjab, Goa, Maipur, Mizoram and Nagaland
tend to marry
later, and in
Adolescent groups are the
these states
fewer
than
vigour means and extremely
15% of girls
important producers, who
aged
15-19
are married.
will form the main workforce
T
h
e
percentage of
of India tomorrow. Thus,
adolescents
their health status,
married before
they are 18 is
education, and awareness
68.3%
in
will determine the
Rajasthan, and
7 1% in Bihar
economics of our country.
as against 1 7%
in Kerala and
1 1.6% in Punjab. (NFHS-1998-99).
Adolescent reproductive health
The ages from 10-19 are rich in life transitions.
How and when young people experience these
vary greatly depending on their circumstances.'
At age 10, the expectation in most societies is
that children live at home, go to school, have
not yet gone through puberty, are unmarried
and have never worked. By their 20,h birthday,
many adolescents have left school and home.
They have become sexually active, married and
entered the labour force.
The lack of knowledge about reproductive
health, including the emerging threat of HIV/
AIDS and the changing environment is affecting
relationships, and demand on adolescents as
adults. They are becoming products of
confused information, western morals, peer
pressures, lack of programmes and strong
influence of mass media.
We the policy makers, communities, leaders,
social activists and families need to create an
atmosphere which is positive and friendly for
these young people to bloom, and
acknowledge their unique health and
information needs.
The age at which people get married reflects
their role as adults and their contribution
towards community. Early marriage violates a
number of human rights and especially for girls.
This in turn severely affects the risks faced by
infants, children, society and productivity of
nation.
Age at marriage
Sexual activity and behaviour
Despite of the new >wave of late marriage
across the globe, 82 million girls in developing
countries who are now aged 10 to 17 will be
married before their IB'1’ birthday. In India itself
50% of girls get married much before the age
ot maturity, marking the onset of reproductive
behaviour and sexual activity. Age of marriage;
therefore has far reaching consequences on
fertility rates, child bearing, infant and maternal
mortality and many such issues. This further is
highly co-related with education levels, poverty,
lack of employment opportunities, parental
desire to ensure sexual relations within
marriage, and image of girl as homemaker, wife
and mother.
Considering the highly conservative attitudes
towards sexual behaviour in India, number of
studies have reported findings of early sexual
ac tivity initiation occurring outside the
institution of marriage, particularly for boys.
They are also more likely to approve of
premarital sexual relations for themselves;
and have more opportunities to engage in
sexual relations. Both adolescent boys and
girls who engage in sexual activity often
begin with zero or little knowledge of
sexuality, reproductive health, safer sexual
practices, or their right to refuse and abstain
(Jejeebhoy, 1996).
In India, the legal age for marriage is 18 for
females and 21 for males. Still in many parts of
country, early marriage for girls is a religious and
social imperative. Thirty per cent of adolescents
Little is understood about adolescent's sexual
awareness, behaviour, their attitudes and what
they see as their reproductive and sexual health
needs. The available data suggests that
between 20 and 30 per cent of all males and
HEALTH FOR THE MILLIONS / February - March 2004
• 13
I
I
I
I
I
I
♦
up to 10 per cent of ill females are sexually
active during adolescence before marriage.
Adolescents usually view their sexuality
positively, but some early sexual experiences
may be accompanied by feelings of anxiety,
shame and guilt. They want to keep their
relationships secret, for fear of adult, and
society disapproval. Many are ignorant of their
bodies and how reproduction works; they
know little about different kinds of sexual
activity and the consequences. They often
have no knowledge of, or access to, family
planning services, and are at risk of an
unwanted and unprotected pregnancy or
acquiring a sexually transmitted disease.
As our own system and conservative pattern of
relationships do not provide right atmosphere
for adolescents, to grow healthy, most of them
get their information from the media and their
peer groups; this may be inaccurate or
misleading, and even encourage risky behaviour.
Failure to provide enough information to enable
adolescents to protect themselves from
harmful effects and to develop the foundation
for healthy, responsible sexuality and
reproduction must be interpreted as a
contravention of their human rights. Further
increasing the length and breath of all our
existing problems in country.
Fertility rate
Adolescent fertility in India occurs mainly within
the context of marriage and this makes the age
at marriage of paramount importance for
fertility rates. As a result of early marriage,
about half of all young women are sexually
active by the time they are 18; and almost one
in five by the time they are 15. If this magnitude
of teenage fertility in India is considered: well over
half of all women aged 15-19 have experienced
a pregnancy or a birth (Jejeebhoy, 1996).
A progressively large share of all births
occurring in the country occurs to women
aged 15-19: 11 per cent in 1991, 13 per cent
in 1981 and 17 per cent in 1992-93
(International Institute for Population Sciences,
1995). Age specific fertility rates are given in a
time series in the table below.
TABLE 4: Age specific fertility rates in
India
74
Source: CSO, Women and Men in India 1998.
14 ■ HEALTH FOR THE MILLIONS / February - March 2004
UNFPA in its profile 'Adolescents in India' in the
year 2000, rt've.iled that adolescent fertility rate
for India is IK) births per 1000 women in the age
group ot H-1‘) years, with the rate in rural areas
lying twice as high at 131 than in urban parts of
the country. The adolescent fertility varies greatly
between states. In the age group of 13 to 19
years, adolescent fertility is 153 births per 1000
in Madhya Pradesh, 143 :n Haryana, 141 in
Maharashtra, and as low as 38 in Kerala.
The impact of western culture, restrictions by
society on relationships between boy and girl,
misleading information through magazines and
cyber world, curiosity, and experimentation of
this age along with unprotected sexual activity
is leading to increase in fertility among
unmarried adolescents too, particularly in urban
areas.
Nationally not-more than 7.1 per cent of
married
women
aged
15-19
using
contraception, compared to 21 per cent
among slightly older women aged 20-24. But
30 per cent of these married women aged 1519 expressed desire to delay the next birth or
childbearing (NFHS. 1992-93).
In totality pregnancy at young age exacerbates
their own poor reproductive health and the
poor survival chances of the infants they bear.
Without education, without a skill or
opportunity for employment, and with relatively
poor health and nutrition, they are caught in a
web of ignorance, poor reproductive health,
life-long economic dependency, physical
seclusion, early marriage and frequent
childbearing.
The only door to freedom is empowerment of
women, be it a daughter, mother or wife.
Educating one woman means educating the
whole family. And what is true of families is also
true of communities and, ultimately, whole
country. To stabilize our country's growing
population we have to target on making
educational facilities accessible to all individuals
with special emphasis on girls and women.
Reproductive health risks of early
marriage and childbearing
Adolescents facing pregnancy and childbearing
are exposed to number of risks. Age at which
they are physically growing, time that demands
additional nutritional inputs, if comes in heel
with pregnancy, and its additional requirements
can have severe consequences to their
reproductive system. This combined with high
maternal and neonatal mortality rate, pregnancy
complication, and low-birth weight baby adds
to the whole situation.
Adolescents are more likely to experience
adverse pregnancy outcomes than older women.
10 per cent ot all adolescent pregnancies end in
miscarriage or still-birth compared to 7 per cent
among older women. Also infants of adolescent
mothers are more likely to experience higher
perinatal and neonatal mortality than infants of
older women (NFHS, 1992-93).
On the other hand unprotected sexual
behaviour among adolescents too can have
severe implications, particularly for adolescent
girls through unwanted pregnancy, abortions
and HIV/AIDS. Poor access to contraception
and contraceptive failure, lack of information,
and also the incidence of rape contribute to the
high rate of abortion among adolescents
(Ministry of Health and Family Welfare, Country
Paper, 1998).
Reasons for abortions vary from family spacing
and son preference for married adolescents to
social stigma for unmarried adolescents. While
abortions are legal under the Medical
Termination of Pregnancy act (MTP) 1972, yet
the number of illegal providers of abortions
services are very high.
Most of these problems can be prevented by
appropriate Adolescent Reproductive Health
(ARH) services. Currently there aren't many
such programmes and services for adolescents
and also lack of reproductive counselling
centers, and receptiveness of society makes it
further difficult in providing them help.
Maternal mortality
Adolescence being the growing phase puts
additional requirements on one's body in terms
of nutrition for full growth. At this point
pregnancy means double demand and extra
pressure, in return making the adolescent girl
prone to pregnancy complications. The inter
woven problems of gender discrimination, poor
nutrition, early marriage, high fertility, early child
bearing, illiteracy, low societal status, and many
other prejudices towards girls and women
together leads to millions of maternal death in
India. In general, young adolescents are twice
las likely to die as women older than 20 from
pregnancy related causes (Mehta, 1998). Socio
cultural factors, such as the stigma attached to
unwed motherhood and therefore, the
prevalence of abortions only serves to increase
the incidence of mortality.
Maternal mortality beside, affecting life and health
of adolescent girls have severe intergenerational
effects. Early age of marriage coupled with poor
physical and nutritional status, low weight
pregnancy, and lack of proper medical care
H
results in babies suffering from low birth weight.
Stating high prevalence of infant mortality among
adolescent mothers. Further, emphasizing on
urgent need of accessible ARH facilities in every
corner of our country.
Sexually transmitted diseases
and HIV/AIDS
Young people have high rates of sexually
transmitted diseases (STDs) and the incidence
among adolescents has been increasing
noticeably in recent years. The most common
among adolescents are gonorrhoea, chalmydia,
syphilis, herpes, genital warts and HIV. In India
alone the number of people living with HIV/
AIDS is approaching five million. Of this youth,
ages 15-24, are the fastest growing segment of
the newly infected population, with one youth
infected every 15 seconds. Young people
between the ages of 10 and 25 make up 50
per cent of all new infections, with shift of this
epidemic towards women and young people
(Population Foundation of India, 2003).
This disturbing trend clearly points out, the lack
of knowledge about STDs and how to prevent
them among, youngster, high sexual behaviour
patterns, and low levels of contraceptive use.
Unprotected sexual behaviour-* among
adolescents can have severe consequences,
particularly for adolescent girls through
unwanted pregnancy, maternal mortality (due to
early childbearing), abortions and HIV/AIDS.
,
HEALTH FOR THE MILLIONS / February - March 2004
E 15
*
TABLE 5: Age-wise break-up of drug
users
Age group
No. of abusers
Per centage
12-17
778
4.54
18-23
2373
13.86
24-30
5178
30.25
31-45
6041
35.30
46-60
2142
12.51
61>
600
3.5
17112
100
All India
Source: MOHFW Country Paper for the South Asian
Conference on Adolescents, 1998
Adolescents' ignorance about sexual and
reproductive behaviour is compounded by
reluctance among parents and teachers to
impart relevant information. In both rural and
urban slums, mothers expect their adolescent
children, particularly daughters, to remain
uninformed about sex and reproduction. Sex
and
puberty
are considered to be
embarrassing, distasteful and dirty subjects, not
to be discussed with their adolescents
daughters (Bhende, 1995).
Empowering this age group is crucial in turning
back the epidemic. The government has
recognised this and the National AIDS Control
Organisation is actively working to spread AIDS
awareness in schools and colleges through
integration of AIDS training into the curriculum.
National Aids Control Programmes has
recognised the need to go beyond high-risk
groups, and address behaviour change in the
general reproductive age-group, which includes
young people.
But this whole knowledge on STDs and HIV/
AIDS will be ineffective, unless adolescents are
rightly equipped with the social skills to negotiate
sexual behaviour and understand the importance
of preventive behaviour, especially girls. This age
group which is most receptive and responsive to
their own needs can surely make a difference if
investment at the right time and right age is made.
It we fail to do so, millions of families will be left
behind without sons or daughters, and many
children without a mother or father.
High risk behaviour
Adolescence, the age of experimentation,
adventure and exploration is known to be
vulnerable to number of risk causing behaviours
like substance abuse especially drug abuse, pre
marital sexual activity and antisocial behaviour.
In 1993-94, 4.54% of drug users were in the
16
s HEALTH FOR THE MILLIONS / February - March 2004
age group of 12-17 years and I TBG'X. were in
the age group of 18-2 1 years. I he ac tual age*
of first use ot drugs is known Io be as low as
5 years. Also a < onsiderable number starts
taking drugs when they are still minors. There
is ample evidence to show that a majority of
first time drug users belong to adolesc ent
group. As this age group is known lor forming
life long habits, suc h early use ot drugs usually
leads to addiction for life.
Its well established that the use of drugs is
closely associated with anti-social behaviour
and higher crime rates, as well as increased risk
of contracting HIV/AIDS. Needle sharing for
drug use is highly known for spreading the HIV
virus directly into the blood stream. Further,
mixing it with sex provides a way for spread of
HIV to wider population. Even alcohol abuse
can fuel young minds to engage in risky sexual
activity, increasing the spread of HIV epidemic.
Making the whole situation very sensitive.
Many adolescents start getting depressed due
to academic failures. Their inability to find
meaningful avocations, increasing pressures
from family, and peer group compounds this
trend of risky behaviour.
While generally one can say that the low
education anci economic levels have been the
main causes for juvenile delinquency, the
percentage of adolescents (to the total
juveniles) coming from low-income group
(Rs.500 per month) households declined from
54.1% in 1994 to 45.37<» in 1997. On the other
hand, the share of the middle-income group
delinquents (Rs. 1000 to 2000 per month) rose
from 117, in 1994 to 15.4% in 1997. The
other interesting factor is that children living
with parents/guardians constituted 90.1% of the
juveniles apprehended, while the share of
homeless children was only 9.9,’4, (Crime in India,
1997: National Crime Records Bureau, GOD.
At this point what we need is substance abuse
awareness, adolescent counseling, educational
information and health services, reinforced by
right to education for all.
Violence and crime
Violence and crime crosses cultural and socio
economic lines, taking new shape each day
ranging from eve teasing and abduction to rape,
incest, prostitution, battering and sexual
harassment. It occurs in homes, schools,
workplace and other public places. The
per jetrators are usually—but not always—male.
They can be family members, neighbors,
teachers, schoolmates, and on occasion,
strangers. Because it is an exploitation of power,
•r
adolescents and young people are more
vulnerable to violence and crime than adults.
A need to establish an identity and self image,
pressures ot making major lite decisions
pertaining to career and life partner, and taking
on socio-economic responsibilities without
autonomy and support lead to conflicts which
adolescents, particularly boys are not ecjuipped
to handle. Resulting in frustration and extreme
Cases of suicide.
Research on adolescent violence in India is
limited; very little is written about the same.
Violence against women and girls is a
neglected area beside the fact that it is a
growing phenomenon across the globe.
Partially defining women's capacity to protect
themselves against STDs, pregnancy and
unwanted sexual intercourse, which directly
affects female reproductive health.
Crimes are perpetuated both on adolescents
and by adolescents. Adolescent girls are
definitely the more disadvantaged, though
adolescent boys also suffer abuse. Physical,
mental and psychological violence against
adolescents both at home and outside is
spreading like fire and is a matter of grave
concern. Some major causes are the social
custom of dowry, low status of women and
girls in society, false sense of superiority of
adolescent boys and young men, and the desire
to show-off and take revenge. Even though
these cases remain under silence and
community pressure, they are slowly eating
away our morals and values.
As a result of globalisation of electronic media,
increasing sex and violence in films, and
bombardment of images promoting violence
and consumerism, rape, blackmail of young
women for sex, and harassment at the work
place are steadily on an increase. The number
of girls apprehended for crime, particularly
prostitution increases sharply at adolescence in
the 16-18 age group. Tracing its roots in
poverty, migration, tourism, illiteracy, lack of
employment,
globalization
of
trade,
urbanization and liberalization.
Work force participation
Despite child labour being illegal for children
below 14 years, it is commonly prac tised in ail
parts ot the country. Adolescent participation
rates in the labour force are relatively high. The
1994-95 National Sample Survey Organisation
found that the work force participation rate
among rural adolescents aged 15-20 years was
77% for young men and 31% for young women.
They are employed in occupations ranging from
work in glass factories to domestic labour, bidi
making, gem-polishing, coir-making, paper bag
manufacturing, embroidery, zari embroidery, and
the lock, glass and carpet industries. Many
adolescents work in the agricultural sector or for
local village industries as a part of a family labour
force. In urban areas,
girls form a large part
Adolescents of our country
of the unorganized
sector working as
will surely help us realise the
domestic
help,
vision of India 2020. Only if
Besides
receiving
unequal
wages.
we empower them, expand
working girls are more
their capabilities, offer more
vulnerable to sexual
abuse and violence
opportunities, invest in their
than older women.
education and health, and
India's employment
promote gender equality.
statistics present a
disturbing picture.
The 10,h Planning Commission document has
already warned that at present the country's
infrastructure won't be able to provide jobs for
new entrants or clear the backlog.
Unemployment may go up from 9.21% in 2002
to 9.79% in 2007.
It is paradoxical that on the one hand there is
growing unemployment and lack of awareness
about career options and on the other hand
there are many new avenues and areas for
employment. Adolescents are often led or
driven into vocations and careers unrelated to
their aptitude and suitability often under
parental and societal pressure specially with
regard to traditional careers like engineering,
medicine, teaching etc. There is almost a
complete lack of career guidance to
adolescents and their parents.
Psychological concerns
It is during the period of adolescence that
potentialities are realised, abilities and skills
developed, and habits and attitudes formed. In
today's fast moving world the psychological
concerns of adolescents are accentuated by
parental discord, rapidly changing social and
cultural values, increasing exposure to global
media, different life styles, and exposure to
different cultures.
Conclusion
Adolescents living in difficult and sensitive
situations have very distinct and special needs.
Lack of focussed policies, programmes and
services for adolescents; clearly reflects absence
of their health and developmental ariority from
the governmental agenda. This age group making
l/5,h of our total population, requires great
understanding and collective efforts from the
HEALTH FOR THE MILLIONS / February - March 2004
BS 17
*
government, leaders, parents, families, and
educators to separately address their concerns
and needs. The very first step should be to
generate and increase availability of reliable data
and information on adolescents. This would serve
as a tool of advocacy and guiding force for future
actions. Secondly, policies and programmes
should keep in mind diversity of their experiences,
living conditions, changing scenario, social
behaviours, conflict and disaster situations, along
with impact of urbanization and migration, lack
of education, dearth of vocational training and
employment opportunities, and increasing gender
discrimination. At the same time, it is equally
important not only to make adolescents'
beneficiaries, but also valuable partners in the
process of planning, national development and
decision making.
Adolescents of our country will surely help us
realise the vision of India 2020. Only if we
empower them, expand their capabilities, offer
more opportunities, invest in their education
and health, and promote gender equality.
References
Behavioural Epidemiology and Demographic
Research Branch, Division of Reproductive Health,
Centres for Disease Control - Adolescent Sexual
Activity and Childbearing in Latin America and the
Caribbean: Risks & Consequences, USA, 1992.
CEDPA - Facts on Asia and Country Profile, "Girls'
Rights: Society's Responsibility - Taking Action
Against Sexual Exploitation and Trafficking", Mumbai,
1997.
Central Statistical Organisation - Youth in India:
Profile and Programmes, 1998, Government of India,
New Delhi 1998.
Central Statistical Organisation — Women and Men
in India 1998, Government of India, New Delhi,
1999.
CHETNA -Health, Education and Development of
Adolescents - CHETNA's Perspective, 1998.
Department of Child and Adolescent Health and
Development - Progress in Child and Adolescent
Health and Development: Activities of the former
Division of Child Health and Development and the
Adolescent Health and Development Programme in
1998, WHO, 1999.
Department of Child and Adolescent Health and
Development - CAH Progress Report 2000, WHO,
2001.
Ms. Neetu Kapa si is a
nutritionist and a
programme officer with
VHAI and the editor of
this health journal.
Understanding Adolescents: An IPPF Report on
young people's sexual and reproductive health
needs, UK, 1994.
Janshala (GOI-UN) Programme, Ministry of Human
Resource Development, Department of Elementary
Education & Literacy — Educating Adolescent Girls:
Opening Windows, Government of India, New Delhi,
2001.
Jejeebhoy, J.S., Adolescent Sexual and Reproductive
Behaviour: A Review of the Evidence from India,
ICRW Working Paper No. 3, Mumbai, 1996.
Jejeebhoy S - Adolescent Sexual and Reproductive
Behaviour: A Review of the Evidence-from India.
Social Science and Medicine, 1998
MAMTA - Adolescence health and Development in
India - An Action Approach: MAMTA — Health
Institute for Mother and Child, 2001.
Mehta, S. — Responsible Sexual and Reproductive
Health Behaviour among Adolescents. Theme
Paper prepared for United Nations Population
Fund sponsored South Asia Conference on the
Adolescent, July 21-23, New Delhi, 1998.
Ministry of Health and Family Welfare - India
Country Paper prepared for United Nations
Population Fund sponsored South Asia Conference
on the Adolescents, July 21-23, Government of India,
New Delhi, 1998.
Ministry of Health and Family Welfare — Annual
Report, 1998-99, Government of India, New Delhi,
1999.
Ministry of Health and Family Welfare, Department
of Family Welfare - Reproductive Child Health,
Government of India, 1998.
Ministry of Human Resource Development,
Department of Women and Child Development —
India Nutrition Profile, Government of India, New
Delhi, 1998.
Ministry of Human Resource Development,
Department of Secondary and Higher Education,
Planning, Monitoring and Statistics Division . Selected Educational Statistics 1998-99, Government
of India, New Delhi, 2000.
Ministry of Human Resource Development,
Department of Higher and Secondary Education Annual Report 1999-2000, Government of India,
New Delhi, 2000.
Population Reference Bureau - HIV/AIDS in India,
Population Foundation of India, New Delhi 2003.
Planning Commission. Report of the Working Group
on Adolescents for the Tenth Five Year Plan (20022007). Government of India. New Delhi. 2001.
Family Planning Association of India — Annual Report
1998, Mumbai, 1999.
Planning Commission - Tenth Five Year Plan (2002 2007), Volume 1, Government of India, New Delhi,
2002.
International Institute for Population Sciences - National
Family Health Survey 1992-93, Mumbai, 1995.
United Nations Development Programme — Human
Development Report 2000, New Delhi, 2000.
International Institute for Population Sciences National Family Health Survey 1998-99 (PRB
datasheet), Mumbai, 2000.
UNFPA — Adolescents In India - A Profile, UNFPA,
New Delhi, 2000
International Planned Parenthood Federation —
18 ■ HEALTH FOR THE MILLIONS / February - March 2004
UNFPA - State of world population 2003 - Investing
in adolescents' health and rights — UNFPA, 2003
Do the National Policies in India address
adolescent health?
Dr. Mridula Seth
dolescents comprise a sizeable
proportion of the Indian population.
Nearly 230 million, comprising 22.8%
of the population, fall in the age group of 1019 years'. There is lack of clarity on the age
group comprising adolescents by different
organizations. It is often confused with young
people, defined between the age group of 15
to 24 years.
I
imggaiaaa
hirr- ,
The importance of adolescent health is
underestimated because the only criterion used
is the current levels of mortality and morbidity,
which for this age group, does not seem to be a
major concern. However, if we consider health
as a state of physical, mental and social well
being, the need for addressing their concerns
related to health definitely call for programme
interventions. Similarly, health-risking behaviour
adopted during adolescence and youth such as
smoking, sexual behaviour, alcohol and substance
abuse have long-term impact, not only on these
young people and their families, but also on the
public health system and the national economy.
Thus, preparing our adolescents to face
adulthood smoothly, safely and positively is an
investment for generations to come.
The need of this hour is to clearly describe the
success and effectiveness of interventions for
adolescents, in the context of their transition to
adulthood, and the knowledge, capacities and
opportunities that they need, and will benefit
frorrb’.
Background
Policies, laws and programmes at national,
local and even institutional level falls under
the general category of "Policies". Through
policies, issues get prioritized and addressed.
Providing a framework to translate intentions
into actions through programmes, policies do
give direction and willingness to address the
issues. Backed by political will, policies ensure
availability of resources for implementing
programmes. Development of policies
provides strategic opportunities for
institutionalizing a package of health and
other developmental support for people.
These opportunities arising once in few years
should be capitalized to the maximum.
I
Mi
\ Xi
The National Youth Policy approved in
December 2003, has a focus on youth
covering the age group 13-35 years and has
included adolescents from 13-19 years as a
distinct group. The policy identified eight key
areas of concerns for youth; health occupying
the most prominent place with focus on
general, mental and spiritual health; AIDS;
sexually transmitted diseases; substance abuse;
and population education.
The country witnessed some perceptible
changes in policy environment during the last
decade, on issues related to adolescent
reproductive health. The National Behavioural
Surveillance Survey3 by the National AIDS Control
Organsiation (NACO) reported casual sex
encounter among 15-24 year olds. Vulnerability
of these young people to HIV has brought large
attention to urgently reduce their unsafe sexual
behaviour and requirements of strong political
commitment. The Prime Minister, Mr. Atal Bihari
HEALTH FOR THE MILLIONS / February - March 2004
* 1
3 19
1
Vajpayee also urged (Im? paikif!M.*ni «i 2001 to
consider HIV//MDS. as (Ik* most
public
I walth (moI)I<ih I.K ing th - < ountrs *
India is a signatory and has cimIixm-d all the
InternalKHial Confuniw us aixl ( imm-thmmis that
h.i\u inlluuiu u
tlw p<»li< ius rcl.ih'd to
.»< It il<^4 unis. ( )l Ihusu. llx mitsl iwtftf«,i|»lu onus
are - Inlumafion.tl ( <• iiutuniu <wi l'<^«4.ifw»n and
• )uvulo|Hnunt (K PI)'. ( (mhuiUkmi <m (Im* Kights
of tlx* (.Iwld tCK’O. aivl tlx G'nwnhon on tlx
Elimination of All Forms of I )iscrimiaKxjn Against
Women (CEDAWJ. ICPI)*5 recommendations
substantially contrilxitcd in NgNighting adolescent
sexual and reproductive health. On the same note,
(miMs like derivation of an International Year or a
durade focused on issurs like gender equality liave
after ted jxilicy initiatives of tlx* crxinlry. Altogetlur,
highlighting tlx* •mfxx’tanrx? of commitnwnt frrxn
polir y-makeo and advocacy efforts for public
a\v.ueiM*ss,
I he relevant policies of the various Ministries and
Departments are mentioned in Table i. Whether
they address adolescents' concern is the real
qur?slion in front of us.
Table 1: National Policies relevant to adolescents
Ministries/ "
DeP^tmenU^
Policies
"
Goals
Ministry of Health and Family Welfare
Health
//
’!
' '7*
Family Welfare v
National Health Policy, 2002
Provision of an acceptable standard of good health
’
•- amongst the general population of the country
through equitable access to health services.
National Population Policy, 2000
Population stabilization at a level consistent with the
requirements of sustainable economic growth, social
development and environmental protection.
National AIDS..; ..
Control Organisation
,
INational AIDS Prevention and
Control Poficy, 2000
Prevent the epidemic from spreading and reduce the
impact of the epidemic not only upon the infected
persons but also upon the health and socio-economic
status of the general population at all levels.
Ministry of Human Resource Development
Education
Elementary Education
and Literacy
Secondary and
Higher Education
National Policy on Education,
1986 (as modified in 1992)
Equalizing education opportunities in the age group
of 15-35 years, free and compulsory elementary
education for all children upto 14 years of age, and
functional literacy to adult illiterates.
Women and Child
Development
Draft National Policy and
Charter for Children, 2001
Adequate services to children both before and after
birth and ensure physical, mental and social
development (NPC, 1974)
National Policy for the
Empowerment of Women, 2001
Advancement, development and empowerment of
women.
National Nutrition Policy, 1993
Improve nutritional status of people by increasing
purchasing power, providing basic services and
devising a security system for protecting the most
vulnerable groups (women and children)
Food and Nutrition
Board
Ministry of Youth Affairs and Sports
Youth Affairs'and
Sports4 *..
...
*
National Youth Policy, 2003
- ■ '•
20
a HEALTH POM THE MILLIONS / February
March 2004
Galvanize the youth to rise up to the new challenges,
keeping in view the global scenario and motivating
them to be active and committed participants in the
exciting task of national development.
. . .
*
Policy analysis
Adolescents are included in the general population category in most of the national policies and their needs are
addressed according to the policy focus. The following review is an attempt to examine adolescent health issues
addressed in some of these national policies.
Table 2: Adolescent health addressed in the Policies
Policies
Policy extracts
Remarks
Situation analysis
Adolescents in
the
National
Health Policy
❖
I
Persistent incidence of macro and micro-nutrient
deficiencies, among women and children (1.7); The
social, cultural and economical factors inhibiting
women from getting access to existing public health
services (2.20.1); Women, along with other under
privileged groups handicapped ' due to disproportionately low access to health care
(4.20.1).
’ v.>’
*
Adolescents
not
identified
separately but grouped with children
or pregnant women.
Need for specific programmes
targeted at women's health
recognized.
■
_
School and college students most impressionable ‘
targets for imparting information with regard to
health promoting behaviour (2J 4.2).
■
_______
__ ___ information
Focus on____
disseminating
relating to 'health' and 'family life'
and not skill building. Adolescents in
non-formal education not prioritized.
Strategies
❖
*
Priority to school health programmes aimed at
preventive — health education; providing regular
check -up and promotion of health-seeking
behaviour (4.14.2)
J
I
i
I
i
v:
I
-
Adolescents in
the National
Population
Policy
'
Age specific health needs of the
adolescent groups not included.
A ." -1.
Efforts to bring about behaviour change to prevent
HIV/AIDS and other life-style diseases (2.14.1); Inter
personal communication and traditional media to
bring about behavioral change (4.14.1)
Adolescents not identified as a
target group. Illiterate population
targeted through IEC.
Public health programmes need high visibility at the
decentralised level in order to have an impact
(2.14.1); Specific targets for association of PRIs /
NGOs /Trusts in activities (4.14.1).
Participation of PRIs recognised but
role of youth organisations not
mentioned.
Situation analysis
❖
Over 50% girls mainly below the age of 18,
resulting in a typical pattern of "too early, too
frequent, too many." Around 33% births occurs
at intervals of less than 24 months resulting in
high IMR (9)
❖
Discriminatory childcare leads to malnutrition and
impaired physical development of girl child. Under
nutrition and micronutrient deficiency in early
Problem of early marriage, teenage
pregnancy and spacing addressed.
Recommendations for enforcing the
Child Marriage Restraint Act for
reducing teenage pregnancies.
Promotional and motivational
measures considered for couples
below the poverty line who marry
after the legal age of marriage,
adolescence goes beyond mere food entitlements.—
(15); Low social and economic status of girls and
women limits their access to education; good
nutrition as well as money to pay for health care and z
- family'planning services (17)>
'
....
.
Problem of social injustice and
gender discrimination
discrimination recognised,
recognised.
gender
Need for higher retention of girls in
schools emphasized.
•’<<«
'
I
22 ■ HEALTH FOR THE MILLIONS / February - March 2004
i
V
I
Policies
-
*’
Special requirements of adolescents comprise
information, counseling, population education;
making contraceptive services accessible and
affordable, and nutritional services through the
ICDS (26).
• i ♦
Remarks
t:
Policy extracts
Health package for adolescents
recommended as operational
strategy but not spelt out.
Nutritional services through the
ICDS programme recommended.
Strengthening primary health centres
and sub-centres recommended as a
strategy to provide counseling to
adolescents and newly weds.
However, needs of unmarried
adolescents
not
adequately
addressed.
i Strategies
""
♦
I
'
f
v
. needs
ir
i i--------*- •—
-i..-J:-'" protection frrxrq
The
of adolescents
including
from
unwanted pregnancies and sexually transmitted <
diseases (STD) have not been specifically addressed
in the past. Programmes should encourage delayed
J—------c
marriage and child bearing and' education
of.
adolescents about the risks of unprotected sex (26).
.....
——
--
Adolescents recognised, as an
Provide integrated interventions to adolescents in
pockets with unmet needs of urban slums, remote
rural areas, border districts and tribal populations
Marginalized adolescent groups
prioritized in terms of geographical
location and reach of services.
under-served population group with
special sexual and reproductive
health needs. Critical role of
adolescents
in
population
stabilization recognized.
(NPA vi C4).
-
Need
N-d to undertake national campaigns on
■ v. population related issues via women and youth
organisations (36).
Involvement of youth and other
social sectors recommended for IEG
utilize
Utilize self-help groups to organize and provide
care,,
basic services for reproductive and child health care.
combined with ongoing ICDS (NR\ i, ii); Pre-school
activities must be widened to include MCH services
(NPA 8)
Adolescents not identified as a
separate group for economic
activities. Needs perceived primarily
in the context of maternal and child
health.
Situation analysis
the National ?
AIDS Prevention j ♦ Majority of Injecting Drug Users (IDUs) are youth
and Control^ ; A
15-25 (5.10)
Policv^’’^^-'
W
‘
.
■
• ;--.-xisi ■■;
I
Risk to adolescents addressed and
'Harm Minimization' approach
involving education and services
recommended.
y ,:';
STDs among women though highly prevalent, are
suppressed because of the social stigma attached
to the disease (5.4.ii)
»
Gender discrimination recognized.
Strategies
i
I
r*
Prevent women, children and socially weak groups 7
from becoming vulnerable to HIV infection (3 vii)
Adolescents not identified as a
vulnerable group. Beside the fact,
that HIV/AIDS has become a
disease of young people, with young
adults aged between 15-24
accounting for half of the some
r«■;
HEALTH FOR THE MILLIONS / February - March 2004 ■ 23
Policies -
Remarks
Policy extracts
❖
AIDS education should be imparted through
curricula and extracurricular approach; network of
youth organisations (5.2.3)
Even addressing their needs
(information, skills and services) and
assistance from them in curbing this
epidemic not realized.
❖
Protection of human rights to safeguard human
dignity (6)
Peer education as a strategy
advocated. Specially packaged
programmes tor students, out-of
school youth and sexual partners of
migrant workers recommended.
Widespread abuse of human rights
and discrimination against people
living with HIV/AIDS recognized.
Measures for adopting a rightsbased approach recommended.
Situation analysis
Education Policy : ♦
■
■
■
■
:
*• ■ •
•
.‘
equalizing educational opportunity, ensuring
universal free and compulsory elementary education
and reduction of illiteracy. POA stresses on need for
quality improvement, common school structure for
all stages and renewal of curriculum.
■-A:'
’’a-
j
¥3^35
NPE has focus on children and adolescents for
❖
Vocational education - Health education at the
primary and middle levels will ensure commitment
to family and community health and lead to health
related vocational course (5.18).
....
,
,
National Curriculum Framework,
2000 (NCF) highFights issues related to
remove gender bias in curriculum/text
books, linking education with life skills
to fight challenges related to teenage
pregnancy, AIDS and health problems.
Decentralization and involvement of
paramedics provides scope for
creating employment for youth in
the health sector. Exposing
adolescents to career options is an
important area of concern.
-v>- .
k
Strategies
I
■
?
‘■■■W •■■■'
■
■
I
'■
I
•I
•J
..
■
!■!
Role of adolescents in population
stabilization and parenthood
recognized.
Focusing on 'informing' youth rather
than targeting skill building and
behaviour change.
♦i* Elements to promote values such as equality of
sexes, observance of small family norm and
scientific temper (3.4)
Visualizing education as a tool in
promoting women's empowerment
and equipping her with choice of
family planning.
..
■
.
Population education must be viewed as an
important part of nation's strategy to control the
growth of population, starting at the primary and
secondary level, programmes should be modulated
and inform youth and adolescents about family
planning and responsible parenthood (6.16)
i
.
k’.
.
.
Adolescents lnSituation analysis
the National ^;
Nutrition Policy? < Increased food production does not by itself
necessarily ensure nutrition for all (II); Prevailing
^patterns of intra-household food distribution,
^’^particularly in rural areas, affect nutritional status of
? <;•. women and children (III B)
*
• ’W
-..yr. .
,ron
J.ower than recommended leyekdn
adolescents' girls (III 70; ..
L-/
24 ■ HEALTH FOR THE MILLIONS / February - March 2004
Inequities recognized at the macro
and
micro
level.
Gender
discrimination acknowledged.
Adolescent girls identified as a
vulnerable group.
•;
Policies
Rem irks
Policy extracts
■•'I
Strategies
❖
Reaching adolescent girl within the ambit of ICDS
should be intensified for a safe motherhood status
(IV C)
Need perceived only in terms of
motherhood, leaving adolescent
boys and girls as individuals.
❖
Integration of nutrition and health education into the
school curricula and nutrition programmes. Health
education important for overall nutrition also (IV vi)
Malnutrition and under nutrition
addressed through educational
interventions.
❖
Active community involvement not only in terms of
being aware of services available but also driving
maximum benefit by giving timely feedback at all
levels (IV xiv)
Community participation strategies
identified including generation of
demand. However, adolescents and
youth not identified as stakeholders.
■ Per’°d’cal monitoring of nutritional status of
. J adolescent girls below the poverty line (IV viii)
Mechanism
for
Nutritional
Surveillance through National
Nutrition Monitoring Bureau (NNMB)
' advocated.
$ ^^.Improvement in the status of women through
V • education, employment (IV xvi)
Importance of inter-sectoral
coordination highlighted. Need for
tackling
cycle
of
poverty
recognized, for education and
improved health status.
^AdolescentsjjJrt®^Situation analysis
jy-th^National^,Policy>)foi’J*T*f
❖
Discrimination against girl children, adolescents girls
and women persist (1.8)
Gender discrimination in different
stages of life recognised.
❖
Critical link between health of adolescent girls,
pregnant and lactating women with health of infants
and children (6.6)
Nutritional need of women at all
stages of life cycle recognised.
^Empowermeira||
of Women
■
L Strategies
J ❖
I‘ r
|
*
;
.
L.
r
Changes in laws relating to ownership of property
and inheritance laws by evolving consensus in order
to make them gender just (2.3)
Equal access to education for women and girls;
special measures to create a gender sensitive
educational system; address sex stereotyping (6.1)
Property rights in a patriarchal
system contributing to the
subordinate status of women
recognised. Changes will have long
term impact on adolescent boys
and girls.
Importance of education for social
empowerment recognised.
Violence arising from customs, traditions, accepted
All forms of violence against women
practices to be dealt with; measures to deal with > and girls addressed.
aS
7
... x
<•
Legal - Judicial system will be made more
Gender-based violence recognized
reSpQnsive and gender.jsensitive,especially in.cases,-. as a problem ror,..;rir>rt
sz-h™
requiring ioo-»i
legal action.
^Otdomestiaviplence and personal assault (1J ife
’
’
” "
■ Women^ai^personnel po ides to encoura'ge
Need for supportive environment
v. women to participate5 effective<y in developmental
and positive discrimination in favour
process (3.1)
♦ of women recognised.
HEALTH FOR THE MILLIONS / February - March 2004 M 2
t
4
Policies > ■
Policy extracts
❖
■I
t
-
❖
Reproductive rights to enable them to exercise
informed choices, STDs tackled from a gender
perspective (6.2)
Gender sensitive rights approached.
girls
Laws against prenatal sex selection and practices of
female foeticide (8.1)
Rights of the girl child recognised.
Partnership with voluntary sector organisations
(16.1)
.
Adolescents not identified as
stakeholders.
Media used to portray images consistent with
ftkv- human dignity of girls and women (9.1) A ,
Removal of gender stereotypes
encouraged.
Situation Analysis
tai
Charter for
❖
Measures to address problems of infanticide and
foeticide, especially for female child and all the
other emerging manifestations, which deprive the
girl child, her right to survival (1 .a.)
Following the pledge in the National
agenda of Governance, the policy
and charter make the intent explicit
to remove the structural causes
related to all issues affecting
children's rights in the wider societal
context. Right to survival of
children, especially girls realized.
❖
Measure to cover, under primary health care,
facilities and specialized care and treatment, for all
children of families below poverty line (2.b.)
Disadvantaged groups prioritized for
services.
At the secondary level, state shall provide access to)
education for all and provide supportive facilities
from the disadvantaged groups. (7.b.); Ensure that
all educational institutions function efficiently and
are able to reach universal enrollment, universal
retention, universal protection and universal
achievement (7.C.); Measures to ensure that
education is sensitive to the rights of girl child and
to children of various cultural backgrounds (7.e.)
Right to education with positive
discrimination in favour of girls,
addressed.
Cultural diversities addressed,
Ensure that offenses committed against the girl child,
including child marriage, forcing girls into prostitution
and trafficking are speedily abolished (ll.a.);
Undertake measures, including social/ educational
and legal, to ensure that there is greater respect for
girl child in the family and society (11 .bj; Measures
to ensure that the practice of child marriage is
speedily abolished (ll.c.)
Denial of rights recognized.
Gender-based discrimination and
violence addressed.
’
Children
I
■ ■
■
■
”
Needs of
addressed.
Early marriage recognized as a
problem of infant and maternal
mortality.
-s
.
Adolescent
Special attention to needs of women and girls at all
stages of the life cycle (6.2)
Registration of marriages to be made compulsory
(6.3)
-'s - ?<
■■
Remarks
❖
’’
■ IS
■
•'
7 -
Mr. Provide:the necessary education and- skills to j Term "adolescent children* focused
.
tq become
becqrr e ’ • on early adolescents. Health needs
adolescent children so as to equip them’to
7'. - economically rtrr
<-L iz-fnio citizens,’ special nrnnnn
ic ■ 4
productive
programsof
boys not addressed.
undertaken to improve the healtlr/arid^
bealthYand^
' •••Will'be
, will be undertakers
“V
26
■ HEALTH FOR THE MILLIONS / February - March 2004
♦
Policy extracts
;
Policies
Remarks
National Youth
Situation Analysis
Policy and
Adolescent
• i ♦ The policy will facilitate a multi-dimensional and
Health
integrated approach with the State agencies striving
to accelerate the formulation and implementation of
programmes (2.2)
♦
• i
-
Youth of the country should enjoy greater
participation in the process of decision-making and
execution at local and higher level (2.3)
Active participation of youth,
including adolescents, visualized at
all levels.
Youth in the age group of 13-35 years covered with
..sub-8rouPs 13-19 years and 20-35 years (3.1))
Adolescents as a sub-group
considered. However, the grouping
is not in line with the national data
reporting system i.e., 10-14 years
and 15-19 years. Early adolescents
(10-13) not included.
•
j. .. ..
*
Youth empowerment through education, nutrition,
leadership development and equality of opportunity
(5.1); Inter-sectoral approach pre-requisite for
dealing with youth related issues (5.3); Gender
justice through education, access to services
including reproductive health and decision making
process to productive resources and economic
opportunities (5.2)
Integrated approach for youth
development and empowerment.
Move towards a right based
approach.
Diverse
needs
recognizing coordination between
policies, programmes and delivery
systems of various Ministries,
Departments and other agencies.
■»
Information and Research network to facilitate
formulation of focused youth development schemes
and programmes (5.4)
The Rajiv Gandhi National Institute
for Youth Development (RGNIYD)
recognised as apex Information and
Resource Centre. State Youth
Centres and Youth Development
Centres
for
local
youth
recommended. Only role of NYKs
clearly identified.
’
<>
-
. ’•
. .
-4-'
’
♦
•
<
■
Decentralised approach envisaged.
■
-"‘T
♦
r
■/ ■
Key sectors of youth concern: education; training
and employment; health and family welfare;
preservation of environment and wild life; recreation
and sports; arts and culture; science and technology
and civics and citizenship (8.1)
HIV/AIDS, STD, substance abuse
Holistic approach towards health, mental, physical
and spiritual after careful assessment of health
needs (8.4.1)
Need
based
advocated.
and population education included
in health component. Nutritional
needs of young women and
adolescents recognised.
programming
State-sponsored and free counseling services fori Psychological
problems
of
problems
youth, particularly adolescents^ (8.4.8); HIV/AIDS
adolescents recognised. Training and
........ Adolescent being highly impressionable are prone to ’ capacity building of professional
.. : r «• high:risk behaviour; two pronged approach;of J groups
including
NGOs
education and awareness for prevention and proper
recommended.
treatment and counseling for cure and rehabilitation; . Information on reproductive health
J.
ktablishment of adolescent.tMci in large.hc^fc^ 'as part of the curriculum and setting
■'* ■: (8.4-1
<
up clinics in rural areas to address
OB
.’•/• health needs
recommended.
< •
-
. ■
‘ .■
of
adolescents
3
HEALTH FOR THE MILLIONS / February • March 2004 ■ 27
Policies ■
*; i
Remarks
Policy extracts
♦
Population education - Adolescent age group to be
sensitized in regard to age for marriage, first
pregnancy, spacing and limiting size of family
(8.4.13)
Responsible
parenthood
emphasized; need for ante-natal,
natal and post-natal services of
quality recognized.
❖
Young people as "Health Promoters" (8.4.14); "Peer
Education" an important element in promoting
health services (8.4.15)
The scope of population education
expanded to include strategies
related to adolescents and young
people as beneficiaries as well as
change agents.
National Youth Centre to provide young people a
common platform to express opinions. State Youth
Role of arts and culture as a vehicle
for promoting ideals and values
— -7 •'
.
Synthesis
Adolescents as a distinct group have been
recognized only in the last few years. Thus,
most of the national policies included them
either in the general category, as children, or
in the category of women, in case of
adolescent girls. Their vulnerability in terms
of special health needs have not been
prioritised. Even the recently approved
National Youth Policy has not clearly
identified strategies for adolescents, though
the policy includes 13-19 year olds as a
distinct category. The draft national policy
and charter for children 2001 mentions
provision of education and skills of
"adolescent children", a newly coined term,
showing lack of clarity on the age group.
Variation in understanding adolescence and
needs of this age group persists, and will
need to be clearly spelt out for identifying
strategies in meeting the diverse needs of
adolescents.
Themes Addressed in policies
Diversity — regional disparities have been
addressed for access to services of the
general population. Recognition of diversity
is based on geographical location prioritizing
rural, tribal and slum populations in most of
the policies addressing equity issue. Diverse
needs of youth, including adolescents, have
been addressed in the youth policy
encompassing physical, mental and spiritual
health. Counseling needs have also been
recognized. However, needs of married
female adolescents as part of the health,
population and nutrition policies have been
28
■ HEALTH FOR THE MILLIONS / February - March 2004
needs of adolescents and youth.
addressed primarily related to maternal and
childcare, leaving behind needs of unmarried
adolescents to a great extent.
Gender - most of the policies acknowledge
gender discrimination and have addressed
the issue. Using a life cycle approach, the girl
child and adolescent girl has received
attention of policy makers. However, needs
of adolescent boys especially related to
sexual and reproductive health require focus.
Trafficking of girls and sexual abuse has
received attention mostly in the context of
HIV/AIDS. In totality, the importance of
these issues for health and growth of both
adolescent boys and girls are not recognized.
Similarly, gender-based violence has been
recognized only in the policy for
empowerment of women.
Participation - the importance of youth
participation has been addressed only in the
youth policy clearly stating the goal as
"working with youth, not for youth". Even
though several policies have included
decentralization as a principle and have
identified local groups that can be involved,
very few have actually identified youth
organizations as partners in the development
process.
Poverty - the need for education and
vocational skills for equipping young people
especially from the disadvantaged groups has
been recognized in the Youth. Education and
Children policies. Poverty affecting nutritional
status of adolescent girls has been a concern
reflected in the Health and Nutrition policies,
with recommendation of periodical
nutritional status monitoring of adolescent
girls below the poverty line through the
mechanism of NNHB, advocated in the
nutrition policy. But, direct issues of gender
disparity, early marriage, neo-natal mortality,
illiteracy altogether leading to adverse status
ot adolescent girls is not focused.
Rights - the issue of rights has been
addressed primarily in the context of
children's right to education, health, nutrition,
survival and protection of girl child from
trafficking and sexual abuse. Protection of
human rights to safeguard human dignity has
been included in the National AIDS
prevention and control policy. Reproductive
rights for informed choices have been
mentioned in the policy for empowerment of
women. Even though needs of young people
are beginning to be recognized, the rightsbased approach has yet to be effectively
acknowledged.
Multi-sectoral approach - addressing
diverse needs of young people calls for a
multi-sectoral approach that has been
recognized in the youth policy. The strategies
and institutional mechanisms of several
policies reflect linkages across and within
ministries and departments for convergence
and synergy. However, there is need for
greater clarity for operationalising the
strategies.
Conclusion and way forward
In a large country like India, central policies
provide framework and guidelines. However,
successful actualization of national policies
depends to a large
extent
on
the
effective role of the
State Governments
that follow the central
policies with state
specific
policy
guidelines to address
their own concerned .
•ssues.
Except Kerala, no
other state has done
work in terms of
specific policies for
adolescents. Even in
states
where
the
population
policy
mentions adolescents,
it is primarily in terms
of their sexual and
reproductive health
needs within the context of marriage or
perceiving them as future parents6. Whereas,
the need is to address adolescents more
holistically to meet their socio-cultural and
economic needs which significantly affect
their health and development.
Although several
Although several policies have
policies
have
recognized
the
recognized the importance of
importance
ot
health education, there is
health education,
there is need for a
need for a paradigm shift
paradigm shift from
merely information
from merely information
giving to building
giving to building skills of
skills of adolescents
to enable them
adolescents to enable them
make
informed
make informed choices
choices affecting
their
physical,
affecting their physical, mental
mental and social
health. Since HIV/
and social health.
AIDS prevention
among young people is a universally
recognized good practice strategy to curb
the epidemic, it is important to recognize the
importance of providing information as well
as services to married and unmarried
adolescent boys and girls. Policies are silent
on the component of adolescent/youth
friendly services.
Policies should focus on gender equity, which
means including males too. Unfortunately, our
policies target adolescent girls, ignoring the
adolescent boys and their vulnerability to
STDs, HIV/AIDS, role in family planning,
migrant jobs and other health concerns.
fv
0
r<4l
^>4
*■
:
I
f
■
A
■
-
‘
HEALTH FOR THE MILLIONS / February - March 2004 ■ 29
«
The policies have not given due recognition
to the power and rights of this generation to
assist in change and development. Be it HIV
prevention, education, drug abuse or
reproductive health, adolescents as change
agents are not tully a< knowledged.. Even
where good policies exist, there are gaps in
implementation in terras of allocation of
resources. I bus, the challenge is not only to
formulate a sensitive policy, but also to
ensure that the programmes adequately
reflect the strategies for achieving the goals
of development and empowerment.
Several programmes have been undertaken
at the national and state level for translating
policy recommendations into action. The
Reproductive and Child Health (RCH)
programme will be entering into the second
phase. The draft Programme Implementation
Plan (PIP)7 reflects the need to address
adolescent
health.
The consultative
processes adopted for designing the
programme will result in pilot initiatives in a
phased manner, which will take into
consideration heterogeneity of adolescent
groups and the needs of unmarried
adolescents
to
counseling
and
contraceptives. Testing the effectiveness and
feasibility of models through research is
needed for future programming B.
Dr. MriduLt Seth is
Technical Adviser
(Adolescents and Youth)
with UNFPA, India.
A Working Group set up by the Planning
Commission on adolescents provided
substantial inputs for the Tenth Five Year Plan
and the recommendations are reflected in
the National Youth Policy 2003. India, the
youngest nation in the world, today lacks a
separate policy for its adolescents. Walking
their way forward into adulthood, these
youngsters need support and direction.
These national policies and programmes
require a greater sensitivity to the
environment in which they are functional.
They must necessarily address the dominant
norms, values and ideologies of the existing
system. Largely, working towards attitudinal
and behavioral patterns to result in change
and not continuity. Whether in the years
ahead, we have a separate policy for
adolescents or not, it is important to have a
nodal department to coordinate and monitor
policies and interventions for adolescents.
The Ministry of Youth Affairs & Sports will
have to play an active role in this respect to
address the diverse needs of adolescents
through convergence of efforts of different
ministries and departments.
For adolescent health concerns to be
addressed at the grassroots level, policies
30 >5 HEALTH FOR THE MILLIONS / February - March 2004
need to be translated at the state and district
level to reach the actual stakeholders.
Building a supportive environment is very
important at each level. The stakeholders
include
policy
makers,
educational
administrators, teachers, parents, panchayat
members and health service providers.
Adolescents themselves need to be involved
as peer educators in programming.
Furthermore,
for
increasing
political
commitment, evidence-based advocacy is vital.
Media has to influence public opinion by
conducting a compelling dialogue with policy
makers. Review of existing national and state
policies and programmes is needed to assess
the status, gaps and scope of convergence of
different agencies., All this would require more
information by adolescents and for adolescents
on their needs, concerns and utilization of
services.
Political
will,
inter-sectoral
coordination, community participation, NGOs
commitment, and involvement of adolescents
themselves in the development process is
essential. To meet the needs of adolescents as
a distinct group, their voices need to be heard,
energies channelized and their dreams fulfilled
for a better tomorrow.
References
i.
Planning Commission. Report of the Working
Group on Adolescents for the Tenth Five Year
Plan (2002-2007). Government of India. New
Delhi. 2001.
2.
Population Council and UNFPA. Report of the
Adolescent and Youth Sexual and Reproductive
Health Workshop. May 2002. UNFPA and
Population Council, New York. 2003 pp 10
3.
The National AIDS Control Organisation
(NACO) and UNiCEF. Knowledge, Attitudes and
Practices of Young Adults (15-24 years). NACO
and UNICEF. New Delhi. 2002
4.
Monitoring the AIDS Pandemic (MAP) Network
2001.Report presented at the MAP Meeting in
Melbourne, Australia. 4 Oct 2001. In State of
World Population Report. UNFPA, New York.
2003, pp 52
5.
NCERT. National Curriculum Framework. New
Delhi. 2000.
6.
Mamta. Adolescent Health and Development in
India: An Action Approach. New Delhi. 2001
-7.
Ministry of Health and Family Welfare
(MOHFW). RCH 1 1 and Family Planning:
Programme Implementation Plan (PIP) (Draft).
New Delhi. 2003
8.
Jejeebhoy, S. and M. Sebastian. Actions that
protect: Promoting sexual and reproductive
health and choice among young people in India.
Population Council. New Delhi. 2003 pp 34
Status of adolescents:
Glimpses from states of India
Shrabanti Sen
Of more than 100 million total population in
India, an estimated 21 7<» are in the 10-19 age
group and 10 % are in the 15-19 age group.
Distribution of adolescents varies from a
minimum of 20 7<> in Kerala to a maximum of
23 % in Himachal Pradesh (SRS, 1995).
Meaning, at least one fifth ot the population in
all of the major states comprises of adolescents.
Background
Adolescence is a concept encompassing
physical and emotional stages of transition from
childhood to adulthood, and in turn a crucial
period for healthy development in both
psychological and physical terms, loday
adolescents account for about one-fifth of
India's population and half of them are girls.
Despite the critical importance of the
adolescence period in every woman's life, until
recently, little effort has been made to
accurately address and analyze the specific
conditions, and needs of adolescent girls with
an aim to redress the situation (UNICEF, UNFPA,
1998). The nature of adolescence varies
significantly by age, sex, marital status, cultural
context etc. As a group, however, adolescents
in India have always been neglected in
someway or the other. It's only recently that
the specific problems of adolescents are getting
recognized.
"The girl in every woman precedes and shapes
the woman in her. And to the extent to which
girlhood is denied, liberated and foster,
womanhood perishes or prospers." (Sohoni,
N.K., The Burden of Girlhood: A Global Inquiry
into the Status of Girls, Third Party Publishing
Company, California, 1995)
Critical issues among
adolescents
Profile of adolescents in India
As adolescents nnd their concerned issues are
getting ignored over and over again, till date very
little data or information has been collected on this
group. Sources like National Family Health Survey
and Sample Registration System provides some
amount of information. But, unfortunately, none of
these sources are informative enough. Government
also very innocently keeps on sidelining this issue.
In Reproductive and Child Health (RCH) too,
adolescents are scarcely included.
In India adolescent girls receive the least
attention of all, even though they have to grow
rapidly from childhood to adulthood for taking
up marriage responsibility, and in a short span
of time to motherhood for rearing the family.
In this whole process, they primarily face
problems like high rates of anemia, early
pregnancies, unsafe deliveries, frequent
reproductive tract infections (RTIs), and
vulnerability to HIV/AIDS. Its mainly their lack
or no access to information that makes them
more^vulner able.
Adolescents and marriage
----------
Percentage of adolescents
(10-19 age group), SRS, 1995
Mnwchal Pr*<l»th r 1
................-
Haryana l'-L'
Ralaattwn F-.
■ -
1
Karnataka P.T1." "T
Gcaarat f'J
..........
1’ ""
J
b? x-
' ■»
•
■
"
321.9
B<har IT-. ■,
«ft (.•»• -»
«-> »y<h
■' 4. ■» -- Al*
1 fi
. JT~121.2
W»*» Bong"* la-.'.-', '• y
"T.121 1
Matfv* Pradwh
1 'i.WJtwnPO?
Onssa
Mahamsntra W'fi"'M'.-V HUll.WIJl'120.7
6
Karate
tnda
>22 1
121 Q
Aaaam
Anctva Pradesh
122 3
|2? 1
» - ■'
Uttar PradMh ^4 I1'-'’".
•i i i—h n
-< ■.
323
'
'-’■-.■■w-------
jni'ny
•^'•*;-l,, i2nS
J21.4
ft
Despite the rising age of marriage
and laws prohibiting early marriage,
half of all the Indian women aged
20-24 are married by the time they
are 18 and a quarter by the time
they are 15. In general, the median
age at marriage is 16 years but the
actual range varies from state to
state. In Andhra Pradesh, Bihar,
Madhya Pradesh and Rajasthan,
over half of the girls in the 15-19
age group are married (NFHS-II,
1998-99). According to a study by
International Institute for Population
Sciences, 1995, 14 per cent of all
girls aged 15-19 are married, and
about half of them are sexually
active by the time they are 18
years old.
HEALTH FOR THE MILLIONS / February - March 2004 ■ 31
Percentage of girls marry below age 18,
RHS-RCH, 1998-99
60
I1
I
>(■
24 7
3)
• i
30 9
i
25 3
n i
19 1
20
!!
i
; I
i
I
I
!
. 6 o 0 ! HI L
10
I
In India more than half (56 %) of the women
in the 15-19 age group are suffering from
various types of anemia. I he scenario varies
among the states. Orissa has a shocking
situation with 67 percentage of women
suffering from anemia in the 15-19 age group
followed by Bihar at 64 percentage. Kerala
shows 26 per cent of the* women suttering
from various types of anem'a in the relerred
age group, which is the lowest amongst the
states (NFHS, 1998-99).
Few More Facts About adolescents in India
extracted from NFHS-II, 1998-99
l
U L
ZZX/X///»Rapid Household Survey - Reproductive and
Child Health (RHS-RCH), 1998-99, also reveals
alarming truth on the age of marriage for girls.
37 per cent of the girls in India are getting
married before attaining 18 years of age.
Himachal Pradesh (only 3 %) followed by Kerala
(9 %) have the least percentage of girls married
before age 18, where as, two of the BIMARU
states i.e. Bihar (58 %) followed by Rajasthan
(57 %) shows maximum number of girls getting
married before the age of 18.
1.
33 per cent of the married women are in
the age group of 15-19; where as, only 6
per cent of the married males are found
in this age group.
2.
28 per cent of the adolescents in the 1019 age group are illiterate, and only 7 per
cent are found to have completed higher
secondary.
3.
Lifestyle indicators clearly show that 9 per
cent of the older adolescent boys aged
between 15-19 are caught by habit of
taking pan masala or chewable tobacco,
and another 4 per cent have adopted
smoking.
4.
Only 10 per cent of the married
adolescents of age 15-19 use any method
of contraception.
5.
Shockingly only 37 per cent youths of age
15-24 reported to have heard of HIV/AIDS
Adolescents and anemia
Due to the poor nutritional status of the
average Indian adolescent, the biological onset
of adolescence may occur later compared with
other developed countries. However, marriage
and consequently the onset of sexual activity,
and fertility occur earlier in India than in other
regions of the world. The cultural and social
system usually exerts tremendous pressure on
girls to get married upon reaching menarche.
Consequently, adolescent females are thrust
early into adulthood, frequently soon after
regular menstruation is established, and before
physical maturity is attained (Jejeebhoy, 1996).
Shrabanti Sen is .i
programme officer in
VHAI and is currently
doing her Ph.D in
Population Studies
(Demography) from the
International Institute for
Population Sciences.
Mumbai.
Percentage of women with any anemia (15-19 age
group), NFHS-II 1998-99
On»M i
"
,r
--- I
■
—1
64 2
59 5
Bihar i
Tamil Nadu *
WojI Bengal 1
-
Gutaral
-
■
- i . ■ .
.
—- t
Anjrva Piadeah r~
Madhya Pradesh I
.
■
Rapsthan V
PixipD *'
Uttar Pradesh I ‘
Maharashtra
Karnataka
'
I
~
Z)
54 »
Z)
54 9
' -
3
53 9
’7 ~
J4
ESga.5
52 8
51 7
E
Data Sources Used:
50 7
494
Haryana E
Himachal Pradesh E
National Family Health Survey (NFHS — II), 1998-99
Rapid Household Survey - Reproductive and Child
Health (RHS - RCH), 1998- 99.
432
Kerala E
2A4
54
hdia C
32
59 5
57 7
i «
hT - 1 '
0
,
—|
' . ■ *-’ **
. . *
~
---
-',vl '
-
-
67 1
10
20
30
40
■ HEALTH FOR THE MILLIONS / February - March 2004
50
Adolescence is a period of innocence, and
ignorance of various issues at this age makes
it
comparatively
more
vulnerable.
Adolescents as separate age group along
with their problems have received little or no
attention in India. Until recently when NGOs,
funding agencies bothered to recognize and
include adolescents in their main activities, its
only then that Government came around.
Accounting for l/5'h of total population,
adolescents are the future of our country.
Holding the power to change, they will surely
give us better and improved tomorrow. Thus,
negligence on part of this proportion of the
population will result in major consequences
in the future.
60
70
Sample Registration System (SRS), 1995.
Adolescence in urban India
Dr. Peggy Mohan
Background
I have always fell that a writer with a patient's
perspective on a condition could offer new and
precious insights. Not the least of these is
empathy, the chance of reaching out to readers
as fellow travelers. A patient's perspective is
also a chance to notice different things as
important, and to raise different questions from
those a medical expert would be drawn to—
the kind that might not have clear answers.
In 1997 VHAI asked me to write a book for
adolescents in India. In English, so this meant for
urban adolescents, semi-westernized, but not
really served by the literature written abroad for
western adolescents. At that time my own child
was going through an urban Indian adolescence
of her own, so I had some experience and
current focus, and a researcher's curiosity
about making use of this new perspective.
Being open had earned me a great deal of
dialogue and feedback from my daughter and
her friends, and this persuaded me to go
further, and take on writing the book for VHAI.
I clarified first with myself that I was ready to
write a book for adolescents, not about
adolescence. Even so, parents who read the
book couldn't help seeing me as another parent,
and some did not like me getting into topics they
themselves would have been uncomfortable
dealing with. But these were precisely the things
adolescents were asking me about!
There was another reason why I felt I shared a
perspective with urban adolescents in India and
not with their parents. I myself am from an
Indian community in the West Indies. When I
came to live in India in 1979, I had found India
alien and a lot like the transitional world my
father must have grown up in, in the West
Indies as it had been then. But I found my
daughter's life in Delhi during 1990s amazingly
like my own adolescence in the Trinidad of the
1960s, where urban teenagers were opening
up to North American culture, wearing short
pants, going to the swimming pool, disco
dancing, and cautiously beginning to "date".
While our parents agonized about whether all
this conflicted with our "Indian" culture, and
sometimes abruptl/ stopped us in our tracks. I
felt I had seen it all before and lived it. I was
also determined to avoid the authoritarian
discipline my parents had taken with me, and
try a little empathy instead.
The group of adolescents, VHAI and I
interacted with was drawn mostly from Class 9,
from different schools in Delhi, though there
were also younger and older adolescents
interacting with us more informally. Their
questions and suggestions, sometimes handed
to us in writing, unsigned to preserve
confidentiality, gave a good picture of the life
and concerns of urban adolescents in presentday India.
Except for the section on sexually transmitted
diseases, which I also think I wrote mechanically,
everything else in the book reflected our
adolescents' questions and concerns. Broadly
speaking, they wanted three kinds of
information: about the physical and emotional
changes they were going through; about
relationships; and they wanted discussion of
problems they were facing with their parents
and families.
HEALTH FOR THE MILLIONS / February - March 2004 ■ 3
Physical changes
The CBSE Tenth Board syllabus for Science
does address the issue of sex edu( ation, but
very briefly, and in biological language that
leaves you visualizing bacteria multiplying in a
petri dish. Words like g.imete and zygote! All
the adolescents I talked to knew th.it this was
gross evasiveness, and found it amusing, but
they did not know from where to get the
information they needed. They were curious,
and had discussed their physical changes
among themselves quite openly, but each one
still felt like something of a freak, and less
attractive than during pre-adolescence. What
they missed was information that would link
their experiences to those of others in their age
group, and give them a sense of normalcy. And
together
make
The most significant
sense as a larger
of
psychological change in explanation
something that they
adolescence is that of
were actually going
through.
becoming "self-
conscious" Able to look
at yourself from the
outside and to imagine
how you look to others.
The changes during
adolescence cannot
be dismissed with a
quick road map of
how to conceive
and produce babies.
At any rate, the very
idea of adolescence is of a period, when one
is not ready to start having babies, but when
there is a still lot of change going on, away from
just being a child towards being able to have a
child. Adolescence is the time when you walk
through childhood into adulthood. Adolescence
involves a number of other things, like pimples,
body hair and body odor that also asks for
explanation. Reason being they do not, at the
outset, seem designed to enhance the prospect
of forming relationships and becoming parents.
As well as perplexing things like the deepening
of the male voice, not in a smooth descending
scale, but by "breaking" remains unexplained.
No boy I talked to could describe—let alone
explain—the voice changes he was
experiencing.
And all this was sadly
unaddressed in their textbooks.
Lacking information, adolescent brains were
working overtime, sometimes with bizarre
results. Lumpy breasts or two breasts growing
at different rates, though all perfectly normal,
were suspected to be symptoms of cancer. And
there was no useful information on menstrual
periods. Why did some girls find them painful?
Why was there >o much variation between girls
in the heaviness of the flow? What was the
reason why adolescent girls were steered away
from tampons?
34 ■ HEALTH FOR THE MILLIONS / February - March 2004
Boys t(X), often had Io fall back on information
from the grapevine, which played on their
insecurities and guilt about their growing
sexuality. What was a "normal" penis like*? Did
a boy lose some of his strength whenever he
ejaculated? And was one drop of semen reallv
"equal to a hundred drops of blood"?
Psychological and emotional
changes
The most significant psychological change in
adolescence is that of becoming "selfconscious". Able to look at yourself from
the outside and to imagine how you look to
others. This involves a lot of lonely
introspection, and without realistic images
of normal adolescents to go on, an
adolescent comes face to face with the
distorted images generated by the Market
and Media.
There is a lot of danger in wanting to look
like the most successful models. First of all,
models nowadays tend to be very tall and
have abnormally long limbs. This sets them
apart fiom at least 90 per cent of what we
find in our society. They are chosen as
models for this very reason. The Market
needs icons that require the Market's help, if
you want to measure up! It has to sell
products to survive. All magazines,
newspapers, cyber sites and movies depict
the lean, slender model or actress figure.
Leaving no other choice of role model for
our youngsters. Second, and more
dangerous, models tend to be abnormally
thin. Today's models are thinner than 90 per
cent of the healthy people in any society.
Some are so thin that they look weak and
starved, which they often are. Media tops
the same by reporting their diets as success
mantra for our young generation to follow.
It is extremely difficult for a healthy person
to get this thin, even by sensible dieting and
exercise. Your body will simply resist losing
too much weight by going into "starvation
mode" to conserve weight, and your
metabolism will drop, so that you burn less
energy in everything you do. Your body
wants to live!
When a young person still manages to get so
desperately thinz it is generally because they
have beaten the body's natural defenses
against starvation through disorders like
bulimia nervosa, or more dangerously,
anorexia nervosa.
India has begun to catch up fast to the
worldwide obsession with thinness. Adolescent
»
girls, some of them already painfully thin,
openly bemoan the fact that they look "fat*.
While the word anorexia is lightly bandied
about between friends, there is very little
understanding about what it is, and very little
medical experience in India to connect a girl's
"glamorous" thinness with the fact that she
menstruates only once every four months, if at
all. Or to grasp that she just can't see how she
really looks. She actually sees all that fat that
isn't there. This is something new in India, new
enough that gynecologists are often not alert
to these signs of psychiatric distress. And it is
something so new that parents, while admiring
and encouraging their daughter's thinness,
cannot see the deadly disorder it is based on.
about their problems, and talking face to face
with parents and friends all too often elicits only
embarrassed dismissiveness. If you don't talk
about the problem, the logic goes away.
Leaving our children with no choice, else to
trust their confused
mind. Parents pile on
the pressure, convinced
that everything in their
child's future life hinges
on Board Exams. And
peer perception can
add to this cruelly.
Making young minds
victim of impractical
demands and deadlines.
What is lost sight of here is that a certain
amount of fat comes simply from being female.
Female hormones distribute fat over girls' body,
especially on the hips, breasts and thighs, while
the dominant male hormone, testosterone,
creates muscle. The lean and fit look promoted
by the media and increasingly, even by doctors
is actually not a female look at all! But
confronting these media images is not easy—
too much money is riding on thinness for the
Market and media to back off easily. And, like
sacrificial lambs, our adolescents get there first
and take the brunt of the attack!
How many adolescents
who
attempt
or
succeed at suicide were
depressed to start with?
It is not easy to find
out,
because
*
depression
would
reflect on one's family
and genes. Far easier
for families to point a
finger, futilely, at the
larger
educational
system. Imagine timely
information and guidance would have saved
how many lives!
Another noticeable emotional change in
adolescence is the onset of hormonally driven
moods. Moods are something adolescents are
conscious of, but their basis in physiology is not
well understood. Some girls do take note of a
dip in their mood, in the week before their
period, but without a sense of its normalcy,
they take it as something that ought to be
within their control.
India is just beginning to wake up to suicidal
behavior among adolescent boys and girls,
driving themselves under the stress of Board
Exams. In the media too, this is seen as having
to do with the exams themselves, or the stress
of an overloaded syllabus. But in reality, this
extreme reaction is also a very adolescent
response to stress, and a self-consciousness
that can be so damning that it calls out this final
option of suicide.
The actual event that elicits the stress and
sense of defeat may be the exams, but the
plunge to suicide is typical of adolescent mood
swings. Recently, concerned activists have
begun to set up helplines, in Indian cities, for
students feeling so much stress that they put
their own lives at risk. Providing them a platform
to open up and discuss. The confidentiality of
this approach does draw a number of
adolescents to phone in, since they want to talk
i
Pre-relationships
The first signs of an interest in relationships are
those wistful distant attractions known as
"crushes*. Our adolescents talked about them
in an almost matter or fact way, as though they
expected them to happen. As they proceeded
from pre-adolescence to actual adolescence,
their crushes became less secret, and more
openly discussed in the secrecy of their friend
circles. These crushes existed not just among
co-ed school students, but also, and sometimes
more fervently among those going to boys-only
and girls-only schools.
.
Another manifestation of the increase in all
round but unfocussed sexuality is the interest
in books based on relationships, or just on plain
sex. The book stores and pavement sellers'
stacks abound with what is actually soft-core
pornography, which appeals to girls, and which
is based on love relationships. The girls I spoke
to were disdainful of overt pornography. But
the number of Internet porn sites accessed
attests, clears the distant sexual curiosity that
besets adolescents and even adults!
This distance, in India, is not merely a function
of adolescence. It is also linked to the persistent
HEALTH FOR THE MILLIONS / February - March 2004 ■ 35
separation of the sexes, particularly outside the
English-speaking class, even into young
adulthood. Many a times our culture and
community together silently put bars. This
fascination of distance manifests itself in some
strange ways. For example, completely one
sided relationships are also formed, where a
young man marks out a young woman as "his"
girl. He never actually speaks to her, and she
may have no idea that he even exists. But
among his circle of friends it is known that she
is off limits to everyone else, and boys outside
that circle come to know
she
is "taken" if they try
In urban India, in families
to approach her. There
where adolescents have a can be nasty atavistic
scenes between boys,
modicum of freedom to
with threats of violence,
which make no sense at
rebel, the well-known
all to the girl involved. Or
struggle takes place,
one day, out of the blue,
where adolescents try to she might find a young
man offering her a gift,
create their own space.
on a chartered bus they
both go in every day, and
insisting that she take it. And everyone else in
the bus knows what it is about, except her.
Less benign is that thing quaintly called "eve
teasing". This too is linked to feelings of
frustration, of boys being deprived not so much
of sex as of female company. Since they have
been brought up to believe that a "good" girl
would not want to talk to them, they try to get
girls' attention by provoking them, on the street
and in buses.
Bollywood films are full of such scenes, of the
young hero meeting the heroine in just this way,
following her on a street, maybe on a bicycle,
and making comments at her, while she fends
them off, but in the process she has to speak
to him. The ritual behavior is clear: he is
allowed to make that sort of approach (public
space or male space!), and she is obliged to
show her good character by rejecting all his
advances. But sometimes there is a
breakthrough, and she takes him seriously at
the end, and stands alone thinking about some
clever thing he has said.
In real life these scenes are not so innocent. The
frustration and conditioning are too strong, and
these encounters end up expressing the boy's
contradictory wishes, for contact with girls as
well as an acute dislike for girls. In these cases
there is usually a further element: a class divide,
where the girl is visibly from a better off family,
and otherwise off limits to the boy making the
move. So his resentment is based not only on
her being female, but also on the impossibility
of his own upward mobility, something larger
and not linked to her personally at all.
The topic that provoked our adolescents to
send the most unsigned queries was
masturbation, fraught as it was with taboos. I
was surprised at how much our adolescents
were discussing it among themselves, even girls.
Though some girls were blissfully ignorant
about what it was all about - often the same
girls who were the most attracted toward boys!
Clearly some of the discussion in foreign books
on sex had trickled down, and many
adolescents knew what masturbation was "all
right". Still, boys were not yet free of the perils
of the grapevine. Many had sneaking worries
that masturbation might be "habit forming", "be
associated with pimples", "lead to insanity",
"reduce the quantity of semen", generally
"weaken boys" and "make it difficult to enjoy
sex with another person". But there was less
despair than I expected, and more of a wish
for confirmation and reassurance that they
were not going off the track.
Relationships
There were two sorts of relationships that
occupied major space in our adolescents' minds:
love relationships with boyfriends and girlfriends,
and relationships with their own parents.
The urban Indian phenomenon of co
educational schools has done much to bring
boys and girls together in their adolescence,
and make it possible for them to see each other
as something more substantial than just distant
objects of fantasy. It has also helped in
promoting a greater sense of equality between
36 ■ HEALTH FOR THE MILLIONS / February - March 2004
the sexes. Our adolescents reported the clear
existence of two-way relationships, mostly not
mentioned to parents. These were ritually
started by an a< t of "proposing", followed by
a period of "going around'' together. Muc h of
this activity took place in school, but there was
a lot ot activity on the phone too.
Fo. most, by the time relationships turned
sexual, the big conflicts with the parents were
over, and they knew how to handle things
discreetly. Still, most girls had strong misgivings
about actually getting into sex before
marriage—culturally, it felt alien.
One experience adolescents in urban India
fear, and which surely affect how and where
they plan to meet, is being apprehended by
the police while sitting together in public
space: a park, or a parked car. The peace can
be nastily disrupted by the appearance of a
policeman, pretending to be affronted by this
culturally inappropriate behavior on the
young people's part, and threatening to take
them both to jail.
This is usually no more than a way of extorting
money from them, logic being, if the couple
has to sit together in public space like this, they
must not be married. Therefore they must be
afraid of their parents coming to know of their
relationship. The young couple, too, even if
secure that their parents would be supportive,
know that they would be unsafe in jail, where
they would be exposed to the police (who are
not culturally uncomfortable with things like
rape and extortion).
When I wrote my book I was careful never to
imply that all love relationships must be
heterosexual, because they aren't. There are
some adolescents who are gay or lesbian. And
there are others who pass through same-sex
orientation as a phase, often if they are in girlsonly or boys-only schools, particularly boarding
schools. This means that same-sex attraction
and same-sex relationships are reasonably
common, and often more casually talked
about, or joked about than treated with alarm
by "straights"—those attracted to the opposite
sex.
The really problematic relationships for
adolescents in urban India seem to be the ones
with their parents. Our adolescents railed
against parental restrictions and parental lack of
trust, not only in the context of their love
relationships, but in everyday matters. In urban
India, in families where adolescents have a
modicum of freedom to rebel, the well-known
struggfe takes place, where adolescents try to
create their own space.
Why didn't this take place in their grandparents'
generation, or in rural India? There seem to be
two reasons. One, you need a little openness
from parents, or from other parents in the peer
group—for this kind of conflict to come to the
surface. Earlier, and in today's villages, the family
hierarchy was and is very rigid: you simply did
not question elders. So a lot of adolescent
rebellion just got squashed.
Also, in our grandparents' generation, and in
today's villages, people got married earlier,
during adolescence, and had their own families
to look after early, often without even leaving
home. They were not frustrated and kept away
from ^ex: they had relationships, they were
adults, with all the responsibilities (and
sometimes with the independence too).
This prolonged adolescence, and delayed
marriage, is a new thing in India, and we haven't
really had a chance to think this out. Our
concepts of "Indian culture* still hark back to
the time when young people did not have the
pressures and the alienation they have now.
Urban girls, who must compete with boys in
Board Exams, are often cast in the same
traditional mould as rural girls when it comes
to conforming to sexual double standards. And
yet, it is’true that urban India has moved on
unevenly, such that public space is still less safe
for adolescent girls than for boys. Parents
worry about the physical safety of a daughter
out on the roads at night.
Transition
The contradictions of transition are a good and
open-ended note to close on. There is danger,
but there is also change going on. Our
adolescents' struggling and questing for
independence are teaching them the strategies;
they will need in forming the new society urban
India.
Though it seems strange to say this, the present
conflict between adolescents and their parents is
actually a good thing. It does not do adolescents
any good to remain helplessly obedient. Just as
it does not do adolescents any good, either, if
their parents simply give in and agree to
everything they say. What adolescents need from
parents is a "reality check", a dear fine of thinking
to measure themselves against, and a chance to
discuss things.
While it is hard for parents to take this in the
beginning, the end result is something
wonderful: young adults who are strong and
independent, and whom their parents can
depend on. This is the way it happens!
Dr. Peggy Mohan is an
eminent educationist and
author of the book
'Adolescence to walk
you through' pubSshed
by VHAI.
HEALTH FOR THE MILLIONS / February - March 2004 ■ 37
Reality in Shivpuri
Dr. S. K. Singh
illiteracy. Most of the adolescent girls and boys
are not even aware of their physical,
psychological and emotional developmental
needs. Growing under difficult circumstances
with no information, they fall prey to societal
pressures. Rather than blooming at this most
beautiful period of life, adolescent girls in
villages are often caught dressed barely in half
clothes as casual labour, doing household work,
looking after their siblings or grazing their goats.
Sambhav's real life experiences
Sambhav is implementing the Khoj Poject in
Shivpuri district. It aims at improving the overall
living conditions in the communities through
information sharing, promoting the community
based organizations, and generating demands
on the system for adequate delivery of services.
The project also aims at preparation of the
community level leadership through training and
exposure. With main thrust on tribal and
unorganized rural poor population, the project
team is working in 25 villages covering a
population of approximately 30,000.
hivpuri is one of the most backward
districts not just in the state of Madhya
Pradesh (MP), but also in the country.
Well known for its tigers and rich minerals,
Shivpuri is also very popular for early marriages
and sale of young girls. Largest Bedia tribal
population engaged in prostitution has been
living here for decades. It is also dacoit-affected
district, where apart from kidnapping for
ransom, dacoits have been regularly forcing
communities to send girls as a commodity for
their pleasure. Hundred and thousands of
adolescent girls, who become victim in hands
of sexual abuse, carry burden of these
traumatic experiences silently throughout their
Finding adolescent girls trapped in hands of
cruel, but actual and harsh situations are daily
affairs in these villages. The following mentioned
realities are some of their experiences, and a
true picture of living conditions.
❖
Time when most of .the adolescents grow
exploring their surrounding, and try solving
mysteries of this age, here in Shivpuri
adolescent boys and girls are deprived of
authentic and adequate knowledge about
changes at this age. This phase is a daunting
process for them. Especially true in the
case of girls whose world gets curbed,
controlled, and at the same time complex
during adolescence. On the other hand,
socio-economic demands, as well as, social
progress gradually require them to play
more active role at home.
❖
All the girls are highly discriminated in the
family. Especially, when it comes to
accessing the health services, there is no
comparison between what a boy gets and
what is left over for the girl. Ignored and
neglected by day to day circumstances,
they are sulking within themselves.
Unheard by family and community they
have actually reached a stage, where they
life.
Literature defines adolescence as a period of
rapid physical, psychological and social
maturation, the period extending from puberty
to the attainment of full reproductive growth.
But unfortunately, here in Shivpuri and many
other villages of India, the concept of
adolescence especially for girls doesn't exist.
For most of them each day is similar, full of
humiliation, and violence with no ray of hope.
Walking straight from childhood into adulthood
they are trapped in hands of early marriage,
child-labour, sexual discrimination, poverty and
38 ■ HEALTH FOR THE MILLIONS / February - March 2004
can not express their personal, health or
emotional problems to anyone.
❖
Age when most of the adolescent girls
indulge in fun and play, and explor*.* to
unfold new things, girls in Shivpuri bear the
burden of family responsibilities. Leaving
their childhood behind, they care for young
siblings, carry water, cook for the entire
family, and do all the household work
without experiencing the age of
innocence.
❖
❖
❖
❖
❖
Restrictions on girl's mobility are put once
she is about 10 or 11 years old. Not
allowed to go anywhere, she spends her
day doing household tasks and whole life
within the four walls of home. Whereas,
boys have full freedom to do what they
like, go where they want, and even commit
crimes, leaving girls to be victim of gender
discrimination. One often finds boys busy
playing cards, listening to music or simply
chatting with friends, while girls are invisible
all over the village with no one to hear and
share them.
paid just half of the adult rate, they live
under ignorance. Among Gurjers and
Dhakads too. adolescent girls are often
seen engaged in cattle rearing and
agriculture-related work.
❖
Sexual and physical abuse seems to have
been living here for decades. Commonly
one finds girls being assaulted at
workplace. Money being openly used for
enticing girls to accept sexual advances of
the employers and their associates. At
stone quarry sites too, one often spots
tribal girls been caught in the hands of
contractor. The scars of this abuse are
embedded so deep, that they leave lasting
impression on girl's psyche.
❖
A very obvious
gender bias operates
in case of education
as well. Among
these communities
girl child education
occupies no priority.
Most of the girls
haven't
even
experienced a single
day in classroom.
Caught in web of
illiteracy,
early
marriage,
high
fertility, violence and
sexual abuse, they
spend all their life
with experiences
and memories of
discrimination.
Unaware of their reproductive anatomy
and physiology, they have no clue about
what causes menses or how pregnancy
takes place. Undernourished and anemic
they remain unequipped with information
on growth that takes place during this
crucial phase of adolescence.
There is not even one family or community
practice/mechanism for counseling and
educating the adolescents on various
aspects of sexuality, reproduction,
responsible behaviour, and physical and
emotional needs. Forcing them to live with
misconceptions for the rest of their life.
The most critical dimension in the process
of growing up during adolescence relates
to social relationships. Adolescents expand
and redefine relationships with parents,
peers and members of the opposite sex.
This is the time when they build trust and
attain sense of self-esteem. But, here in
villages of Shivpuri the situation is totally
different. There exists no place for
relationship between girls and boys before
marriage; rarely you'll find them interacting
at community level. Seen with frowns and
suspicious, relationships are a taboo in this
community.
When it comes to child labour and
exploitation, the situation is worse than
one can imagine. Saharia and Dalit girls
start working at a very young age. Getting
❖
The most critical
dimension of the process
of growing up during
adolescence relates to
social relationships.
Adolescents expand and
redefine relationships
with parents, peers and
members of the opposite
sex.This is the time when
they build trust and attain
sense of self-esteem.
Early marriage for girls and boys is a ritual
here. Despite laws that specify the legal
age of marriage for girls as 18 years and
for boys 21 years, cultural pressures often
force parents to marry them off at a very
young age. Significant numbers of girls
become mothers by the time they are 13
or 15 years old. High fertility at this age is
the reason of great concern, since most of
them at adolescence are physiologically
immature for reproduction. Childbearing at
such young age also poses health risks on
both mother and child, contributing to
maternal mortality, increasing incidence of
low birth weight babies, and neonatal
morbidity.
•>
The large joint family setup in which we all
use to live is gradually crumbling, resulting
in withering away of the support structure
that is required in rearing a child. At the
same time adolescent boys and girls often
find
themselves
unprepared
for
HEALTH FOR THE MILLIONS / February - March 2004 ■ 39
*
parenthood. Result, irresponsible and
uninformed parents neglecting tlteir child's
health, and adding on to the neonatal
morbidity and mortality.’
()n the whole, adolescent girls in Shivpuri are
subject to various forms of violence, be it
domestic, dowry harassment, kidnapping,
abduction, trafficking or sexual abuse at home,
public and work place. Living in dangerous and
endless risks they are wailing to exhale every
second!
7
of growth. We are doing (his with help of
VHAI's educational Kit 'Towards Better
Adolescence'.
❖
Prioritizing health of adolescent girls
Sambhav is reaching out with message of
reproductive Child Health (RCH) by
organizing series of medical camps. The
female doctor from the District Hospital is
invited for these camps. Girls are provided
counseling and medical treatment on
various health issues. These camps have
been highly appreciated to support
adolescent girls and women with right
education, and at the same time have been
very successful too.
❖
Interactive group sessions with adolescent
girls help in answering their queries, and
make them aware about human rights.
<•
Theatre activities are regularly arranged to
sensitize communities on rights and
problems of adolescent girls.
❖
We are constantly enhancing their selfesteem, confidence and leadership
qualities by organizing activities like game,
singing and dancing competition, and other
cultural programmes.
❖
Discussions on sexual behavior and how to
deal with sexual harassment with support
of women activists and trainers are helping
all the girls.
❖
Wide spread information campaigning on
the matters of child rights, rights of girl
child, punishable act like female feticide
and sex determination, non-judicious
abortion of female fetus, and health and
nutritional care of women and adolescent
girls.
❖
Spreading message of gender equality in
school and colleges through exhibition,
lectures and film shows.
Interventions to support
adolescents
Understanding the importance of adolescence
period as a time of tremendous opportunity, as
well as, of risk our programmes focus greatly
on adolescent girls. At Sambhav, we are
continuously making an effort for addressing
their health, education, social needs to bring
harmony,
gender
parity,
economic
development, and quality life for all of them.
The activities include monthly meetings of
adolescent girls' groups, Yuva Mandals or
adolescent boys' group, where health-and
developmental issues are discussed. Regular
sports activities, painting competitions,
vocational courses etc. are also undertaken.
We encourage formation of Self Help
Group (SHGs) among women and
adolescent girls, to promote interaction and
interpersonal sharing. The project has 68
women SHGs. These groups are playing
pivotal role by advocating gender equality.
Leaders from groups serve as role model
for the girls to follow. We also strongly
believe that women SHGs plays an
important role in inculcating qualities like
dignity and leadership among girls. Real
example of this is when once, all the village
girls courageously got together, and
launched an anti liquor movement within
the communities. They even mobilized a
signature campaign to draw attention of the
Chief Minister towards growing consumption
of the liquor in the tribal areas.
❖
Creating awareness on constitutional and
legal guarantees for adolescent girls and
women.
Dr S.K. Singh is the
Director of Sambhav, an
NCO based in CwaBor.
❖
Disseminating scientific information about
basis of sex determination in mother's
womb.
❖
Organizing informal discussions with
adolescent girls on their health problems
and sensitizing them on physical,
emotional, social and behavioural aspects
These approaches altogether are helping us in
achieving success to great extent. Through our
educational programmes 150 girls have already
completed their grade five education. Making
difference in everyone's life, we feel proud to
see adolescent girls and women openly
discussing their problems, practicing personal
hygiene, and inquiring on methods of family
planning. Each day we see a new wave of
change in community, when girls speak for
themselves, fight for their own rights, and earn
their living to stand on their feet independently!
They are slowly and gradually changing the
reality of their fives.
40 ■ HEALTH FOR THE MILLIONS / February - March 2004
■tr si
\.
- '■^Frw'T11
■.
/> ■"’,
>P5
r
-March 24KM ■ 41
f
Adolescents on the fringe in
urban poor India
Dr. Sunil Mehra and Dr. Deepti Aggarwal
Introduction
Adolescence as a term or a distinct phase of life
has only recently been recognised across the
developing countries. India, being no exception
too had limited understanding of 'adolescence'
due to the restricted information on this phase in
the rural context. Closer review of the past work
in the country strongly suggests that this phase
meaning 'to grow or mature' has by and large
been subsumed under the category of child or
married adults. Delay in the onset of puberty (due
to poor nutritional status), and prevalence of early
marriage (signifying adulthood) explains the
scenario well.
The recent UNFPA report 2003,f Making I Billion
Count cautions that the largest generation of
adolescents in history-1.2 billion aged between
10-19, is stepping into adulthood, faced with
risks of deadly diseases, curtailment of
education, early marriage, unwanted pregnancy,
and poverty. 7 his is also a reflection of what;
we in India are going through. Based on the
presumption that we continue to experience
the fertility decline as projected in the
population momentum, the decade of 2000
will witness the largest number of adolescents
ever seen before or expected to be seen in
future. This is well reflected in Table 1.
Presently adolescents comprising about 1 /5th of
India's population (ignored in the policies and
programmes and caught in hands of no focussed
investment). Totaffing to approximately 230 million
boys and girls, it is a number too big and too
significant in the national health and development
context. It is the understanding about the lack of
emphasis on this age group, which might really be
the turning point for achieving 'health for all' goals
much faster.
We would like to state that the lack of reliable
data and information on the adolescent age group
is a major impediment in undertaking any review
on adolescents. Disaggregation of data on the
basis of age is in the age groups of 0-15 years or
15-24 years, with adolescents rarely considered
as a distinct age group in official statistics.
Emphasis on youth (15-35 years in India)
subsumes the older adolescents into this broad
and large category. Also the existing data are
rarely disaggregated in intraurban location or
t
Year-
test
20
Male
^enialeA^Tbt^^
(11.73)
Male
Fet
■7i754 ■ - 36^j?8f
36^38® ^.74^®
5^8W 82^ 7,754
■?
1996'<>;';
“M71^ ^0)
(8.98)^
90,-7211
!1,676
40,334;:
0!
’723!^ 42^48^
gg)
(8J
Is
Source: Population Projections, Registrar General of India, 1996
Figure in Parenthesis is Percentage Share of Total Population
^2 ■ HEALTH FOR THE MILLIONS / February - March 2004
.
socio-econoniic criteria. Data sets as DHS (in India
NFHS 1998/99) disaggregate by "urban " and
"rural", but go no further. Thus, the slum
population and the poorest squatters are
statistically identical to middle class, and wealthy
urban dwellers. In this article, an effort has been
made to present data specific to adolescents in
urban slums, from varied sources, wherever
available.
Development, population
movement and adolescents
(young people)
Development processes do not occur
homogeneously, as they tend to be localized, and
create differences between geographic areas, and
encourage population movement. Since the
visionary announcement by McLuhan in the
1960's about the arrival of the global village,
globalization is increasingly occurring. Even the
rural households that seem to five by subsistence
farming alone are no longer doing so, and are
increasingly dependent on links (marketing of
production and migration of rural youth) to urban
areas, for remittances and capital to purchase
new inputs required for agricultural intensification.
Push and pull factors triggered by enhanced
communication further encourage movement. For
example, soap operas are not just seen for their
stories, but are carefully observed by rural
viewers who take note of the electricity, running
waters, refrigerators and other modern amenities.
These millions on the move, both spatially and
socially, are continuously attempting to improve
the situation for themselves, and their families.
Young people, particularly those from rural and
low-income communities, are becoming
increasingly attracted by the diverse offerings of
the cities and especially economic ones. With
parallel shortage of skilled and unskilled labour,
these cities provide them ample opportunities for
earning a livelihood and aspire for better lives.
Opening doors to meet new people, learn new
skills and adopt new behaviours, urban
atmosphere allows them to escape from the
constraints of traditional societal norms or cultural
rules. Exactly in tune with what our young
generation desires!
India's urban population and
adolescents
India has the fastest growing segment of urban
population, believed to be doubling or even
tripling from mid -1990s figures of 250 million
and expected to touch 660 million by 2025,
placing India only second to China in urban
growth (EHP Activity report). This growth in
numbers is most likely to affect poor urban
communities, as cities increasingly attract young
people from rural settings and since they h.ijjfx’n
to lx? the most fertile section of the pijxilalion,
the growth becomes self- perpetuating (RossiEspagnet, Goldstein).
In the face of rapid urbanisation, the civil
amenities are unable to keep pace making life
difficult for the urban poor communities.
Approximately 23 urban centres in the country,
holding over a million inhabitants each, are
estmated to have 30-40% of urban dwellers living
in extreme poverty. These low-income
communities residing in slums, tenements,
shantytowns or squatter settlements, share
common characteristics of population density,
poverty, squalor, lack
of services, and socio
cultural heterogeneity.
Most of them being
illegal tenements, lose
their eligibility for
water,
sewage,
electricity, education,
infrastructure, and
other
municipal
services,
making
factors
such
as
marginalisation,
literacy, class or caste
status, and political
interest determine
their fate (EHP Activity
report 109).
Challenges and risks faced in
adolescent years
It may be noted that for the purpose of this article
most of the issues mentioned below have been
dealt at an introductory level. However they need
a more detailed review on their own for a better
understanding of complexities of these issues and
their impact on the lives of adolescents.
The problems faced by adolescents in urban poor
communities are more or less the same as faced
by most adolescents in any developing country
irrespective of the urban or rural settings.
However adolescents living in urban poor areas
are especially vulnerable as most of them:
❖
❖
❖
❖
Are denied the opportunity to complete
their education.
Have no stable homes or support systems,
and are living on the streets in the absence
of basic infrastructure and exposed to the
risks of malnutrition and disease.
Lack access to basic services including health
and education facilities.
Work for long hours for little pay, and are
exposed to hazardous work processes.
HEALTH FOR THE MILLIONS / February - March 2004 ■ 43
I
❖
❖
•>
After being displaced from their native
villages, they live in slums or shantytowns
where traditional values, and community
structures are impossible to maintain.
Vulnerable to sexual abuse or violence.
Are denied the same opportunities for
development as some of their peers.
|xol>lems that passes from one gent^ration to the
next. Thus, programme interventions targeting
their health are essential to compensate early
deficiencies and ensure normal growth of girls. In
case of adolescent boys, under nutrition or
malnutrition affects their ability to lx? (xoductive
citizens and contribute to the country's
development process.
Malnutrition
Across the communities, families usually
recognize nutritional requirements of infants and
children, completely ignorant of increased
nutritional needs of adolescents to even consider
it as a priority. Increased nutritional demands in
the face of accelerated growth spurt and
increased physical workload coupled with unmet
nutritional need leads to chronic energy
deficiency, anemia, and results in impaired
physical development (sometimes manifested as
stunting). In many cases, malnutrition prevalent in
childhood is likely to be carried into adolescence,
which provides the last, and the final opportunity
for growth.
General health problems
Adolescents in urban poor areas are by and Urge
subject to same illnesses as children or adults.
Some of these are concerns related to the
process of growing up. Less likely to recognise
their own problems, adolescents in most of the
cases don't even know where to seek treatment.
They too face illnesses associated with poor
sanitation and unhygienic living conditions. It will
not be incorrect if one states that very little
national data is available for the morbidity and
mortality patterns/distribution of common or
adolescent specific diseases/illnesses in this age
group.
Early and unprotected sexual activity
While information on sexual activity and
behaviour is limited, a consistent finding from
existing studies is the significant level of premarital
sexual activity, mainly among adolescent males.
A disturbing trend is the lack of contraceptive use
(due to cost, inaccessibility, lack of information)
and the knowledge of sexually transmitted
infections. Of these, many adolescents who
become sexually active, without being aware of
the risks and consequences are facing results of
coercion or pressure. The largest risk posed by
unsafe sex is infection with HIV/AIDS. Young
people are increasingly at the centre of this
epidemic, both in terms of transmission and
impact. Over 50% of all new HIV infections in
India are reported among young adults below 25
years.
It is estimated that 60-90% of street children in
Mumbai are sexualy active. About 20% of street
boys in the 16-20 age group visit commercial sex
workers regularly and 80% periodically. Another
study conducted in slums of Chennai found 80%
of youth engaged in pre-marital sex; 85% of the
same group reported to have never used
condoms (wwwindianngos.com).
For adolescent girls, apart from growth spurt,
factors such as onset of menstruation, early
marriage and pregnancy, childbirth, and
motherhood create an extra demand on
nutritional requirements. Most of them already
being anaemic find it difficulty to face challenges
of pregnancy and lactation. The shortfall results
in further depletion perpetuate a cycle of health
44 ■ HEALTH FOR THE MILLIONS / February - March 2004
Despite stringent controls on the mobility, and
activity of unmarried adolescents particularly
females; opportunities do exist for sexual
relationships, sometimes with adverse
consequences on yotng people's health and lives.
Liaisons k nd to be secretive, and awarene ;s of
safe sex, and the protective nature of condoms
are limited. Opportunities for social interaction,
and even the development of sexual relationships
I
immediate ones, it directly demonstrates the
failure of our system to meet every child's basic
rights as stated in Child Rights Convention.
These include inadequate provision of
infornution, and opportunities to develop life
skills, poor access to education and health
services, an environment that is neither safe nor
supportive, and last but not the least
inadequate and ineffective participation in the
society.
Adolescents deprived of their rights quickly get
caught into web of high risk behaviours like substance abuse, unwanted or unsafe sex,
unhealthy eating habits/lack of nutritious diet,
leading to situation of accidents and violence.
This is compounded by lack of knowledge or
skills, no <~ —
.SLerV’5eS' and ,lhe '
unavailability of support that they need from
their families or communities directly impacts
them physically, mentally and socially.
Critical issues for prime attention
Some of the critical issues requiring urgent
attention include education, health services
vocational training, employment opportunities^
basic infrastructure and civic amenities. All of
have
direct or
or indirect
indirect bearing
bearing on
on the
the
;these —
* a
a direct
health of adolescents.
It is well documented that outcomes of
poverty, illiteracy and poor health interact
with each other. Low levels of literacy
adversely affect health awareness and thus
the quality of life. The consequences are
reinforced by the fact that children of young
and illiterate parents tend to face the same
cycle of deprivation and under nutrition as
experienced by their parents. Illiteracy holds
people back even in the most basic day-today activities. Inadequate schooling prevents
adolescents from taking advantage of new
opportunities, for example, jobs in the
emerging knowledge-based industries.
It becomes difficult for illiterate or lesseducated adolescents to obtain information
about basic health care. Poor health and
lower survival rates reduce the incentive for
parents to invest in children's education.
Apart from formal schooling, adolescents
further need education, which reflects the
complexity of their lives. This includes
livelihood training, ce?2re.pren____
' '!R'
rf
^ULrsh
negotiation skills, gender equity, and health
and nutrition-all aspects of preparing for a
self-reliant individual.
Infrastructure provision in urban slum areas has
a multiple effect. Provision of adequate water
supply, sanitation and electricity improves the
health status, and enhances the productivity of
the community. Such infrastructure provision
provides a security of tenure, and leads to
investments from the dwellers in shelter and
environment improvement through the
mobilisation of internal resources. This in turn
(xovides a nurturing environment for children as
wel as adolescents, to meet their physical and
social needs. It facilitates a supportive
environment conducive for promotion of social
justice, gender equality, participation in
community life as well as healthy, crime free
communities where they are protected from
labour, abuse and economic exploitation.
Child labour especially among adolescents
continues to remain a poverty issue since
education and health care are the cornerstones
of social development and economic progress.
Working at the expense of attending school,
they never develop the skills and training, one
requires for contributing towards the economic
progress of our country. Premature and
e^nS‘Ve
jn 'wor!< can damage
a°o,escents hea,th and social development
L— f?7Petu?t,r?8 the ,cyc,e ofpoverty. Further
dimm’shtng their work capacity, child labour
.S Pnx,uct,v’ty/ and reduces their financial
earnings.
Future threats
The adolescent population will continue to
grow in absolute
numbers even if
the fertility rate
continues
to
decline.
As
mentioned earlier,
the number of
adolescents in
urban India will
continue
to
increase, since
there
is
a
population
momentum inbuilt
into this segment
of the population.
Given the various
factors,
which
enhance
the
vulnerabilities of
these adolescents,
the incidence of HIV/AIDS will continue to rise
unless there is adequate provision of health and
education facilities along with better life
opportunities for them. Unless the poor
nutritional status of adolescents and especially
young mothers becomes a priority issue to be
addressed through programmes and services,
the health and development of future
HEALTH FOR THE MILLIONS / February - March 2004
■ 47
standards of the rural poor, and reduce their
migration.
generation remains at stake with risk of
transmission of physical social and economic
disadvantages into the next generation.
Broad polic y reforms are re<|uired in order to
deal with situation of adolescents in urban fx>or
communities, which are a result of various
interrelated factors.
Targeting government spending to primary
education, reducing communicable diseases,
improving water and sanitation and reducing
household insecurity through public health
programme resulting in better family health,
smaller family size, and healthier children for
educated women.
The World Bank report (World Bank country
Report, 1997) suggests that it would be
important for anti-poverty programmes in India
to bestow at least a proportion of benefits on
urban poor class. The financial resources can
be best invested to increase access to health
and education services that can equip them for
the life ahead.
Analysis have shown that health education
concerning basic hygiene, the value of better
nutrition, and preventive care such as public
health campaigns against tobacco/drug use,
and spread of HIV-AIDS and other sexually
transmitted diseases; is an imoortant part of
encouraging behavioural changes needed for
long term improvements in health outcomes.
Comprehensive reforms of agricultural policies
are essential to broaden the base of growth,
increase agricultural productivity, improve living
Access to sanitation and especially private
access to water is a major determinant of
vulnerability to or protection against various
Roadmap to follow
Some steps for immediate action that would
particularly benefit adolescents ~ *
il
<
l
F
v
IV
I/
f
r
t
f
(
(
I.
T
t
F
I
I
<
s
i
r
I
Strengthening national capacity in data collection, compilation, updating and
analysis of quantitative and qualitative data on adolescents. Create a national age
specific / sex specific /urban-rural specific, disaggregated / married / unmarried/
adolescent database on various health determinants.
i
I
I
❖
Formulating a comprehensive nationaLstrategy and programme of action to
address the multidimensional needs of Adolescents in urban slums, and involve
adolescents in all stages of planning and implementation.
* -
<
I
<
❖
Adolescents in’urban poor environm'erits-need much more intensivednput to
understand their health status, concerns and programmatic understanding.
❖
Adolescent counselling and guidance centres to be established in all urban slum areas
in partnership with NGOs and Private/Public institutions. STDs like HIV/AIDS
prevention and support, reproductive health knowledge, vocational training etc., should
form an integral part of this effort.
❖
----------- ■
❖
i -
rirn > Tnrtiril/ _
i n-1
in' -'—
'
~
~
~
.hjm
nutrition and personality development in pur existing health care system. Ensure
access to quality health services that are gender sensitive andAdolescent
friendly. Reorient and enhance skills of health providers to address, this important
''
L—
❖
Enforcing girl child schc^etent^p^feral^lill ga years ariddncorporate life
skill education in all schools.
■
t
❖
Recognizing and promoting,the rights of‘adolescents, including their rights to
education, to enter into marriagefwithrfree^and^full consent, to have their views
taken into account in matters that concern them, and their right to decide when
to have/not to have children, and the number and spacing of these children.
(Rights Bound Approach)
48 ■ HEALTH FOR THE MILLIONS / February • March 2004
i
i—
Integrating adolescent health especially pregnancy, childcare, cbnt&ception,
area-
I
I
i
l
illnesses
and
diseases.
Combating
communicable diseases, and expanding the
traditional jHiblic health interventions <>t
guaranteeing safe water and sanitation, as
well as disseminating information on bask
hygiene and the value of preventive care,
would deliver the highest gains from public
health spending.
Adolescent phase is the last and final chance
for catching onto growth. It is important to
realize that the nutritional requirements of
the adolescents are high, and has as
significant an impact, as on children below
five years. Specific reforms are required to
consolidate various nutrition programmes,
and to advance a nutrition strategy which
encompasses/includes the adolescents (at
least the early adolescents) amongst the
beneficiaries. Programmes like the ICDS and
the RCH which have targeted children and
pregnant women and lactating mothers by
providing a package of services including
health education, growth monitoring, health
check-ups and immunization, referral and
supplemental feeding would do well by
including adolescents as beneficiaries, as
most of these services are urgently needed
by them.
All these findings bring into sharp focus that
the effectiveness of safety nets in protecting
the poor, depends heavily on that of the
delivery of some crucial services such as
education, water, hygiene, sanitation and
public health, which1 are not strictly the part
of the safety net.
Reference
Bezbaruah S, Janeja MK, in Adolescents in India:
A profile, UNFPA, September 2000
Rossi-Espagnet A, Goldstein GB, Tabibzadeh I
(1993). Urbanization and Health in developing
countries: a challenge for Health for all. World
Health Statistics Quarterly 44: 186-245.
Population Movements, Development And HIV/
AIDS: Looking Towards The Future, Fifth
International Congress On AIDS In Asia And The
Pacific, Kuala Lumpur, 99, UNOPS, UNDP.
Bareli A., and Beardmore R., poverty reduction in
India: Towards building successful slum-upgrading
strategies. Discussion paper for urban futures
2000 conference Johannesburg, South Africa,
Available on the world bank site: http://
wblnO018.worldbank.org
Frey S, Cousins B, Olivola K, in Activity report
109:Health of children living in urban slums in Asia
and Near East: Review of existing literature and
data. Prepared for the Asia &near East bureau of
USAID under FHP project 26568, May 2002
(iwatkin R.D.. Rustin S._ Johnson K._ I’ande PR.,
W.ig.istall A., in S<»< 10- t*< onomic dilterem es in
he.illh. nutrition and population in India, HXP
Poverty thumatir group. World Bank. May 20')0
Adolescent friendly Health Srrvir r
lor (‘fiange, WH(), ( )< tob<*r 2002
An Agon, la
Youth health-tor .1 change, UNK II. |‘»97
World bank country study, Rc*du< ing poverty in
India: options for more etfec live* public services.
The World Bank, Washington DC 1998.
Nutritional Status of Adolescents Girls and
Women of Reproductive Age. Report of Regional
Consultation Geneva, World Health Organization,
SEA/NUT/141 1998; p 3.
Kanani S,Causul P. Nutrition health profile and
intervention strategies for underprivileged
adolescent girls in India: A selected Review. Indian
journal maternal and child health, 1990; 1(4): 129133
Sexual Behaviour Among Unmarried Adolescents
In Delhi, India: Opportunities Despite Parental
Controls, Mehra S, Savithri R, Coutinho I,
Presented at XIV International AIDS Conference,
Barcelona, 2002.
Jejeebhoy, S, "Adolescent sexual and reproductive
behaviour: A review of the evidence from India."
In Radhika Ramasubban and Shireen Jejeebhoy
(Eds.). Women's reproductive Health in India.
20(H), Jaipur and New Delhi: Rawat Publications,
pp. 40-101.
Sexual Behaviour among adolescents and young
people in India: some emerging trends, working
paper series no. i, MAMTA health institute for
mother and child, 2002
Sexual violence and young people: the human
rights approach, working paper series no.5,
MAMIA health institute for mother and c hild,
Nev/ Delhi, 2003
HIV/AIDS Resources: Children, young people and
HIV, Facts and Figures, www.indianngos.com
Dorabjee J,Sarin E .Singh S, Deepak V in Rapid
situation assessment of dug use in Delhi. SharanSociety for service of urban poor. New Delhi ,
2001, Pg.3.
India poverty consultation workshop, world bank
and UNDP, India habitat centre, New Delhi January
5-6, 1999
State of world population 2002, Population,
Poverty and Global Development Goals: the Way
Ahead, available on www.unfpa.org/swp
Mehra S., Agrawal D., in Adolescent health
Determinants for Pregnancy and Child Health
Outcomes among Urban poor, in press (Indian
Pediatrics).
Dr Siitiil Mrhi.i is f/w
/ xt't ulh f l)ifv< htr nt
MAM1A-I hxilth
Hh
MoiIh i And ( hikl Nf\\
Delhi. Il is ,1 NC,( ) ii«vLi/ig
<wj .k/o/cx <71/ Inxillh .uni
d('\’el<»i>nu‘nl
m tin'
urban dums ot DvRii .,nd
many ulht‘i stale'- i»t imlia.
Dr. Decptl A^rawal rs tin'
Senior Pro#•ranvne
Man.^*er in the
ttrfiani^alion.
HEALTH FOR THE MILLIONS / February - March 2004
49
9
Voices from Kashmir
•’
J!
R*
fter emergence of the Democratic
Government in J&K State, the health
status started a gradual march towards
betterment. Health infrastructure was created
in various parts of the state, to make health
facilities accessible for every individual. Things
began to take shape and the state started
flourishing. It was at that juncture of the late
80's, when militancy placed its foot in the valley.
Everything came to halt. Tourism, health,
growth, education, job opportunities, markets,
and even day to day life got affected
particularly in Kashmir valley. Hope vanished
and terror reflected in everyone's eyes.
Access to various governmental services
including health became difficult. Most of the
time, the health centres remained empty,
without doctors and other health
functionaries. Reasons for the same are well
known to all. Militancy and danger for life,
were number one on the list. Medical
specialists like surgeon, gynaecologist,
pediatrician, anesthetist etc. as per orders
were suppose to report daily on duty for the
district hospitals, in the rural areas, but in
actual practice they never lurned up. Even,
the acute shortage of medical supplies,
50
a HEALTH FOR THE MILLIONS / February - March 2004
surgical instruments, and other diagnostic
equipments continued in government
hospitals. And if ever, patients found
treatment in these hospitals, they had to
compulsorily spend exorbitant amount to get
the routine investigations done at private
clinics.
In these circumstances, it became extremely
difficult for the people to get proper medical
care. Women, especially pregnant mothers
were suffering like never before. They were
deprived of proper antenatal care, which
gave way to number of other complications
like- anemia, calcium deficiency and
hypertension. The incidence of pre
eclampsia, eclampsia, ectopic pregnancies,
post- partum hemorrhage, stillbirths,
neonatal, and prenatal deaths made news
waves everyday in rural and backward areas.
Observing this grim health situation in the
J&K State, particularly in Kashmir valley
caused due to the turmoil, Voluntary Heath
Association of India (VHAI) in 1997 under
the supervision Shri Alok Mukhopadhyay,
Chief Executive, VHAI boldly initiated
number of activities. Mass Health Camps and
Health Awareness Programmes marked the
beginning to make health related services
available all over the Kashmir Valley. The
same was followed by seminars and a series
of mass interact’.ons with various health
specialists, doctors, experts, and social
activists to improve the reach of health care
facilities, particularly in rural areas.
In 1999 Jammu & Kashmir Voluntary Health
Association (JK-VHA) with financial support
from VHAI, New Delhi initiated a Community
Health Programme in five backward villages
of Budgam District under the Shehjar Khoj
Project and in June 2000 the second
Community Health Programme under the
Shadab Khoj Project was started in Pulwama
District of Kashmir.
The foundation-training programme was
organized by JK-VHA from 23w of September
to 14‘h of October 1999, wherein; the Village
Development Committee identified 13
educated adolescent girls within the Shehjar
Khoj Project area of Budgam. Selected girls
received complete training in the area of
community health, and were further given
practical exposure in Government Lal Ded
Maternity Hospital of Srinagar. Subsequently
another batch of 12 adolescent girls from
Wakherwan and Gongoo villages of the
Shadab Khoj Project got trained in the District
Hospital of Pulwama.
Today all these adolescent girls are working
as Village Health Worker (VHW) in their own
capacity under various projects. Their work
entails daily house to house visits with the
TBAs for creating awareness on health,
hygiene and sanitation, along with providing
treatment for minor ailments. Over the
period of time, these girls have tremendously
contributed towards Kashmir's health. At this
young age they are dedicatedly working
under severe circumstances of militancy
towards improvement of the valley. Many of
them regularly communicate with us, their
stories of success. The extracts enlisted
below are some of the experiences and
feelings of these young and enthusiastic
workers in the field, especially while
mobilizing other adolescent girls like them
and women into forming SHGs for income
generation. This also in the process leads to
their empowerment.
Muneera (VHW Zoohamaz
Budgam)
It all began in 1999 after my 11“* class
exams. Like many other girls, I was also
spending most of my time at home. But
things changed when one day Mir Saab (Mr.
A. M. Mir) came to our village with Shehjar
Khoj Project and ottered me an opportunity
to work tor the betterment of our
community. Frankly speaking, I had no
knowledge of health and hygiene, and any
kind of exposure outside my own village was
completely out of question. I knew nothing
about VHAI and the nature of work I was
suppose to do. I was a bit confused too, but
the desire to bring in a change pushed me.
Also, I perceived this chance as a way to
fulfill my dream of a better, beautiful and
healthy Kashmir.
Within few days I was called for an interview,
after which the details of my work, area and
project were explained. Soon, I received
training in health, hygiene and sanitation to
begin my work in the village Zoohama. I was
only 18 years old and became a butt of
risqu^ jokes, reason being, sexual
discrimination and societal taboo for an
unmarried girl to talk on issues concerning
reproductive health, pregnancy and
childcare.
I would like to share
with you an incident
that increased my
pride and Izzat in the
village.
Today, everyone in the
village is proud of me.
Now, no more nasty
comments, infact what
I usually hear is 'here
A
lady
in
our
neighboring area had a
come our doctorni ji’.
history of giving birth
to weak and sick children. During my daily
home visits as a VHW, one day I found she
was pregnant again. This made me convince
her for getting regular health check-ups and
counseling done. I enrolled her in Shehjar
OPD for regular treatment and constant
monitoring. The whole village was amazed to
see her enjoying healthy pregnancy. Within
a few months time she gave birth to a
healthy child, who was quite unlike the ones
she had given birth before. This incidence
gave a big turning point to my career and
earned me respect. Today, everyone in the
village is proud of me. Now, no more nasty
comments, infact what I usually hear is 'here
come our doctorni ji'.
Nighat (VHW Dadompora,
Budgam)
I joined as a VHW in 1999 under Shehjar
Khoj Project, Budgam after passing my 12th
class with science stream from higher
secondary school. Let me admit, that I knew
nothing about various health problems
particularly of adolescent girls and pregnant
HEALTH FOR THE MILLIONS / February - March 2004 ■
0
women. The villagers were unaware too,
about the importance of immunization like
BCG, Polio, DPT and Measles for their
children. The situation was so worse, that
villagers were using banks of river as latrines
and downstream people were using the
same water for preparation of their meals
and drinking purpose. Result was regular
outburst of stomach and respiratory
infections.
After getting trained as Voluntary Health
Worker (VHW), I gained loads of knowledge
on various issues of health, hygiene and
sanitation. I also acquired basic education
and knowledge on community health to be
promoted in my village. But when I began my
work, there was hardly anyone to believe in
me. During my daily visits, people were
tough, had fixed notions, and never co
operated.
My
messages
of
I would say its not my
health particularly
of pre and post
success story, but the story
natal care were
of courage and patience in
for
unheard
months
and
every individual of our
months. I even
villages to change his/her
tried motivating
circumstances, surrounding some adolescent
girls about the
and overall health. I am just adverse effects
of
early
a medium, but real agent
marriages. Got on
to
educating
of change are all those,
them and helped
who are continuously
them
form
various
Self
help
making efforts to lead a
Groups (SHGs).
healthy life.
It was hard to
make place for myself and preach my work,
but gradually success came my way. Our
dedicated and motivated efforts in the
Shehjar Khoj Project made many adolescent
girls literate and helped them attain training
in crafts. Today, they are independently doing
variety of craft work to earn their living and
in return gaining respect among their families
and society. Everyday gender discrimination
towards female child is decreasing to quite
some extent. Female feticide, which was
prevailing secretly, is also declining. I see
people washing hands before their meals and
drinking boiled water. No more latrines on the
banks of river. Children are happy and
healthy. On whole it's an achievement for the
village.
I would say its not my success story, but
the story of courage and patience in every
2
HEALTH FOR THE MILLIONS / February - March 2004
individual of our villages to change his/her
circumstances, surrounding and overall
health. I am just a medium, but real agent
ol change are all those, who are
continuously making efforts to lead a
healthy life.
Shabnum (VHW Surasyar,
Budgam)
I discontinued my studies after IO”’ standard
due to my father's death. This cruel destiny
played havoc on our domestic conditions,
things became worse, and each day was
difficult to pass with endless problems on our
head. Until one day, Shehjar Khoj Project
team came to our house and persuaded my
mother to allow me for joining the Project.
Due to the prevailing social constraints, my
mother was in a fix, whether to allow me or
not, but then after realizing the adverse
conditions at home she reluctantly agreed,
and I was enrolled in the Shehjar Khoj Project
as volunteer at the age of 17 years.
My working helped in improving our
economic conditions at home. Besides
joining the project, I got the opportunity to
serve the ailing people of my village in
difficult days of militancy, when
Government Medical Institutions were ill
equipped to function properly. Our team
started baseline data survey amongst
villagers for ascertaining their health
conditions, education status, available
amenities, and other demographic details.
We faced various difficulties; some people
suspected us to be Indian agents (looking
for militants), while others were unhappy
sharing their personal information with us.
However, we continued our efforts and
worked with best spirit, and dedication to
complete our survey.
Training under Shehjar Project provided all
the adolescent health workers with an
opportunity to experience life outside the
State, work confidently and boldly. All of us
are now further educating the illiterate
adolescent girl and women, making them
aware about various health problems, and
even helping them form income generating
SHCs.
I am very content, doing my job as a VHW.
The feeling that I had extended my hand to
people, when the village was passing through
thick shadows and horror of insurgency, gives
a true meaning to my life. Even though I have
faced a lot of humiliation and harassment
both in the hands of militants and
*
paramilitary forces, but my motivation built
in me by our project team leader helped me
sail over all problems. I am no longer a timid
Un orphan girl. I am very thankful Io the
C hief I xecutive of VHAI, New Delhi, and
other senior stall members for running the
Shehjar Project in our villages.
Zubeda (VHW, Nawhar)
I was born to a tailor in an aveiage rural
family. My lather has studied upto primary
sc bool whereas; my mother is an illiterate. All
her life she looked after domestic affairs and
our two cows. My parents went through lot
ot hardships and tough limes to educate me
till 1 1"' class. With time and death of our
cows, monetary situatic>n at home became
difficult, and soon my education was
stopped. Even though, my younger brother
continued his studies. Not much pronounced,
sex discrimination did exist in our family and
village.
This whole incidence shattered my dream of
becoming a doctor. I was a helpless, and
caught by unproductive household work.
But as its said, 'there is always sunshine after
the rain', soon brightness came my way,
when my
name was suggested for
voluntary work. I was only 19 years old,
when I first appeared for an interview. So
nervous and shy, that I could not speak my
name, Yet, gathered all my courage to say
that I was really interested in this kind of
work.
After selection along with other batch
mates I received training in community
health, hygiene and sanitation. Everything
was new and each day was an experience.
Gradually, I gained confidence in performing
my role as VHW in Shehjar Khoj Project.
Though, in the whole process, I received
endless humiliation, threat and abuse from
many groups, who suspected my intentions
to be of a spy in paramilitary forces. But I
never stopped.
Still, remember the most terrifying
evening, when four unknown-armed
people entered oui house, and shot my
lather with bullets. Thank to my training,
I provided him first-aid immediately, and
rushed to the hospital. He recovered and
returned home after one month. Since
then people call me 'Dr. Zubeda'. I am
proud for saving his life, and all the work I
am doing for improving the health
conditions of our villagers, and especially
young girls and women.
Arshida (VHW, Rinzipora
Village)
I grew up with a story ot how my mother
(ried when I was born, fainted when she
gave birth to my younger sister and felt
blessed on her third child being born as a
bov. My brother was pampered by all the
family members in comparison to my
younger sister and me.
This live example of gender discrimination at
home motivated me to work for women and
girls, who have been facing endless health
{xoblems in (ommunity due to their ignorance,
illiteracy and poverty. I joined Shahdab Khoj
Project as VHW. In the project, I received
training on community and mental health as a
counselor. This equipped me to treat people
suffering from minor physical and mental
tensions.
I remember once I had gone on a training camp
to other city and on my return, I learnt that
Ameena (my classmate in school) had passed
away due to some disease in early adolescent
age. This personal tragedy motivated me to
focus completely on health care for
adolescence girls. Today I am helping many girls
to overcome their situations, problems and
circumstances.
Another incidence, which changed my life, was
of my own brother. He was 17 years old,
unemployed, and pressurized by his peer
group to join the on-going militancy, which he
tir.ally did. Family members lost their balance
and tried all possibilities to contact him, but
failed. Within few months time, the local
police and BSF officers came to our village
and handed over his dead body. It was the
saddest day of my life, seeing my brother
lying in one corner, and my parents under
severe shock on the other side. Somehow, I
gathered myself and with help from other
psychosocial worker of team, fought all odds
for almost a year. Today my parents are still
trying to come in terms with the lose.
I am proud of the work I am doing; helping
people in my village overcome the trauma
that the current militancy has brought upon
us. Large numbers of young people have died
in this turmoil, leaving helpless families
behind. I am trying to make a difference in
their life, by helping them overcome this
whole situation.
I remember my father saying, "You have to
prove that girls can also do a good job and earn
name for their family", while I was joining my
VHW job. Now, my work is speaking it all.
HEALTH FOR THE MILLIONS / February - March
I
Population Scan
The Missing Children
Ashish Bose
It is tragic to note the high rates of infant and underfive mortality among the children in the SAARC
countries and also in other developing countries. Given
below in table is a glimpse of the detailed data
presented in the latest UNICEI publication: The State
of the World's Children 2004
of other fronts: health and status of women,
early childhood care, nutrition, water and
sanitation, reduction of child labour and other
forms of exploitation, and Peaceful resolution of
conflicts
❖
Educated mothers have healthier, betternourished children, according to a review of
extensive evidence from the developing world.
Each extra year of maternal education reduces
the rate of mortality for children under-five by
between 5 and 10 per cent.
❖
Countries that have achieved gender parity in
education face a new challenge: finding ways
to expand social expectations for their
educated girls.
❖
The "reverse gender gap' - Although the global
gender gap clearly puts girls at an educational
disadvantage, it is important to recognize that in
some regions - including much of the
industrialized world - it is boys' disaffection with
school that is a cause for concern. In a minority
of countries, there are fewer boys than girls
enrolled in school: a 'reverse gender gap'.
❖
Investing in girls' education - Girls' education
is an ideal investment. It adds value to other
social development sectors, eases the strain on
the health-care system, reduces poverty and
strengthens national economies.
Highlights of the report as presented by
UNICEF:
❖
Girls' education is one of the most crucial issues
facing the international development community.
The report is a call to action on behc.lf of 121 million
children who are out of school around the world
today, 65 million of whom are girls. Despite
thousands of successful projects in countries across
the globe, gender parity in education - in access to
school, successful achievement and completion - is
as elusive as ever and girls continue to systematically
lose out on the benefits that an education affords.
I
❖
❖
The report findings clearly show, how universal
education has been considered a luxury rather
than a human right, economic development
programmes have focused on economic
performance rather than human welfare, and
limited policies have looked only to the education
sector when identifying solutions.
Girls' education is so inextricably linked with the
other facets of human development that to make
it a priority is also to make progress on a range
Basic Indicators in Selected Countries,: 2002:
Countries
Infant mortality rate •Life expectancy^
(under 1 year per ' ^:at-birtHXy®^)^
Under-5 mortality rate
(per 1,000 live births)
.17 ;
1,000 live births)
China
•
’'
. •
77
Bhutan
94
India
Maldives
Nepal
Pakistan
3i 5
.
39
SAARC Countries
Bangladesh
. J- '■
'74
93.
‘
58
77
i
v /1
Sri Lanka ; v./ j ' •
■
-•
91
:'•
107
•
Regions j ■: j .' 1
Developing Countries .7;
'
‘ ?63
■ 2 v. : ■
:
■
......
<83.
^19
"
.
90
-‘"T5 '‘5iiT*■
6\
------
Source: Compiled from UNICEF: The State of the World's Children 2004, New York, 2003, pp. 102-105.
Professor Ashish Bose is Honorary Professor at the Institute of Economic Growth, Delhi and a member of the independent Commission on
Health in India. He is also a member of the Committee on 'Vision 2020' set up by the Planning Commission.
'W.‘
!
_____________ _]> i
•X,HSAl.TH FqR.niBMiujON$7, February - March 2004 v.
V
■
_ _________ Li.:~
SW3
Africa isn't dying of AIDS
Rian Malan, Cape Town
!
tatistics are often the lowest form of lie'
^^oncc said Mark Twain, but when it comes
Io HIV/AIDS, we suspend all skepticism.
Some of you might think why? AIDS is the
most political disease ever. The world has
been fighting about it since the day it was
identified. The key battleground is public
perception, and the most deadly weapon is
the estimate. In 1985, a science journal
estimated 1.7 million Americans to be
infected with AIDS virus, with 'three to five
million' soon likely to follow. Oprah Winfrey
on her famous show even told the nation,
that by 1990 'one in five heterosexuals will
be dead of AIDS'.
Botswana estimated population of 1.4 million
in 1993. Today, this figure is under a million and
heading downwards. Statistics revealed
Botswana to become the first nation in
modern times, which will die literally out of
AIDS. But on the contrary, Botswana latest
census show population growing at the rate of
about 2.7 per cent a year. In the last decade
the total population has risen to 1.7 million. If
anything, Botswana is experiencing beyond
AIDS, it is this minor population explosion.
Similarly over hyped figures of AIDS in
Tanzania turned wrong, as the new census
show population growing at the rate of 2.9 per
cent a year. Even, in the district of Kagera,
population growing at the rate of 2.7 per cent
a year before 1988, accelerated to 3.1 per
cent this year. Whereas, figures show AIDS
epidemic to be peaking here. Uganda's census
tells broadly the same story.
This decline in AIDS impact is less devastating
than most figures show, but this is not reality.
In Africa, the only good news about AIDS is
bad news, and anyone who tells you positive
story is branded a moral leper, bent on sowing
confusion and derailing 100,000 worthy
fundraising drives. Looking around, it seems
AIDS fever is nearing the danger level and that
some calming thoughts are called for.
The very first question that comes to our mind
is who were these estimators? For the most part,
they worked in Geneva for WHO or UNAIDS,
using a computer simulator called EpimodeL
Every year, .all over Africa, blood would be taken
from a small sample of pregnant women and
screened for signs of HIV infection. The results
would be programmed into Epimodel, which
ti.immuted them into estimates. If so many
women were infected, it followed that a similar
pro|xirtion of their husbands and lovers must be
infected, too. These numbers would be
extrapolated out into the general population,
enabling the computer modelers to arrive at
some vague figures of deaths.
Reporting on AIDS in Africa became a quest
for anecdotes to support Geneva's estimates,
which grew to 9.6 million cumulative AIDS
deaths by 1997, rising further to 17 million
after three years.
At that time. South Africa was the only country
where more than 80% deaths were routinely
registered to attempt and produce national
estimates of mortality, and judge computer
generated AIDS estimates against objective
reality.
Professoi Ian Timaeus of the London School of
Hygiene and Tropical Medicine, in the year
2000 joined a team of South African
researchers bent on eliminating all doubts
about the magnitude of AIDS impact on South
African mortality. Sponsored by the Medical
Research Council (MRC), the team's mission
was to validate (for the first time ever) the
output of AIDS computer models against
actual death registration in an African setting.
The MRC team was granted privileged access
to death reports. The first results became
available in 2001 and they followed- 339,000
adult deaths in 1998, 375,000 in 1999, and
410,000 in 2000.
This was grimly consistent with the predictions
of rising mortality, but the scale was
problematic. Epimodel estimated 250,000
AIDS deaths in 1999, whereas, there were only
375,000 adult deaths in total that year — far
too few to accommodate the UN's claims on
behalf of the HIV virus. In short. Epimodel had
failed its reality check. It was quietly shelved in
favour of a more sophisticated local model,
ASSA 600, which yielded a 'more realistic'
death toll from AIDS of 143,000 for the
calendar year 1999. At this level, AIDS deaths
were about 40 per cent of the total — still a
bit high, considering there were only 232,000
deaths left to distribute among all other causes.
Modeled AIDS deaths and real deaths were
HEALTH FOR THE MILLIONS / February - March 2004
■ 55
ret onciled, and the MRC ground-breaking
labour was published in lune 2001.
or even declining in the worst affected
countries. UNAIDS has been at great pains to
i cl mt su< h ideas, desc ribing them as 'dangerous
low.wds the end ot 2001. the vaunted ASSA
600 model was replat ed bv ASSA 2000,
produting estimates even lowei than its
piedet essor. ASSA 2000 < l.iiined onlv *>2,000
AIDS deaths in total, lor the t alendar yeai
1 *)<)*>. this was just more than a third oi the
original UN figure, while experts (l.iimed ASSA
2000 to be very accurate.
myths'.
But it wasn't. In December 2001, ASSA 2000
was retired too. A note on the MRC website
explained ’modeling is an inexact science and
that the number of people dying of AIDS has
only now started to increase'. Furthermore, said
the MRC, 'there is a new model on the way,
one that would probably produce estimates
about 10 per cent lower than those presently
on the table'.
People are dying, but this doesn't spare us from
the fact that AIDS in Africa is indeed something
of a computer game. When you read, 29.4
million Africans are living with HIV/AIDS, it
doesn't mean that millions of living people have
been tested. In real life picture, the computer
model assumes 29.4 million Africans to be
linked
via
enormously
complicated
mathematical and sexual networks.
However, modelers arc the first to admit that
this exercise is subject to uncertainties and large*
margins of error, l arger than expected, in some
cases.
Year back modelers produced estimates that
portrayed South African Universities as
crucibles of rampant HIV infection, with one in
four undergraduates likely to die within ten
years. Prevalence shifted according Io racial
composition and region, with Kwazulu-Natal
Institutions worst affected and Rand Afrikaans
University (still 70 per cent white) coming in at
9.S per cent. Real-life tests on a random sample
of 1,188 RAU students rendered a startlingly
different conclusion: on-campus prevalence
was 1.1 per cent, barely a ninth of the mcxleled
figure. 'Doubt is cast on present estimates,' said
the RAU report, 'and further research is
strongly advocated.'
A similar anomaly emerged when South
Africa's major banks ran HIV tests on 29,000
staff employees earlier this year. A modeling
exercise put HIV prevalence as high as 12 per
cent; real-life tests produced a figure closer to
3 per cent.
Such mutterings have been heard throughout
southern Africa — the epidemic is leveling off
56
HEALTH FOR THE MILLIONS / February - March 2004
Why would UNAIDS and its massive alliance of
ph.irin.K culic .ilI < ompanies, NGOs, scientists,
and charities insist that the epidemic is
worsening it it isn't? A possible explanation
i omvs from New York physician Joe
Sonnabend, one of the pioneers in AIDS
research. Sonnabend was working in a New
York clap clinic when the syndrome first
appeared. He went to form the American
Foundation for AIDS Research, when many of
his colleagues started exaggerating the threat of
a generalized pandemic with the view to
increase AIDS visibility, and add urgency to their
grant application. Sonnabend said, 'the AIDS
establishment is extremely skilled at the
manipulation of fear for advancement in terms
of money and power’.
With such thoughts in the back of my mind, I
feel that AIDS is a real problem in Africa.
Governments and sober medical professionals
should be heeded when they express deep
concerns about it. But, there are breeds of
AIDS activist and AIDS journalists who make
the whole situation sound hysterical. To hear
them talk, AIDS is the only problem in Africa,
and that the only solution is to continue the
protest until free access of AIDS drugs is
defined as 'basic human right'.
Ask them, what about those people who are
dying of diseases that could be cured for a few
cents if medicines were only available. About
ISO million Africans — nearly half the
population — get malaria every year, but
malaria medication is not a basic human right.
Two million get TB, whereas in reallity spending
on AI13S research exceeded spending on TB by
a crushing fat tor of 90 to one. As for
pneumonia, cancer, dysentery or diabetes, they
aren't bothered.
I think it is lime to start (juestioning some of the
claims made by the AIDS lobby. Their
certainties are so fanatical, the powers they
claim so far-reaching. Their authority is
ultimately derived from computer-generated
estimates, which they wield like weapons,
overwhelming
any
resistance
with
dumbfounding atom bombs of hypothetical
human misery. Give them their head and they
will commandeer all resources to fight just one
disease. Who knows, they may defeat AIDS,
but what if we wake up five years hence to
discover that the problem has been blown up
out of all proportion by unsound estimates,
causing upwards of $20 billion to be wasted?
HFM NEWS
Tobacco affecting children’s health
Plan to privatise State Hospitals
Nearly 55,000 children join the club of tobacco
consumers in the country every day. while 77
lakh Indian children below 15 years of age take
tobacco on a regular basis according to WHO.
Former Director-in-chief of Bihar Health
Services and president of National Organisation
of Tobacco Eradication, Bihar chapter. Dr.
Mahavir Das said, "India was the third biggest
producer of tobacco and nearly 5,78,800 tonnes
raw tobacco were produced every year in the
country. Nearly 20 crore .men and 4.50 crore
consume tobacco In one form or another**.
Quoting World Health Organisation (WHO)
figures, Dr. Das said eight lakh Indians in the
productive .age group die due to tobacco
consumption* every year’ Three lakh youths in
the age group of 15 to 24 join the large club of
tobacco consumers every year and 33 per cent
of the total cases of cancer were caused by
tobacco consumption.
The Karnataka state government is planning
to privatise government hospitals, chief
minister S.M. Krishna announced "The
government is even considering starting
hospitals with private investments to ensure
that medical services reach the most remote
villages".
Privatisation will improve government
hospitals and help provide better treatment to
rural people," he further added. The chief
minister was confident that better services at
government hospitals would attract more
patients to these hospitals rather than turning
them away. Mr. Krishna also said.“Tele
medicine which has been introduced in some
district government hospitals, would be
extended to all district hospitals".
At least 43 lakh of coronary heart ailments are
caused by tobacco consumption. In India, 40
per cent of people consume tobacco through
"bidis" while 30 per cent through cigarettes.
Tobaccodsi also consumed through non
smoking medium like tobacco chewing and
others. WHO estimates that nearly 700 million
or almost half of the world's children breathe air
polluted by tobacco smoke particularly at home.
"We had initially introduced super speciality
treatment for some diseases like heart
ailments at a few district hospitals. These
services will now be extended to ail district
hospitals,” he added further. On the steps
taken by the government in the health sector
to improve the lives of the people, the chief
minister said that the state has collected Rs.7
crore under the Yeshasvini health insurance
scheme and released Rs.4.5 crore to farmers.
Source: Central Chronicle, Bhopal, 15 December2003
Source: Asian Age, New Delhi, 17 December 2003
Draft Bill on HIV/AIDS soon
The draft of the country’s first comprehensive legislation on HIV/AIDS is in the process of being
*
Presented t0 the Government. Prepared by a group of eminent lawyers,
health activists and offidalsrit provides for effective steps In educating people as well as taking
preventive and curatiyOteps to deal with the burgeoning problem.
Parliamentary approyaynay not be immediately forthcoming in view of the coming elections. “With
S'rt
<0
d^yed soon, the proposed legislation is likely to be held up for sometime".
d
MP and a member of the group working on the legislation.
'a
^at
S®"atOr Pa,lone’the Pyemic, unlike other epidemics, required
Pro9ramrnes for prevention and understanding the disease. -Unless
Pk^.cfearty speafying the rules towards containing the spread of the disease
9 down “* nomber’ said Mr-SibaL
lndia no‘ beln9 a part of 1110 Global Fund’ which has a $1 Sbillion
^id^^^Sa^
President, George W. Bush, towards fighting the disease, Mr. Sibal
^PWrt to
^SSSary I .'3 66 lnClUded in *he liS' because “ needed international
support to fight AIDS. There are about five million affected people, who need help-
Source: The Hindi, New Delhi, 12 January 2004
*
Health subsidies in India have a pro-rich bias: World Bank
A World Bank report on health policies in South Asia has accused India of maintaining an
abysmally low per capita health expenditure and allowing a |pro-rich bias to creep into subsidy
allocations.
The voluminous report. Health Policy Research in South Asia, edited by Abdo S Yazbeck and
David Peters, has pointed out that the poorest 20 per cent capture 33 per cent. The °n y
exception in the pro-rich pattern of health expenditure is Kerala "Kerala has a more equitable
health system than North India,’ Yazbeck remarked while releasing the report. He pointed ou
that the country’s per capita spending on health was one of the lowest in the world - comparab e
only with that of Rowanda, the African country being ravaged by a civil war.
Among the other startling findings of the report is the failure of the consumer redress
mechanisms to the disadvantage of the poor in India. The governments throughout the region
lack the regulatory capacity needed for monitoring. The report flays the country s management
of consumer complaints In the majority of hospitals. “In 90 per cent of the cases, the time ta en
to resolve the conflict went well beyond the stipulated period of 90 days, it said.
Yazbeck said that calling for privatising the health sector In the country was meaningless
since 82 per cent of all health spending was private. Majority of the state governments have
displayed a pro-rich orientation In formulating their health policy.
The report suggested a strong consumer movement to reverse the trend and make the health
programme directed towards the masses. Among the South Asian countries, Sri Lank alone
has done remarkably well In providing an effective healthcare system, the report said.
Source: Times of India, New Delhi, 9 January 2004
T rH^iti^Scheme for unorganised sector approved »
The Union Cabinet today approved the Social
Security Scheme for workers of the unorganised
sector that will benefit 370 million workers.
In Parliament after two years,’ he said, adding,
the Bill had already taken a lot of time to reach
the Cabinet stage and it was in the interest of
the workers to avoid any further delay.
The scheme, which provides for family pension,
Keeping in its purview the workers not covered
personal insurance to cover death or total
under the provisions of the Employees
disability for the workers and universal health
Provident Fund, the scheme provides a flat rate
insurance scheme for a worker^and his family,**,
registered pension of Rs.500 per month on
.
,
..
4
~
...
i6 ?
disablement, to the widow on the death or me
Territories before It is
dill after ~
-_before
Is approved as a B«l.a^er^^
a||
|n
unorganised sector
two years. The implementation pf the scheme.'’
drawing wages not more than Rs.6,500/- per
will not entail an additional cess on petroleum 'J
month and will be financed by the contributions
as would have been necessitated had the
_
from workers
at the
scheme been passed In the form of a Blll> wuiwianm
uiv rates of ’Rs.50/- per month
and
Talking to reporters after the approval of the-v in
>" the
*he age
a0e group
9rouP oi
0* 18-35
18'35 years
year?.^
d RsJOGZRs W<V
per montti in the egq group of 36-50 years.
scheme, the Union Labour Minister, Sahib Singh
Verma, said the unorganised sector workers The contribution from tire employers will be
had been given social security under the
Rs.100 per month In the first age-group and
scheme as the passage of the Bill would have
Rs.200 per month in the second and the
taken a lot of time since it had to be routed
Government contribution will be at the rate of
through the Standing Committee.
1.16 per cent of the monthly wages of the
worker or the national floor wage, which is
“Any practical problems faced during the
presently Rs.1,800/- per month per worker.
implementation of tne scheme will be
Source: The Hindu, New Delhi. 8 January 2004
incorporated in the draft Bill which will be tabled
«
Civic body focus on mosquito control
Chennai recorded more than 29,000 malaria
cases last year, an increase of nearly 7 per
cent compared to 2002. This has brought to
focus the need to address the problem at its
root - attack the source of breeding of
mosquitoes. In November last, 4,275 malaria
cases were reported in the city, the highest
in a single month, even as the Chennai
Corporation continued to carry out regular
fogging and spraying of insecticides.
has the same breeding source as anopheles
stephensi’. the malaria vector. Entomologists said
it was time the civic body adopted permanent
measures for malaria control. Fogging and
spraying of insecticides were interim measures
that have, over the years, become the
Corporations mainstay in anti-mosquito
operations. Known to be neuro-toxins, prolonged
use of these chemicals could have an aoverse
impact on people’s health, they said.
S. Vincent, senior lecturer in Zoology and Faculty
The civic body has now trained its guns
Advisor, Enviro Club, Loyola College, said the civic
towards controlling the breeding of malariabody should concentrate on stormwater drains to
.causlng mosquitoes. Beginning from
prevent mosquito breeding while the summer
y November,
it has penalised 410
operations should also continue. Use of bio‘ houseowners for leaving their overhead
flanks, wells.and.dstems<uncovered, under^.pesticides along with the chemicals should be
'the provisions of’the Tamil Nadu Public n introduced. Biocides from neem extracts have
been successfully tested In many places and their
Health Act, 1939. The penalty for violation is
RS.50.
t
• '-■* ■ • ‘
effect, although slower than the chemicals, was
’consistent. He mooted a consortium of various
^Incidentaily, dengue’cases too rose to 560
bodies, including the Corporation, the Malaria
£|ast year/compared to 127 In 2002. ‘Aedes
Research Centre and the Loyola College, to
evolve a network for a collaborative approach to
aegypti*, the mosquito that causes dengue,
a permanent solution.
Deaths due to TB ’sir1
!^ per,WHO Glo^^nu^^^ryeillance .
^Report, it is estim^Jed thag^i^t^.717. lack,,
jpatients die of TB. every y^jnJthe'cGuntry
iLe. about.Vminute^The Revised National TB
Control Programme (RNTCP) widely known
as DOTS, which is a WHO recommended
strategy, is being Implemen^ed in a phased
manner, with the objective^ptpchieying cure ,
rate of 85% of new. sputum'positive cases.
Under the DOTS Programme, d^ugs are
provided under supervision and patients are
monitored so that they complete their
treatment. Drugs are provided free of cost in
patient-wise boxes.
The project districts have reported a cure
rate of more than 80%, which means more
than 8 hour of every 10 patients diagnosed
and put on treatment under,the revised
strategy are successfully, treated. This is
double that of the earlier programme. TB
p death rates have reduced from. 29% to 4%.
LPQTS coverage is being rapidly expanded in
ithe country. From-20 million coverage in
998. about 760 million population has been
Covered at present It is envisaged to cover
*850 million population by 2004 under the
revised strategy and the entire population of
the country by 2005.
Source: Rajya Sabha, Unstarred Question
Na 1289, 15 December, 2003
Source: The Hindi, Chennai, 11 January 2004
Obituary
Dr. Shristi Shukla
What is death?
It’s nothing, but my slipping
away in room next door....
I have gone there to find
solutions to my endless
problems...
As how, I myself don’t
know!
Death is nothing, but
'I960 - 2003
transformation of life into
something what I call concrete....
Call me with my old name, say things like you use to
I am around you, just little far....thou
Please don’t shed tears...as I feel I am drifting apart
I am in you, around you....so call me by my name.....
I promise to surround you with my whisper and tales
Don’t be sad, as you have to carry my work....
Don’t stop you got a long way to run.....
Say my name and restructure this world..
I am around you....
Stand tall and live with my namo....SHRISTI -it’s the
starting point of life
Health issues in the
: 'j'J'.V; ‘ ..rJ-J.i W-..'s
Parliament
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Free treatment of HIV positive
children
Monitoring of ultra sound
diagnostic clinics
The Government has proposed to provide
treatment of eligible HIV positive children below
15 years of age with effect from 1“ April 2004
in government hospitals of six high prevalence
states, namely Andhra Pradesh, Karnataka,
Maharashtra, Manipur, Nagaland and Karnataka
in a phased manner.
As ultrasound machines can be misused for
detecting the sex of unborn child, leading to
female foeticide, their use has been explicitly
brought within the purview of the Pre-conception
and Pre-Natal Diagnostic Techniques
(Prohibition of Sex Selection) Act, 1994 after its
amendment with effect from 14.2.2003.
Deliberations have been Initiated with
Pharmaceutical Industiy, producing anti
retroviral drugs to find out the modalities for
reducing the prices of anti-retroviral drugs for
treatment of HIV/AIDS patients. Government has
also initiated dialogue with the Confederation of
Indian Industries and Federation of Indian
Chamber of Commerce and Industry for
mobilisation of resources to strengthen training
and diagnostic facilities in government hospitals.
States/UTs have been directed to sell the
ultrasound machines to the persons whose centre/
clinic is registered under the Act and send regular
reports to the concerned Appropriate Authorities
of State/UT. Department of Family Welfare has also
issued advertisement In about 1100 newspapers
all over the country about the amendments made
In the PNDT Act regulating sale of ultra sound
machines/imaging machines to clinics registered
under the Act Further, the National Inspection and
Monitoring Committee constituted at national level
to take stock of the ground realities in the field is
also visiting centres/dinlcs to check the records of
ultrasound done on pregnant woman required to
be maintained under the Act
Source: Ra/ya Sabha, Unstarred Question No.516,
d December 2003
Anti diabetic drug Phenformin
The drug ‘Phenformin’ was withdrawn in USA in
1977 because of occurrence of lactic acidosis with
the use of the drug. The matter was then
examined in consultation with experts in India and
the experts opined that lactic acidosis reported in
the West is not common in Indian Population and
the drug was effective as an oral anti-diabetic
drug. The drug remained available in Spain, Italy,
Mexico and some other parts of Europe and
continued to be marketed in India also.
As per the reports received from States/UTs
21,667 clinics have been registered under the
Act, 191 ultrasound machines are reported to
have been sealed and seized on violation of the
law. 418 complaints ‘have been filed in the
Courts/Pollce against violators of the law.
Source: Rajya Sabha, Unstarred Question No.526,
0 December 2003
Janani Suraksha Yojana
The drug Phenformin has however, been now
prohibited for manufacture and sale in the country
‘ with effect from I* October, 2003 vide Gazette
Notification GSR 780 (E) dated 01.10.2003 on the
recommendations of Drug Technical Advisory
Board (DTAB) which on reconsideration of the
matter opined that as large number of oral drugs
for treatment of diabetes are now available in the
country, the continued marketing of Phenformin
may be stopped.
The government proposes to introduce a new
Scheme in the name of “Janani Suraksha
Yojana" in near future. Besides the reduction of
maternal and infant mortality," the scheme
intends to protect female foeticide. Towards this,
It aims at providing incentive to increase
institutional delivery. The scheme will focus
necessarily In those States/UTs where rate of
Institutional delivery is low. Modalities of the
Scheme are under finalisation.
Source: Lok Sabha, Starred Question No. 33, 3
December 2003
Source: Rajya Sabha. Unstan ed Question No. 519,
8 Cecember 2003-12-23
60 ■ HZALTH FOR THE MiUJONS / February - March 2004
e
Mashelkar Committee Report
The Expert Committee headed by Dr. R. A.
Mashelkar has submitted its report to
Government in two parts. An Interim report was
submitted in August 2003, dealing with penalties
for various offences under the Drugs and
Cosmetics Act, 1940. A summary of the
recommendations contained in the interim report
is annexed.
death should also be made more
severe.
b.
The offences related to spurious drugs
should be made cognizable and non*
bailable. The bail, if considered by the court
should be granted only after a period of
three months.
c.
The penalty for not disclosing the source of
purchase of drugs by a dealer should be
made stringent.
d.
A provision should be included in the Drugs
and Cosmetics Act to enable the Central
and State Governments to designate
special courts for speedy trial of spurious
drug cases.
As regards penalties for offences provided in the
Drugs and Cosmetics Act 1954, the Committee
has recommended that:
e.
A provision for compounding of offences
should be included in the Drugs and
Cosmetics Act.
a.
f.
Under Drugs and Cosmetics Act, besides
the Drug Inspectors, Police should also be
authorized to file prosecution for offences
related to spurious drugs.
Government has initiated steps to bring forth a
legislation for amending the Drugs and
Cosmetics Act on the lines suggested by the
committee.
The Committee has submitted the final report to
the Government in November 2003. The report
is under examination.
Annexure
The penalty for sale and manufacture of
spurious drug that causes grievous hurt
or death should be enhanced from life
imprisonment to death.' Even the penalty
for manufacture and sale of spurious
drugs that do not cause grievous hurt or
Source: Lok Sabha. Starred Question No.2d, 3
December 2003
Ban on dangerous pesticides
Pesticides banned in various countries of the world are being used in India. They are Alachlor,
Aluminium Phosphid, Benomyl, Captan, Carbaryl, Carbofuran, Carbo’sulfan, Dicofol,
Dimethoate, Diuron, Endosulfan, Fenarimol, Fenpropathrin, Lindane, Linuron, Malathion,
Methomyl, Methoxy Ethyl Mercury Chloride, Methyl Parathion. Monocrotophos, Oxyfluorfen,
Paraquat Dichloride, Phorate, Phosphamidon, Pretilachlor, Triazophos, Tridemorph,
Thiomethon. Thiram, Zinc Phosphide and Ziram. These pesticides are used in crops for which,
they have been recommended by the Registration Committee constituted under Section 5 of
the Insecticides Act 1968.
The banning/restricting of pesticides depend on the agro-climatic conditions and agronomic
practices of different countries. Most of these pesticides have been reviewed by the
Government of India by constituting Expert Committee which have recommended the
continued use of these pesticides. Further, based on the recommendations of such Expert
Committees, the Government of India has banned 27 pesticides.
In addition the Government has adopted Integrated Pest Management (IPM) encompassing
cultural, mechanical and biological methods and need-based use of pesticides, as the cardinal
principle and main plan of plant protection in the country. The Government of India has
sanctioned grants-in-aid to States for establishment of 29 State Bio-control Laboratories in
various states.
Source: Lok Sabha, Starred Question No. 19, 2 December 2003
HEALTH FOR TH£ MiUJONS / February - March 2004 ■ 41
Manipur VHA
Observance of World AIDS Day 2003
Manipur Voluntary Health Association observed
the World AIDS Day 2003 at Thoubal Mela
Ground. More than 300 youth and women had
participated in the programme. In the context of
the observance, Sumang Leela, street
theatre group played messages on the
prevention and control of HIV/AIDS.
A three- day follow-up training programme
was organised by MVHA in collaboration
with Child Welfare Ashram, Jiribam from
October 9 to 11, 2003 at premises of Child
Welfare Ashram, Jiribam. Altogether 25
participants participated in the programme
from 13 different villages of the sub
division. The main activities of the
programme were-
❖
To identify the problems faced by the
health workers.
❖
To utilise the services of the health worker in
their respective areas.
❖
To capacitate the health workers to overcome
the prevailing problems.
Goa VHA
The Voluntary Health association of Goa
carried out a prescription survey to understand
the irrational drug prescription practices.
Towards this purpose 990 prescriptions are
already collected, and coding of these
prescriptions is in progress. To follow up on the
same VHAG organised a seminar on Rational
Drug Usage in January 2004.
VHAG intervened in a dubious Hepatitis-B camp,
and brought to the notice of FDA-how shady
organisations were making money at the expense
of innocent people by holding unauthorised
immunisation camps.
Another significant activity carried out by VHAG
was a survey at Pokharmal, a village in South Goa
where the health and sanitation needs of an entire
village were profiled. Places where there were no
doctors or paramedics even as the Government
made claims of 100% accessibility of health
facilities for all, were also highlighted. Details and
data of survey on Pokharmal were published in all
leading newspapers of Goa.
Health Colleah/Q
Bkw
-
a
Sikkim VHA
8-day VHAS health camp
The Voluntary Health Association of Sikkim
(VHAS), in coordination with the Department of
Health and Family Welfare, Government of Sikkim,
conducted a 8-day long camp on Indian System of
Medicines and Homeopathy from 4-12 November
2003 at Singtam in East and Mangan in North
Sikkim.
More than 10, 000 people visited and benefited
from the camps in different ways. Among these,
people 3409 availed the facilities of free treatment
in Ayurvedic and Homeopathy camps.
The Department of ISM&H, Ministry of Health &
Family Welfare Government of India, sponsored the
programme. The main objectives of the camps were
to provide free check-up with treatment, to generate
awareness amongst the people regarding alternative
systems of medicines for which, they w3l have choice
for health care to teach on locally available medicinal
herbs and plants for minor ailment treatment, and last
but not the least the camps aimed to raise levels of
general health awareness on preventive health care.
Kerala VHA
The J2'•, Annual General Body Meeting (AGBM)
the Kerala VHA was held on 23-August 2003
at Chaithanya Pastoral Centre, Thellakorn,
Kottayam. The annual celebration was
•n.iuguraled by Hon'ble Supreme Court Judge Sri
K T. Thomas and presided over bv Fr. Jose
Nelhckatheruvil, President. Sri Thomas
ShaiZh,.krack!?.' MLA torma,,y launched the
Medical Establishment Protection Scheme (MEPS)
of Kerala VHS. A panel discussion on the
pertinent issues faced by hospitals in Kerala was
conducted. Mr. P. V. Thomas, Board member was
the moderator of the programme. Dr. George F
Moolayil, Convenor Medical Establishment
Protection Scheme presented the topic advantages of MEPS over other such schemes.
Meghalaya VHA
Workshop on reproductive child health
A two-day workshop on reproductive and chid
health was organised at Ri Khasi Free Morning
pper Primary School, Nongstoin, West Khasi
Hills on 16"’ and 17,h September 2003. The
programme was organised in collaboration with
Western Cultural and Social Welfare Association
and supported by Voluntary Health Association
of lndla. 64 participants from Nongstoin and
adjoining areas attended this workshop.
Iby teachers and parents of addicted children, and
Workshop was organized
by VHAM in collaboration
the Mar
........ ...... ‘with “
*'
Chaphrang Development Society, Jowai and was
supported by the Voluntary Health Association o<
India. The purpose of the workshop was to bring
about an understanding on the various aspects
suirounding addiction and its relation to HIV/AIDS
Involvement of both the community and the
families concerned, together with the schools
helped in identifying areas of concerns, and action
plan to be adopted in fighting this problem in the
society.
Kashmir VHA
VHAI organises two-day training
programme
Voluntary Health Association of India (VHAI)
organised a two-day training programme of school
teachers of Congoo and Wakherwan cluster of
villages of Pulwama district for creating health
Tr—7 The field staff of both me
awareness.
the inaoao
Shadab and
and
sher|jar Khoj Projects also attended the training
Programme. The training programme has been
^ganised in collaboration with Directorate of
“u1cati?n aimed at sensitizing the school teachers
,nJ1T ,dent,fication of different ailments of school
ch,ldren-
The purpose of the workshop was to provide
adequate knowledge about various aspects of
rep oduchve drfd health and its significance in the
overall health of an individual and the community
at large. The workshop covered important topics
^y p^^^
The programme was inaugurated at Higher
Secondary School, Pulwama. The role of VHAI in
creating health awareness amongst the school
eachers and rural masses in general was lauded,
M* Mir,
M,r' State
Slate Co-ordinator of VHAI gave
Mr. A
A. M.
br,ef accoun< of community health initiatives taken
"
Budgam S’Z^stT
chdd birth, breast feeding, abortions and its
complications, RTI and STDs.
years- An exhibi';on of VHAI publications was also
organised at Pulwama.
Workshop on
substance abuse
and drug abuse
A two-day workshop
on Substance Abuse
and HIV/AIDS was
held at Jowai on the
26,h and 27,h of
September 2003.
The Workshop was
conducted at the
Drop-in-Centre,
Mission Compound
and was attended by
representatives from
various NGOs in
Jaintia Hills and also
OWMBamGMUCUMMfOfOOC
> rawiMsr hmiih ahocm
• •
Publications by VHAI on adolescents
1. Adolescent girl: Mysteries of adolescent (English & Hindi)
1. Adolescent girl: Mysteries
This booklet by Dr Amla Rama Rao, is meant to be a companion book for the
minds of growing adolescents, their parens and teachers about the changes
transform them physically and mentally at this age into adulthood.
2. Mysteries of adolescence
/
details.
3. Adolescence - to walk you through
This book, by Dr. Peggy Mohan, tries to answer all the questions that comes
to young adolescent mind in crucial years of growth. The informa ion in
book helps them come to terms with the physical changes as well as the
emotional upheavals during the transition phase of their lives.
/
/
*7^
4. Towards Healthy Adolescence
This adolescent kit is an attempt to bring together educational, social and health
concerns of adolescents on one platform. The resource kit can be used by
educational institutions (schools and colleges), health workers, youth, development
workers, and even those involved in building human resources and addressing /
gender concerns. It can be used as a tool for training, awareness and advocacy
>
about the "special* needs of adolescents.
5. Armaan (Video Film)
Armaan is the film on growing girls covering the psychological changes associated with /
age of adolescence. A fragile time
full of self-discovery and doubts. For tar too
only the end of innocence, it is also the end /
many girls in India, adolescence is not c...z------------of spontaneity and joy but does it have to be so? This is the question the film asks
■
v
.10
us.
6. Aparajita (Video Film)
The film •Aparajita' explores the issue of gender discrimination through life of
an adolescent girl. The movie is a sensitive portrayal of her trail and tribulations,
quest for education, and her effort to overcome the odds of society.
7. Kasba — Udaan (Video Film)
•
%
Like most children, Vidya and Anand are caught unaware by the changes that adolescence brings in its
wake.„ Some cope, while others like Vidya are swept away by the winds of change. It ts a sensitive age
and a very critical phase of life, but is our society geared to treat adolescence sensitively?
a
8. Udaan (Audio)
•
Why does childhood come to a halt so abruptly during adolescence? Why is our society
so harsh towards adolescents? A plain simple answer to these is the lack of awareness
and information, for most of the taboos are nurtured by ignorance. 'Udaan' the audio
in question seeks to rectify this lapse and provides information to young adolescents
on the changes (physical, psychological, emotional and social) they should be ready
to face with the onset of adolescence.
64 ■ HEALTH FOR THE MILLIONS / Febnury - March 2004
i
ir-ir---------
If
Price: R$. 40/-
ISSN:0970-8685
4
. .
■ "■< ■- - -
:
1
• ■■is*
'r'■
Our society plagued with virus of gender
discrimination, affects life of million girts
and women each day. Unheard and
invisible they die silently within the dark
four walls of their home. The future of a
society, which has lesser and lesser
number of mothers, wives, sisters and
daughters, is doomed. We need no less
than a war like effort to alter this highly
disturbing situation. The film ‘Aparajita’
is one such effort to bring some light into
their lives.
A film about an adolescent girl s
struggle to overcome the odds
<>
f
t
z
1
X
Highly appreciated by all ministries It Is
translated in 19 different regional
languages with aid from Indian
government.
t
1
1
Director.
Raman Kumar
Story and Creative Directions:
Alok Mukhopadhyay
<^> Voluntary Health Association of India
Producer
Voluntary Health Association
of India
Star Cast:
Kanwaljit Singh, Seema
Biwas, Renuka Sahane, Divya
Dutt a, Avtar Gill and others
Copies available at:
Distribution Section, VHAI
l
j
1
i
Screen Play:
Vinita Nanda
I
•
Aparajita
Movie explores the issue of gender
discrimination through life of an
adolescent girl. The film 'Aparajita* Is a
sensitive portrayal of her trail and
tribulations, quest for education, and her
efforts to overcome the odds and
assume her true Identity. A young girl,
who dreams to make it big in life but
faced with discriminatory societal
barriers, fights the hardest of all
problems with her grit and determination.
■'
>>•
Voluntary Health Association of India
40, Qutab Institutional Area, New Delhi 110016
I’
| ’
I
1
I
A Sameeksha Trust Publication
October 1 1-17, 2003
Rs 45.00
Vol XXXVIII No 41
a
•I■3
3
Financial globalisation
and developing countries
Some empirical evidence
•-'M
''iS
‘Sa
India’s growth chase: high aspiration, low inspiration
1
Ia
India, CDM and Kyoto Protocol
D
Redefining manufacture: intrusion of excise into VAT
VrS
I
Structural breaks in Indian macroeconomic data
I
Prototype carbon fund and clean development
Girl Child Disadvantage
i
Girl child survival: tunnelling out of chakravyuha
What do sex ratios and child mortality risk, data reveal?
Sexual and reproductive health needs of married girls
Married adolescent girls: a neglected majority
Sex ratios and ‘prosperity effect’: what NSSO data show
httpV/www.epw.org.ln
a*
$5
IS
Sexual and Reproductive Health Needs
of Married Adolescent Girls
parents teachers and community leaders, but more importantly, there is also a need to o
the government accountable for enforcing the legal age of marriage for gtrls. F u ther
nro?rammes to enhance married girls' autonomy within their marital homes and those
P encourage education and generate livelihood opportunities need to be simultaneously
developed.
K G Santhya, Shireen J Jejeebhoy •
1
Introduction
adult women and ways in which.they differ. Where data are avail
able, we will draw comparisons ot married adolescent girls
with married adult women, and. if possible, unmarried
adolescents. The paper first assesses the evidence on the sexual
and reproductive health situation of married adolescents, and then
explores factors that may pose obstacles to good health, namely,
their relative autonomy and ability to exert choices in their sexual
and reproductive lives, and care-seeking behaviours experienced
' "V" 'T’hile there is growing programmatic and research interest
\ \/ in addressing the sexual and reproductive health situV V ation and needs of adolescents in India, the thrust is
implicitly on the unmarried, rather (han on (he married as well.
Yet the evidence is that sexual activity among adolescent females
in India takes place overwhelmingly within thecontextot marriage. by (hem.
Evidence presented in this paper comes largely Irom the re
For example, as many as 34 per cent of adolescent girls aged
cently conducted National Family Health Survey (1998-99) and
15-19 are already married and presumably sexually active, while
from a variety of case studies that have addressed the situation
fewer than 10 per cent of unmarried girls are reported to be
of married adolescent and young women in small geographical
sexually experienced [UPS and ORC Macro 2000: Jejeebhoy
areas. We start with a few words ot caution and a recognition
2000]. Not only are larger proportions of adolescents sexually
active within a marital context, but also, as is well known, married of the limitations of this paper. For one, while married adolescents
adolescents are far more likely to experience regular sexual in India are not homogeneous and their situation and needs vary
widely by setting educational status and other factors, what is
relations than are unmarried sexually active adolescents. The
relative lack of focus on this large segment of married adolescent presented here focuses largely on the overall picture and may
‘□iris has been justified on the grounds (hat their needs are obscure these disparities. Second, the situation of married ado
lescent males is excluded: among them, in contrast to girls, only
legitimately met in services available to adult women. Yet it is
verv likely that the sexual and reproductive health situation, the 6 per cent of boys aged 15-19 was married, compared to somCm:. j are reported to become sexually experienced
and hence the needs . of married 20-40 per cent who
ability to exercise intformed
------- choice
in a pre-marital relationship [Kulkarni 2002: Jejeebhoy 2000].
adolescent "iris are quite different from those of married adult
women (or unmarried adolescent girls), and that the unique needs Finally, for the purposes of this paper, where comparisons are
drawn, married adolescents refer to those aged 15-19 and adults
of this large group of sexually active women remain un-served.
The period of adolescence marks an abrupt transition in the lives to those a°ed 20-34. unless specified otherwise.
of larsc numbers of Indian girls - many experience marriage,
II
a break with natal family and familiar social networks, and co
Magnitude
residence with the husband's family, with which few are familiar,
■ind in which a subordinate position must be adopted, new
Despite laws (Child Marriage Restraint Act of 1978) advocat
pressures to initiate childbearing as swiftly as possible, and in
ing IS as the legal minimum age at marriage lor females in India,
many cases new health problems, many of which relate to sexual
large proportions of females continue to marry well before that
and reproductive matters. Despite the enormity of this transition,
asje. as evident from Table 1 [UPS and ORC Macro 2000].
little is known about the lives of married adolescents and data
Although marriage age is clearly rising among younger cohorts,
that enable comparisons of the situation and needs of married
as recently as 1998-99. one in three adolescents agedJ5-l9 was
adolescents with those of unmarried adolescents or married adult
already married, and one in seven was married by age 15. Regional
women are sparse.
This paper synthesises the available evidence on the situation disparities are particularly pronounced, with northern states
reporting considerably larger proportions married in adolescence
of married adolescent girls and sheds light on whether sexual
than southern states. The examples of Uttar Pradesh and Tami
and reproductive health situation and choices differ from those of
I
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l!11
4370
Economic and Political Weekly
October 11, 2003
1
9
deaths are considerably higher among adolescents than older
women. Estimates derived from a community-based study m rura
Andhra Pradesh reported that in the 19S0s the maternal mortality
ratio experienced by adolescents was almost twice that o
ased 25-39 (1484 versus 706-736 respectively - Bhatia 1998).
Hospital based studies reiterate these differences. A national
studv conducted by the Indian Council ot Med.cal Research
sexually active within marriage.
HC.MR) of 43.550 women in 10 facilities reports that maternal
mortality amons adolescents was 6-^5/1.00.000 live births, com
pared to 342/1.00.000 in adult women aged 20-a4 years IKrishna
Sexual and Reproductive Health Situation
19951. Similarly, a study in Mumbai indicates that while the
maternal mortality ratio among women aged 20-29 was 1 aS per
As mentioned earlier, the evidence on the sexual and repro
1 00 000 live births, adolescents experienced consideraoly higher
ductive health of married adolescents is sparse. What is available
ratios - 206 per 1.00.000 live births [Pachaun and Jamshedji
focuses largely on pregnancy and reproduction and less on other
1983].
aspects of health and choice: sexual risk behaviours, reproductive
While mortality is the tip of the iceberg, other adverse outcomes
tract and sexually transmittqd infections or non-consensual sexual
are also experienced. For example, the neonatal mortality rate
relations, for example. Summarised below is a review or what
was 63.1 per 1.000 live births among infants ot adolescent
is known about the situation of married adolescents.
mothers compared to 40.7 among women aged _0-_) 1 UPS and
Nadu presented in Table I are indicative of this wide divide in
marriage age: while in Tamil Nadu, a quarter ot women aged
o0-24 had married before the legal age of
c. IS.
. over three-fifths
of those in Uttar Pradesh (62 per cent) were married by age 18.
Findings suggest thus that of (he roughly o0 million adolescent
females in India [United Nations 2001], some 17.o million are
in
i
Pregnancy and Childbearing
Sexual and reproductive health of adolescents- in India is
conditioned to a large extent by the strong pressures new y
married vouni women face to prove fertility as soon as possible
:
after marriage. Indeed, for many, the only way to secure
1
their positions in the marital home is througn fertility and
particular^ the birth of a son. It is not surprising then that more
evidence is avail-able on the topic ot pregnancy and motheihooc
in adolescence than any other aspect of their sexual and repro
ORC Macro 2000]. Damage to the reproductive tract, pregnancy
complications, peri-natal and neonatal mortality, and low birth
weight have also been observed (see for example. Kulkarm 200 :
Hirve and Ganatra 1994). Several facility based studies, for
example, report higher levels of pregnancy relatea complications
- including eclampsia, pregnancy induced hypertension, intrauterine growth retardation and premature delivery - amon_,
Table V Proportions of Females Married in Adolescence,
by Age, 19S8-99, NFHS
---------------------------------
'
15-19
20-24
25-29
ductive health.
'
.
The evidence suggests that pregnancy and childbeann
India
94.5
78.8
33 5
occur before many adolescents are physically fully devel- Prooomon ever married
12.1
8.9
Percentage married by age 13
29.2
ooed and may expose them to particularly acute health risks
23.5
Percentage married by age 15
58.9
50.0
durino presnancy and childbirth. Adolescent fertility rates are Percentage married by age 18
74.9
67.1
hich/roughly 107 births take place per 1.000 girls aged 1>19 Percentage married in adolescence (by age 20)
•ind the fertilitv of this ase group makes up 19 per cent of tne Uttar Pradesh
97.7
87.0
39.9
nation's Total Fertility Rate [UPS and ORC Macro 2000]. Table 2 Proportion ever married
20.3
16.8
3.0
Percentage married by age 13
42.6
36.0
19.3
confirms that significant proportions of adolescents - over one Percentage married by age 15
73.7
62.4
in five - "ive birth by aae-17. the age below which obstetric^ Percentage married by age 18
86.7
76.5
Percentage
married
in
adolescence
(by
age
20)
risks aooear to be particularly elevated. Not only does childbearino occur early among married adolescents, out subsequent Tamil Nadu
91.3
67.7
23.7
Proportion ever married
1.5
presnancies also tend to be closely spaced. The National Family
0.5
0.2
Percentage married by age 13
8.1
3.7
2.8
Health Survey reports that the median closed birth interval among Percentage married by age 15
32.1
24.9
adolescents was 24 months, compared to 29 months among those Percentage married by age 18
56.0
49.4
Percentage
married
in
adolescence
(by
age
20)
aoedno-^ [UPS and ORC Macro 2000). The experience ol early
and closelv spaced childbearing is particularly nsky tor adoles Source: UPS. India and ORC Macro 2000; 2001.2001a.
cents because large proportions are anaemic and may not have
Table 2: Percentage of Currently Married Adolescents
reached physical maturity - nearly 15 per cent ot ever-married
Giving Birth by Exact Age
adolescent women were stunted, and about one-tilth had
15-19 Year Olds
moderate to severe anaemia. The extra nutritional demands o
No 3ir1h
17
15
pre-’nancy come at the heels of the adolescent growth spurt, a
52.2
neiTod that itself requires additional nutritional inputs. Any short! al
20.9
16.2
Overall
could result in further depletion of the already malnourished
Residence
^'isestimwed at the global level that girls aged 15-19 are twice
as likelv to die from childbirth as are women m their twenties,
while girls younger than age 15 face a risk that is^five times higher
[Unitc'd Nations Children’s Fund 20011. Moreover, more
adolescent "iris die from pregnancy-related causes than from any
XcX [Population Reference Bureau 2000], Evidence trom
Urban
Rural
Education
Illiterate
Primary
Secondary*
Region
North
South
11.2
17.0
22.2
20.7
52.9
52.1
20.2
18.6
7.1
22.7
21.3
17.2
47.2
51.2
62.3
16.2
16.2
20.0
22.5
54.2
48.8
community and facility based studies reiterate that maternal
Economic and Political Weekly
1
h
October 11, 2003-
4371 ...
'4
and Jamshedji
adolescents than among older women [Pachauri
1986.
Sharma and
i
al
1993;
Mishra,and
Dawn
1^
1983; Swain et
: national study cited earlier
r--------Sharma 1992; Pal et al 1997]. The
also reports that risk of sepsis in
i.. abortion was higher among
women [Krishna 1995].
adolescents than
t— older
-
women. In in-dep.h investigations in Mumbai.
e^P'^
women recalled that they were totally unprepared tor .nc=nora"1
about sexual intercourse, and described the hrst sexual exp
ence as traumatic, distasteful and painful. 1
US“ ‘
frequently mentioned [George and Jaswal I99o; Geo e^.00.]_
In rural Gujarat too. in-depth interviews mdmate^th for 62 of
69 women, the first sexual experience was trau
[
al 1998]. Similarly, a study of abonion related decisi Reproductive Tract and Sexually Transmitted
amon0 married women in rural Uttar Pradesn r^p 1 ]
Infections
vast majority here too recalled early sexual encounters with their
husbands Again usually in adolescence - to be. cn-cter.se
Few siud.es have specifically addressed
bv male sexual coercion and female submissmn [khan et al 199^
A recent studv in rural Maharashtra reported that 86 per c-n
of married adolescents reported that the f>rst sexua experience
was frightening and 8 per cent that it was pamtul [Apte
IA qualitative study of recently pregnant women - either pre nan
T Tv suffered from one or more RTI. noi counung cases
for the first time or new mothers in the post partum peri .
X:
2 Ar mfecuons and prolapse. Cbmcal and
maioritv of whom were
were adolescents - m Baroda ano
.
Satory examination diagnosed IS per cent with an STI.
1
•
- •
and where they first learned about
Wives of . reports that regardless of when
TT'fcWwrand'army personnel seemed more likely than sex, the event or first intercourse was frishicning tor young
I had never experienced such a
A
nmen to experience sexually transmitted morbidity, women: "I felt very scared as I ..... with a man made me feel
thing before. The thought oj being
su-esunn that husbands' unsafe sexual behaviours .may have
Afmitti mfections to their young wives; so also duration ot scared” [Haberland et al ~001].
. mrirv nnoeared to enhance women s risk of in
IV
a studv of HIV among mamed women attending S
n Pune shows that 13 per cent of all women were HIV-.
I ■ .Ame analvsis suaaests that, after controlling for socio
economic and husband' s’characrenstics. adolescent wonaen^nd
-hose a°ed '’0-',9> were considerably (but not significantly) mor
iikelvtobeHIV-thanwereoldermarriedwomen[Gangaknedkar.
Factors Underlying Poor Sexual
and Reproductive Health Situation
Lack of Awareness
Several studies have reported that adolescents in g-neial and
irrespective of marital status - are poorly informed about sexual
and reproductive health matters. With regard to menstruation or
Bentlev Divekar. Gadkari et al 1997], And recent estimates
example, many young women report that they were unaware until
su Jes'uhat almost I per cent of young women (10-24) m India
menstruation was first experienced, and then were informe n
A infected with HIV. compared to 0.0 per
more than its mechanics and the social practices surroun mg i
md 0 8 oer cent of the population at large [UNICEr. UNALDb
[Jejeebhoy 2000]. Similarly we have seen that few married
and WHO 2002] - the overwhelming majority of tnese women
adolescents were aware of sexual intercourse or what was exoected of them once mamed. isolated from new ideas (tor
are undoubtedly married.
example. 45 per cent of married adolescents comparea to u9 per
cent of adult women were not regularly exposed to any me la
Unmet Need for Contraception
and supportive networks, married adolescent girls are correMarried adolescents are far less likely than adults to use
soondinglv less likely to be aware of central sexual and repro
contraception (Table 3). and this may well refect their desir. ductive health issues. While awareness of contraceptives is nearly
mbToA regnant. Indeed. whHe oniy 8 per cent of advent
universal among both married adolescent and adult females,
women were practismg any form of contraception m 998-9).
awareness about specific contraceptive methods, especially
45 per cent of older women aged 20-j4 were; and differences
reversible methods that are more suitable tor adolescents, is
■ire starker (5 per cent and 40 per cent) when use ot modern
relatively limited among adolescents. For example, only t r^e
methods of contraception is considered. What is disturbing is
fifths of married adolescents were aware of condoms, compared
the findin., that adolescents are also more likely to report unmet
need for 'contraception: 27 per cent of married adolescents,
Table 3: Contraceptive Practice and Unmet Need
compared to 19 per cent of adults reported an unmet need tor
for Contraception among Adolescent and Adult Women
contraception, the majority for delaying the next birth.
--------------------------------------------------- 15-19 Yea^
20-34 Yea?7
Non-Consensual Sexual Activity
Studies rarely shed light on sexual experiences within marriage.
The few small qualitative and admittedly unrepresentative studies
do su-est that sexual coercion may not be unusual among
adolescent brides. Retrospective information from older women
on their experiences as newly married adolescents high ights the
sexual vulnerability of newly married - usually adolescent
4372
Current contraceptive use:
8.0
Per cent using any method
Per cent using a modem method
Per cent using a traditional method
3-3
Percent expressing an unmet need tor contraception
27.1
Per cent lor spacing and limiting
25.5
Per cent lor spacing only
1.5
Per cent lor limiting only
Economic and Political Weekly
45.5
40.0
5.2
19.2
10.1
9.1
October 11. 2003
i
I
In-depth interviews with first-time pregnant women and first
•;-;ree-fourths of adult women. Age specific differences
.-d to awareness of AJDS were similarly wide: fewer time recently delivered mothers in Baroda and Kolkata reiterates
'vifh
third of married adolescents compared to more than this finding. Young women reported that they rarely had any say
(Ira" -o'■whs' of adult women had ever heard of AIDS. Additionally. in marriage decisions; the more typical response was: Did I get
1 , lh0se who had heard of AIDS, two-fifths of married the chance to say anything? Could I say anything after my parents
'■^nts were unaware of modes of transmission, compared took the decision? What could I have done? (1 S-year old recently
|tiolC>C.r than one-third adult women. Extrapolating from these delivered mother in Kolkata)”. Some young women implied
;>c10 ■'^•nces between adolescents and adults, it is likely that moreover that thev were married early against their will at the
J|tlC!tl
of sexual and reoroductive health matters in general behest of their parents: "at that time I did not want to marry as
"
■----------it was too soon. So I told my mother about it but she did not
■ for example danger signals of pregnancy, or discharge
-ItN’IU..'..nn of morbidity - may be equally constrained among agree and said that I xvill have to get married early. So then as
I liked him 1 said yes (17 year old in Baroda) . 1 here was some
1
adolescents compared to adults.
in.n1''- ■
"
. .mportance of conveying health-promoting messages evidence, however, that practices may be changing: in Kolkata,
v'luti- women early in their reproductive careers clearly eight out of 30 couples reported that they had made the decision
ll). vus to protect them as they make the transition to adulthood
—...... — on when and whom to marry independently [Haoerland et al 2001.
As one voung woman in Baroda said "One expe- Sunthya et al 2001 ].
..ml beyond
After marriage, adolescents. face huge constraints on their
wus enough for me to learn a lot. ( did not need
I tCllCC
autonomy
in the marital home. Table 4 shows, tor example, that
to advise me anymore, in fact. 1 started giving other
.iityoiie
mothers advice. Every little thing that I learned in although decision-making authority is limited lor women in
I i.st ■ it tie
•_ pregnancy was useful in my second pregnancy" general, married adolescents are particularly unlikely to partici
tin :
pate in household decisions, whether those relating to major
III.: :-.nd et al 2001].
purchases, or oxvn health care. What is notable is that age plays
a more powerful role in enhancing decision-making authority
Limned Exercise of Informed Choice
■than other socio-demographic factors, including education to an uneducated married woman aged 15-19. an
The patriarchal family in India is typically age and gender compared
uneducated
older woman is significantly more likely to have
.t,■tuned IKarve 1965). Within the family, women have relatively
im'le power and voung and newly, married women - usually decision-making authority than a secondary schooled adolescent
Molcscent - are particularly powerless, secluded and voiceless for example.
Few studies address exercise of sexual and reproductive
mmters relating to theirown lives. Direct evidence on the extent
choice
in a more direct way. One of the texv studies that addresses
i,f Pich married adolescents are constrained from exercising
' -s in sexual and reproductive matters is even more limited. sexual negotiation among young married women in India
l i. f we rely on both those studies that directly address this issue highlights voung women's lack ot decision-making authoiity in
matters relating to sex: young women revealed that they were
■uid those that explore their relative lack ot autonomy more
1
generally and whose findings may be extended to the sexual and routinely told that it was (heir duty to provide sexual services
to their husbands: This man has brought you here, it not tor this,
rcproduciive arenas.
With regard to marriage related decision-making, arranged why has he brought you. You have to do it [George and Jaswal
1995]. In in-depth explorations with young women on sexual
marriaiie and extensive dowries continue to characterise marriage
decision-making
primarily in regard to pregnancy and postpartum
in much of India, both north and south. A recent case study
abstinence
in
Baroda
and Kolkata, almost half appeared to
exploring marriaae patterns among successive cohorts ot women
c- M.ral Uttar Pradesh and Tamil Nadu concludes that for the have a major say. while over one-third reported that their
1
■-B’
•72
i;
•4
I
!
8
1
•.’.helming majority in both settings, irrespective of age,
iim or religion, marriages were arranged either by parents
..imie or with relatives and^matchmakers. Yet subtle differences
did emerge, and substantial minorities of women reported having
a say. or being consulted in these decisions. While the tamiliar
regional disparities persist, with Tamilian women exerting far
nuirc autonomy in these decisions than north Indian women, age
specific differences are also evident within each setting. Most
obvious is the finding that younger cohorts in south India exerted
c ’iisiderably more ot a voice than older cohoits in marriage
- .ited decision-making than did older women. For example.
■ >ong south Indian Hindus, proportions reporting a say in man iage
decisions increased from 33 per cent among the oldest cohort
(aged 32-39) to over half (53 per cent) among the youngest,
Muslims report somewhat less spectaculai increases correspond
ingly. from 25 per cent to 37 per cent. In contrast, cohort specific
changes among women from Uttar Pradesh, irrespective ot religion
arc modest. No more than a handful of even young women in
Uttar Pradesh - one in ten Hindus and one in eight Muslims —
continue to have no say or veto powers in this decision [Jejeebhoy
aid Shiva Halli 2002].
Economic and Political Weekly
October 11, 2003
Table 4: Decision-Making Authority. Percentage of Women
Involved in Household Decisions, by Age and Socio
Demographic Characteristics, 1998-99, NFHS
Characteristics
Overall
Percentage involveo in Decision-Making Concerning
Visits to Parents/
Purchase ol
Own Health
Natal Kin
Jewellery
______ Care
15-19
20-34
15-19
20-34
15-19
20-34
38.7
49.3
39.9
50.7
37.4
46.2
39.8
38.4
55.9
47.0
43.2
39.3
57.3
48.4
39.3
36.9
51.6
36.3
39.5
45.7
37.3
40.6
' 43.3
46.9
35.3
36.8
40.7
42.2
48.6
55.2
52.9
43.0
49.0
42.7
35.9
39.8
56.1
37.6
35.5
37.6
50.7
44.8
54.9
38.0
42.4
46.3
36.2
39.0
42.2
Residence
Uroan
Rural
Educational status
No education
Primary
Secondary*
Cash employment
41.6
41.2
Working lor pay
Working without pay 37.0
Not working
Region
North
38.3
South
41.5
36.2
51.1
56.3
44.8
49 6
56.8
44.2
45.9
52.2
40.3
45.3
51.6
4373
T'.(
husbands had the final say on whether and when to have sex ILimited Mobility and Social Interactions
[Haberland et al 2001]. Reinforcing lack of decision-making is
Limited mobility and isolation from familiar networks further
the lack of awareness of sexudl. contraceptive and reproductive
the ability of married adolescent to have a say in their own
matters on the one hand and of communication or intimacy with limit
I
husbands on the other. The role of the husband has been noted lives. National level evidence suggests, tor example, that ado
in several studies of decision-making related to the use of lescents are systematically less likely than older women to have
contraception or health expenditure: for example, in a study m the freedom to visit different places without permission, as
rural Maharashtra, of 40 adolescents who reported the use of a observed in Table 5. Again, the effect of age is somewhat more
modem contraceptive, while the majority (23) made the decision powerful than that of education in enhancing freedom ot move
jointly, in 12 cases the decision was made by the husbands ment. In in-depth interviews, married adolescents in Kolkata
alone, and in five more by the women alone. Husbands also report that their freedom of movement became more curtailed
seemed to be the ones to take abortion related decisions; "I don’t after marriage, that in the natal home, they were freer to move
want her to have a child for another two years. If she does about, enaase in economic activity outside the home. At the same
conceive in between. I will make her abort the baby.” At the time, young women in Baroda and Kolkata reported that social
same lime, several women suggested that reproductive decision- networks had shrunk following marriage, and interactions were
makina was beyond the control ot both adolescents and their restricted to the family itself. Exposure to new ideas that comes
husbands — even where adolescents and their husbands would from interaction with others was thus far more likely to be
have liked to delay pregnancy, the decision -to practise contra restricted among these young women than among their husbands
ception was often overruled by mothers-in-law: "But 1 am who were not so restricted, their unmarried peers and ot course,
aauinst them (contraceptives) as they cause problems. I will not older women. Even those young-women who reported some
allow my dauahtcr-in-law and son to use them. In general contact with women in their neighbourhood indicated that the
mothers-in-law were adamant and girls felt pressured to prove interaction was typically limited in content: “Just about the village
their fertilitv - in comparison it was one third ot husbands who and if there is anything that has happened in someone’s
wanted to delay their wives’ first pregnancy but were over ruled house.. .What else will we talk? (18 year old in Baroda) (Haberland
et al 2001: Santhya et al 2001]. Access to resources, similarly,
[Barua and Kurz 2001].
Exercise of choice is constrained also by the threat and ex is consistently more limited among married adolescents than
perience of domestic violence. Several studies have documented among older women.
that significant proportions of mamed women face beating and
mistreatment in the marital home (see for example. Jejeebhoy Limited Access to Health Care
1998; Vijayendra Rao and Bloch 1993). Here there is little
Lack of autonomy within their marital homes also very likely
variation bv region of the country or age of the woman. At the
-national level, for example, reports from the NFHS (though there means that married girls have limited access to health care.
may be considerable under-reporting in this survey) suggest that, Evidence presented above shows that the first delay in seeking
amons those who were married for two or more years, some 16 care - the decision-making process - is significantly affected by
per cent of married adolescents were beaten or mistreated in the women’s powerlessness, and this may be more acute in the case
12 months preceding the survey, compared to 13 per cent of older of adolescents than adult women (see. for example Barua and
I
women. There is. evidence that the threat and experience of
Table 5: Mobility and Access to Resources: Percentage of
violence tends to delay reproductive health decision-making and
Women Reporting Freedom of Movement and Access to
care seeking on the one hand and is associated with adverse
Money, by Age and Socio-Demographic Characteristics,
pregnancy related outcomes on the other (see tor example,
1998-99, NFHS
Jejeebhoy 1998a). Though reported by only a few. young women
Percentage
Percentage Not Percentage Not
Characteristics
in Kolkata narrated instances where exercise of sexual choice
Access
Needing
Neeotng
to Money .
Permission to
were met with threats of remarriage and quarrel: “1 decided to
Permission to
Visit Friends
Go to a Market
stop it since I used to feel uneasy while having sex with a big
20-34
15-19
20-34
20-34
15-19
15-19
abdomen. But my husband used to get angry if I told him that
58.1
45.6
20.8
10.2
I did not want to have sex. He used to tell me that he would Overall
13.3
23.1
remarry if I refused to have sex with him. I tried to explain to Resiaence
72.3
55.0
29.7
14.8
21.2
42.1
Urban
him. but he did not want to listen. He used to get angry if I refused
53.2
44.0
9.4
17.8
12.5
23.3
Rural
and we had some tiffs on this issue. I had to give in to his demands Educational status
49.5
39.2
17.5
8.7
22.3
11.1
after a few days and our tiffs were resolved. We continued in
No education
56.7
47.0
20.1
14 4
10.6
28.3
Primary
this manner till my ninth month. I had feelings of discomfort
71.8
57.1
26.3
12.7
13.4
Secondary+
36.9
but I had to accept my husband’s wishes” (18 year old. recently Casn employment
61.5
27.4
45.0
delivered mother). [Santhya et al 2001].
13.9
17.9
35.9
Working for pay
47.4
39.6
11.9
22.2
Working without pay 12.9
Evidence is emerging, however, that attitudes are changing,
58.7
46.9
18.7
8.9
26.1
Networking
12.8
at least ainonc college students: large proportions ot both male
Relationship to HH head
and female students argued that women must make reproductive
65.3
51.6
13.8
21.6
30.4
19.0
Wile
58.6
47.2
22.0
decisions. 78 per cent and 79 per cent of males and females
9.3
12.4
28.5
Daughter
59.3
14.9
41.5
8.3
20.0
Daughter-in-law
11.5
respectively agreed that women have the right to retuse sex. and
Region
almost the same percentage reported that a man cannot torce his
54.0
43.7
14.1
6.2
18.2
North
7.6
65.6
wife to engage in sexual relations against her will [Barge and
50.2
17.7
31.3
44.1
South
25.6
Mukherjee 1997].
4374
Economic and Political Weekly
October 11, 2003
I
I
control study, also in Maharashtra; India, showed, for example,
that vouns women who delivered in their parental homes weie
significandy less likely to die than women who delivered in their
husband’s home (odds ratios 0.4). The study concludes that young
sick [Ganatra and Hirve 1995].
women delivering in the natal home are far better equipped to
Direct evidence on the extent to which health seeking among
express the experience of a danger signal, and families aie tar
adolescents is more compromised than that among adult women
more likely to'respond in a timely fashion than among women
- while sparse - is. however, mixed. From the evidence, we might
delivering in the husband’s home, that families may be more
tentatively postulate that if the health need relates to childbearing
likely to make timely health interventions in their daughters and
_ whether presnanev or perceived difficulties in conception sisters, and to incur expenses to save their lives, thari their
action is prompt, whether or not the woman herself plays a
dauahters-in-law and wives [Ganatra. Coyaji and Rao 19981. In
decision-making role. For other reproductive health matters
short, because of the value placed on Childbearing on the one
treatment for gynaecological symptoms or symptoms ot infec hand, and the practice of returning home lor the first delivery
tion. seeking contraception or counselling for example health
on the other, pregnant adolescents appear to overcome the
seekins may not be as prompt and may be more directly linked
powerlessness married adolescents face in their husband s home
to theJornan's own decision-making role in the family.
with rccard to fertility related care seeking.
Infertility is deeply feared and evokes the threat oi mistreatmem. abandonment or the presence of a second wile. The recent
Pregnancy Relatedstudy cited earlier of the health seeking behaviours ol young
Prcanancy related care is far from universal -tn India and adults
married women in rural Maharashtra, suggests that this is an area
and adolescents alike are unlikely to receive care during preg . in which women’s own health concerns coincided with those
nancy. delivery or in the postpartum period. The evidence on
of their mothers-in-law or husbands, or both and uvgeneral.
oreonanev related care seeking'among adolescents'as compared
women were persuaded to seek care of faith healers, and it
to adult women is. however, mixed. For example, the National
unsuccessful, follow this with allopathic treatment. Thus, ot 89
Familv Health Survey suggests that despite the elevated risks they
oirls who had not yet conceived despite cohabitation and nonmay face, adolescent women are about as likely as older women! contraception, only seven had sought allopathic care [Barua and
to obtain care durins pregnancy, delivery and the post-panum
period, as >s clear from Table 6. Table 6 clearly shows that age■ Kurz 2001].
is consistently unrelated to health care practices, and far less likely
practices than are other indicators such as educational^ Other Reproductive Health Needs
status, rural-urban residence and region. Ot course, the effect ot
The situation is quite different when adolescents experience
mav well be underestimated in these data, since adolescents
svmptoms of gynaecological morbidity or reproductive tract
Jill be sionificantly more likely to experience a first pregnancy
infection. The evidence suggests that relatively small proportions
- one iha~t is known to be both higher risk and more likely to
of adolescent women experiencing symptoms of morbidity or
attract timely care than later pregnancies - than are older women.
infection actually sought care for the condition. For example,
As mentioned above, given the emphasis on childbearing and
the study of gynaecological morbidity.■ among married adolescents
proving fertility, pregnancy hrelated
----- care is likely to be prompt
_y.3 that two-third’s ot women with
iresDective ofr the
mu.c- in rural Tamil Nadu suggests t.._.
decision-making roie.
role. More' t woman's
woman’s own
own decision-maxing
oTer the practice of returning to the natal home for the first birth symptoms aid noueek wre.. and among those who did. over three
■. the practice of
in four sought treatment from unqualified sources, such as home
mav well play a protective role in tim-ely health seeking among
H. I
The attention she can demand and obtain treatment or untrained private practitioners [Joseph et al -UU_|.
preonam adolescents.
Similarly, in rural Maharashtra, while half (51 per cent) ol married
Hat the natal home are quite
- ->-L-r
------ from -ko
different
the^care she can obtain
adolescents reported a gynaecological problem, only halt or t iesc
husband
in her I.
-------- ’s.home (see for example. Basu 1995). A case
Kurz 2001: Santow 1995). By and large, the real decision-makers
continue to be the husbandSor mothers-in-law. and even educated
women are not always likely to be the main decision-makers when
Table 6: Maternal Health
Percentage Institutional
Delivery
Percentage Receiving
al Least One AnteNatal Check-Up
15-19 ~
20-34
Characteristics
Overall
Residence.
Urban
Rural
Educational status
No. education
Primary
Secondary*
Cash employment
Working lor pay
Working without pay
Networking
Region
North
South
Care Practices among Adolescent and Adult Females
15-19
20-34
Percentage Receiving
Postpanum
Percentage Attended
by Trained Health
_______ Personnel
15-19___________ 20-34"
TTTg
2d3I
Check-Up'
31.8
35.0
41.5
18.1
16.4
65.8
43.4
57.7
86.0
63.8
86.3
59.3
51.0
25.7
65.6
25.0
69.4
35.7
74.5
33.6
17.8
18.1
20.7
15 8
47.7
18.7
37.5 .
56.7
15.2
27.2
49.0
67.9
22.7
46.5
75.6
13.9
54.8
78.9
88.0"
26.8
25.1
12.9
21.3
26.3
72.6
54.0
24.9
37.1
25.2
48.1
20.5
13.6
15.7
39.5
35.0
33.8
44 8
21.8
18.0
16.8
56.9
67.7‘
55.4
57.0
21.7
22.2
61.8
31.2
60.4
11.8
52.5
92.6
31.4
54.0
90.5
68.8
32.9
11.9
33.1
75.3
90.8
•
21.7
35.5 '
49.7
35.9
66.2
29.1
17.2
denominator is non-institutional births during the three years preceding the survey.
Note: ' The
Economic and Political Weekly
October 11, 2003
4375
f
tl
1
$
that married adolescents are more likely than adults to experience
adverse pregnancy outcomes, but these appear to be rn(ye 1 e similarly, NFHS datasuggest that while somewhat :
to be attributable to physiological immaturity than sue actors
l’al'O7 dolescents than adults reported symptoms of abnormal
as lack of decision-making and limited health seeking, econ
■le' J di charae (26 oer cent and 32 per cent among those aged
:I'J-34 respectively), adolescents are constderably ess although unmet need for contraception is considerab e a™0I'1=
adolescents - perhaps greater than that observed amon, a u
m 1 to se'ek care for this condition: 26 per cent compared to - no special efforts have been made to overcome t eir ac'
,,kcly to seA c
rural Maharashlra COn37 TmSov^care ts unlikely to be sought unless feelings decision-makino or constraints on their ability to sc^ ser i
in (his regard. And third, when adolescents expertence symptoms
itract infection or other gynaecological mormdity.
moihers-in-tav perceived of reproductive
thev face huge obstacles in seeking treatment tor these, wm e
’’^^^ovSondWonTo beX'» abtlity to conce.vc
manv of these - shvness, embarrassment, cost, perceptions l
these are normal and self-limiting conditions and so on - aic
UPAi°hou<’h significaTi'proportions of adolescent vvomen express common to women irrespective of age. it does appear .a
adolescent women may be moderately less likely to see - care.
'
n(he first and postpone subsequent pregnanc.es.
Exercise of reproductive choice is undoubtedly limited and
J d“'re
nl t ots expressed an unmet need for contraceptton.
extrapolation, from data on decision-making and mobility pat
’I w Zroprbte contraception is frequently thwarted by
terns. adolescents may be far more constrained among adoles
rCCTflv oressures. In the'qualitative study on first-time pregnant cents than among adult women. Appropriate health seeking,
d'rectmt first-time mothers, cited earlier, young women icfinally, is highly context dependent: while married adolescents
Xed. Xjations where in-laws
in-laws forced
forced young
young couple^ to dtsconappear to be as likely as adults to obtain pregnancy related care,
thev may be less likely to be able to acces- contraceptives on
''^"dZentiomyroom.oseeh.ssonqndbenot.ced
, the’one hand and obtain treatment for symptoms ot reproductive
' ills He asked m'*' husband “Who is taking tlTese pills?” My
(raci infections on the other.
" Pl S<’
vnt.r daunhier-in-law/Then my father-in-law said,
Findinss arsue strongly for programmatic measures that delay
husband said o
=
thcse? Jusl lhrow
marriaoe' and recognise the special vulnerabilities ot married
-Docs she want to _
conceive. Her health will be
adolescent females. There is a need to raise awareness among
them out 0^erW1SC.,, .
p- Then nw mother-in-law came and
cirls. oarents. teachers, and community leaders - through school
and communitv based programmes - about the negative impact
10 d.
•,
of fat on vour abdomen and you will not be aole
•ocoS've (16 year old recently delivered mother in Kolkata) of earlv marriage and pregnancy on women and children s health
Promising findings are reported by a non-governmenta
[Santhya et al 2001].
.
orsanisation in India that has implemented sma -sea e i e s
'tn addition to family pressures, contraception can also be
programmes for out of school youth, particularly females, using
thwarted bv lack of attention from health workers and other a combination of non-formal. family life and vocauonal educaoroviders who tend to overlook this group until they are further
lion, alone with the provision of services, as well as opportunities
advZd
their reproductive careers. Even after g.vmg bimK
"cent mothers were far less likely than older mothers o for participants to learn to use banks and public transport to
participate in recreational activities and to receive leadersh.p
re.eive familv planning advice in the course of post panum check
training (Levitt-Dayal et al 20021. A follow-up ot alumnae one
tin's' 19 per cent of adolescent mothers compared to a0 py cent
to three years following the training suggested that, compare
nf idult mothers received advice about family planning, despite
to vouno women who did not participate, alumnae were more
the fact that these young women are particularly
10 "ee
likely to remain in school, to have greater decision-makmg
counselling on birth spacing and contraception [UPS
authority within their families - particularly with respect to de
cisions about marriage and whether to continue the.r education.
Macro 2000].
Alumnae also demonstrated higher levels ot selt-esteem.
V
assertiveness, mobility, and exposure to media and new ideas.
The Way Forward
Among married women, participants were more likely to marry
at a"e IS or older, and were more likely to obtain appropriate
Evidence on the situation of married adolescent girls in India
carc°during pregnancy, compared to those who had not particiis admittedly sparse, but several concisions may be drawn. For
in the programme.
lame proportions of young women, marriage and childbearing paced
Aside from community level action, equally, there is a neeo
occur in Adolescence before physical maturity is reached and are to hold government accountable for enforcing the legal age o
accompanied by malnutrition, obstetric risks and lack ot
makingand mobility toacquire pregnancy.contraceptive and other marriage for girls.
Simultaneously, programmes need to Find ways to en a c
reproductive health services, and little autonomy over sexual an
married airls’ autonomy within their marital homes, to encourage
reproductive lives. Significant proportions expenence risky education and enhance girls' life and negotiating skills and also
pregnancies and forced sex. are vulnerable to sexually transmuted
help generate livelihood opportunities. Given the low.status o
ife'etions (STIs) usually from their husbands, and experience married adolescent girls in many communities, programmes must
an unmet need for contraception. Exercise of reproduct, vc choi e
taroet not only young married women, but also more powertul
is limited and in many instances care seeking is constrained
family decision-makers, such as husbands and mothers-in-laws.
h is likely, moreover, that they are more vulnerable and more
On the reproductive health front, evidence suggests that pro
inaccessible than adult women but comparative evidence here viders be trained to recognise married adolescent girls as a ig
is somewhat mixed and very sparse. For one. it is undisputed
It.
ir.
ac
ct
a?
SX- shame in russing sexua‘ ma"eK were
Economic and Political Weekly
4376
October 11, 2003
u
i
.,
oroup. Providers need to offer information, counselling and
l!SN ~ jn Ways that consider girls’ lack of power within their
services
C families. Services are needed that reach out beyond
husbands
“h» clinic to enable young women to seek prenatal visits and
adequate obstetric care. and. with careful training, to obtain
counsellins or services relating to coercion and violence, as well
as STI symptoms.
,
This review highlights the knowledge gups that remain. In many
instances, the available evidence derives from small-scale studies
that mav not be generalisable to young people at large. To make
,'it'ormed policy decisions, we need more social science and
Derations research to understand how the situation and needs
/.I' married adolescents differ from those of married adults and
unmarried adolescents. Equally we need to better understand
whether and why the sexual and reproductive health needs or
married adolescents remain unmet, why informed choice con
tinues to elude them and how services should be structured to
overcome the social, cultural and economic constraints that
married adolescents face. This paper provides strong support tor
mvestment in married, no less than unmarried, adolescents health promoting practices and negotiation and communication
skills developed in adolescence will have tar reaching effects
on the health of women and the extent to which they make
mformed choices concerning their own lives. SID
Jejecbhoy. S (1998a): 'Associations between Wife-Beating and Fetal and
Infant Death: Impressions from a Survey in Rural India . Studies in
Family Planning 29(3):300-08. September.
- (1998b): 'Wife-Beating in Rural India: A Husband's Right? Evidence irom
Survey Data'. Economic and Political Weekly. 23( 15):S55-62. April 1 L
- (2000): 'Adolescent Sexual and Reproductive Behaviour: A Review of
the Evidence from India' in R Ramasubban. S Jejecbhoy (eds). Women s
Reproductive Health in India. Rawat Publications. Jaipur.
Jejecbhoy. S. Shiva Halli (2002): '.Marriage Patterns in Rural India: Influence
of Socio-Cultural Context'. (Unpublished).
Joseph. A. J Prasad. S Abraham (2002): 'The Risk of Infection: Gynaecological
Programmes Among Young Married Women in Tamil Nadu in
on
et al (eds). Adolescent Sexual and Reproductive Health: Evidence and
l.nplicmu,,,, /,„■ Sourl: Asia. World Health Oroanisnoon.
Geneva.
•. .
Joshi. A ct al (1998): 'Male Involvement in Seeking Abortion Services i
Rural Gujarat’, paper presented at the South Amuii Initiative in
Reproductive Health Research. Colombo.
Asia Publishing House.
Karve. I (1965): Kinship Organisation in Imliti.
I...
Mumbai.
Khan M E. J W Townsend. R Sinha. S Lakhanpal (1997): 'Sexual \ lolencc
Within Marriage: A Case Study of Rural Uttar Pradesh . presented at
the Annual Meeting of the American Public Health Association.
Indianapolis. US.
Krishna. U R (1995): 'The Status of Women and Safe Motherhood . Journal
of the Indian Medical Association. 93(2):34-35.
Kulkarni. S (2002): 'The Reproductive Health Status of Married Adolescents
as Assessed bv NFHS-2. India' in S Bott el al (eds). Adolescent Sexual
and Reproductive Health: Evidence and Programme Impl,cut ions for
South Asia. World Health Organisation. Geneva.
Levitt-Dayal. M. R Motihar. S Kanani. A Mishra (2002): 'Adolescent Gn'ls
Address for correspondence:
in India Choose a Better Future: An Impact Assessment in S Bott et
al (eds). Adolescent Sexual and Reproductive Health: Evidence and
santhya@pcindia.org
Programme Implications for South Asia. World Health Organisation.
shireen@pcindia.org
Geneva.
Mishra. S and C S Dawn (1986): 'Retrospective Study of Teenage Pregnancy
References
and Labour during a 5-Year Period from January 1978 to December 198’ at Durzapur Subdivisional Hospital'. Indian Medical Journal. 80.
'Adolescent
Sexuality
and
Fertility.
A
Study
in
Rural
Apia Hemani (1997): 'Adolescent Sexuality ana rerumy. a
.— a.
9:150-5’2.
. ,
.
Western Maharashtra' in Population Council (compiled) Summaries ot
Pachauri. S and A Jamshedji (1983): 'Risks of Teenage Pregnancy . Journal
Research Undertaken/Planned on Male Involvement, papers presented
at the workshop on research related to male involvement in reproduces • of Obstetrics and Gynaecology, 33. 3: 4/7-82.
Pachauri. S. K G Santhya (2002): 'Contraceptive Behaviours among
health and contraceptive use. unpublished.
Adolescents in Asia: Issues and Challenges' in S Bott ct al (eds).
Rarua A and K Kurz (2001): 'Reproductive Health-Seeking by Mamed
Adolescent Sexual and Reproductive Health: Evidence and Programme
Adolescent Girls in Maharashtra. India’. Rcproduciive Health Matters:
Implications for South Asia. World Health Organisation. Geneva.
9 17' 53-6'’
Pal. A. K B Gupta and I Randhawa (1997): 'Adolcsccm Pregnancy: A
Ganatra B R and S S Hirve (1995): -Unsafe Motherhood: The Determinants
High Risk Group'. Journal of rhe Indian Medical Association.
of Maternal Mortality. Journal of the Indian Medical Assoc,anon. 9a._:
95(5); 127-28
,
v
Population Reference Bureau (PRB) (2000): The Worlds Youth .000.
Gamun B R K J Covaii and V N Rao (1998): ’A Community-Cum-HospitalMeasure
Communication.
Population
Reference
Bureau.
Washington.
DC.
G Based Case Cont'rol Study on Maternal Mortality'. Final Report Bullen;
Santhya. K G. L MCGrory and N Habcrland (2001): 'First Time . arents
of the World Health Organisation. 76. 6 (December) pp ^1-98^
Project'. Supplemental Diacnostic Report. Kolkata (Unpublished).
Gan-’akhedkar R M’E Bentley. A D Divekar. D Gadkari. S M Mehendalc Sahtow. G (1995): 'Social Roles and Physical Health: The Case ot Female
G 5I E Shepherd. R C Bollinger and T C Quinn (1997): 'Spread of H V
Disadvantage in Poor Countries'. Social Science and Medicine.
Infection in Mamed Monogamous Women in ind.a . Journal of the
40(2):l47-61.
American Medical Association 278 (23);2090-92.
Sharma. V and A Sharma (1992): 'Health Profile of Pregnant Adolescents
George A POO^): 'Embodying identity through Heterosexual Sexuality among Selected Tribal Populations in Rajasthan. India . Journal oj
Newly Married Adolescent Women in India'. Culture. Health and
Adolescent Health. 13. 8: 696-99.
Sexuality. 4. 2: 207-22.
Swain. S. K N Ojha. A Prakash and B D Bhatia (1993): '.Maternal and
Geome A S Jaswal (1995): 'Undcrsiandmg bexuahty: Ethnographic Study
Perinatal Mortality Due to Eclampsia'. Indian Paediatrics. 30.6: 77 1- . .
of Poor Women in Bombay'. Women and AIDS Programme Research
United Nations (2001): World Population Prospects: The 2000 Revision
Report Series No 12. International Centre for Research on Women.
Volume II: The Sex and Age Distribution of the World Population. United
Washington. DC.
Nations.
New York.
Habcrland N L McCrory and K G Santhya (2001): First Time Parents
UNICEF. UNAIDS. WHO(2002): Young People and HIV/AI DS: Opportunity*
Project’ Supplemental Diagnostic Report. Baroda (Unpublished)
in Crisis. United Nations Children's Fund. Joint United Nanons Programme
Hirve S S B R Ganatra (1994): 'Determinants of Low Birth Weight: A
on H1V/AIDS. World Health Organisation. Geneva.
Community-Based Prospective Cohort Study'. Indian Paediairics..:i\.
UNICEF (2001): The Progress of Nations 2001. United Nanons Children s
IQ- pn|.25.
Fund. New York.
UPS and" ORC Macro (2000): National Family Health Survey (NFHS-2).
Vijaycndra Rao. Frances Bloch (1993): ■Wife-Beating. Its Causes and Its
1998-99. India. UPS. Mumbai.
Implications for Nutrition Allocations to Children: An Economic and
- pOOI)' Naiional Family Health Survey (NFHS-2). India. 1998-99. Uttar
Anthropological Case Study of a Rural South Indian Community . World
Pradesh. UPS. Mumbai.
1
Bank. Policy Research Department. Poverty and Human Resources
- pOOla): National Family Health Survey (NFHS-2). India. 1998-99. Tamil
Division. Washington. DC.
'Nadu. UPS. Mumbai.
Economic and Political Weekly
October 11. 2003
4377
SDft- PF- UH - wlS-V
Adolescent sexual and reproductive health in
South Asia: an overview of findings from the
2000 Mumbai conference
Sarah Bott and Shireen J. Jejeebhoy
Conference background
The World Health Organization (WHO) defines
adolescents as the age group 10-19, a definition
used throughout this volume. The meaning of
adolescence as a cultural construct has been
understood in many different ways throughout the
world, however. In general terms, it is considered
a time of transition from childhood to adulthood,
during which young people experience changes
following puberty, but do not immediately assume
the roles, privileges and responsibilities of
, adulthood. The nature of adolescence varies
s jiyiendously by age, sex, marital status, class,
region and cultural context. As a group, however,
adolescents have sexual and reproductive health
needs that differ from those of adults in important
ways and which remain poorly understood or served
in much of the world.
Moreover, social, economic and political forces are
rapidly changing the ways that young people must
prepare for adult life. These changes have
enormous implications for adolescents’ education,
employment, marriage, childbearing and health.
Adolescents are increasingly spending more time
1
in school, experiencing puberty at younger ages,
marrying and having children later than in the past.
Neglect of this population has major implications
for the future, since reproductive and sexual
behaviours during adolescence have far-reaching
consequences for people’s lives as they develop
into adulthood.
In South Asia, by the end of the 1990s, both
researchers and governments had begun to shed
their traditional ambivalence towards young
people’s sexual and reproductive health, and a
growing body of empirical evidence and government
interest provided an opportunity to take stock of
the sexual and reproductive health situation of
youth in the region. In response, HRP1, ISRRF2
and IRR3.jointly organized an international
conference in November 2000 entitled: Adolescent
Reproductive Health: Evidence and Programme
Implications for South Asia”, held in Mumbai, India.
Although international organizations subdivide Asia
in different ways, this conference focused on five
South Asian countries, namely, Bangladesh, India,
Nepal, Pakistan and Sri Lanka. Insights from other
Asian settings were also presented, notably from
China and Thailand.
HRP stands for the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research
Training in Human Reproduction.
2 ISRRF stands for the Indian Society for Research on Reproduction and Fertility.
3 IRR stands for the Institute for Research in Reproduction.
i
i
i
Sarah Bott and Shireen J. Jejeebhoy
The conference aimed to review the evidence on
adolescents’ sexual and reproductive health
situation, needs and perspectives in South Asia,
to learn from programme successes and failures
in the region, and to identify acceptable yet effective
ways to respond to adolescents' unique needs.
The conference addressed a number of central
questions, including: What are adolescents’ needs
in regards to sexual and reproductive health? How
can we increase their ability to make informed
reproductive choices? How do we enhance their
access to reproductive health services that are
acceptable, unthreatening, and affordable? What
kind of information do they need in order to
exercise these choices and access services? How
an we tailor programmes to deliver information
and services? And, how can programmes improve
communication between adolescents and adults?
This conference brought together researchers from
different disciplines, as well as service providers,
programme managers, government representa
tives, policy-makers, representatives from
international and donor agencies and, most
importantly, young people themselves. Participants
came from more than 13 countries, including South
Asia, other Asian countries such as China,
Indonesia, and Thailand, and countries beyond the
region such as Chile, Colombia, several European
countries and the United States of America. The
agenda included 42 full presentations, 12 brief
abstract presentations, comments from nine
discussants and 72 poster presentations,
supplemented by panel discussions among young
people themselves and policy-makers.
In an attempt to record the evidence and insights
that emerged from the conference, organizers
asked the conference participants to write
summaries of their presentations. As a result, this
volume contains summaries of 40 of the 42 major
presentations and two of the three panel sessions.
This overview chapter provides a brief social and
demographic profile of adolescents in South Asia,
together, where possible, with information on other
Asian countries—China, Indonesia, the
Philippines, Thailand and Viet Nam—to enable
readers to place South Asia within the larger Asian
context. This is followed by a review of the entire
collection of papers contained in this volume.
i
I:
I
Profile of adolescents in South Asia
Of the estimated 1.2 billion adolescents in the world
today, nearly half live in Asia, and nearly one in
Table 1. Demographic profile of adolescents in South Asia and other selected Asian countries
ountry
Estimated
population aged
15-19 circa 2000
(thousands)
135163
South Asia
Bangladesh
15 089
100 963
India
2 373
Nepal
14 841
Pakistan
1 897
Sri Lanka
Other Asian Countries
100 760
China*
21 564
Indonesia
8145
Philippines
5 807
Thailand
Viet Nam
8 275
Estimated
population aged
10-19 circa 2000
(thousands)
Adolescents
aged 15-19
(% of total
population)
Adolescents
aged 10-19
(% of total
population)
281 840
31 816
209 148
5116
32 117
3 643
10
11
10
10
11
10
21
23
21
22
23
19
218497
43 355
17 087
11 345
1 784
8
10
11
9
11
17
20
23
18
22
*Note: Not including data for Hong Kong Special Administrative Region of China.
Source: United Nations (2001) World Population Prospects: The 2000 Revision. Volume II. The sex and age
distribution of the world population. New York, United Nations.
.
.4 ;
I
1
Adolescent sexual and reproductive health in South Asia: an overview
not in school, except in Sri Lanka (Table 2). Some
are unemployed, while others work for pay, or work
without remuneration in households, family farms
and businesses. Surveys suggest that labour force
participation rates are relatively high—both among
older adolescents aged 15-19 and among younger
adolescents aged 10-14 (Table 3). In Bangladesh,
for example, a 1995—1996 survey found that over
one-quarter and one-third of younger adolescent
females and males were economically active, as
were about half and two-thirds of older adolescents,
respectively. Labour force participation of younger
adolescents is also high in other countries—among
males in Nepal and Pakistan, for example. By ages
15—19, large proportions of South Asian males (36—
66%) and females (21-49%, excluding Pakistan)
are engaged in economic activity. Rural adolescents
are more likely to work and less likely to study
than their urban counterparts. Caution in
interpreting sex specific figures is advised since
surveys can underestimate girls’ contributions to
household labour and consequently their economic
activity rates (see, for example, Jejeebhoy, 1993).
four (282 million) live in South Asia. Adolescents
aged 10-19 comprise over one-fifth of South Asia’s
population (Table 1). Within the region, Bangladesh
and Pakistan have the greatest proportion of
adolescents, while India has the greatest absolute
number.
Though the situation of adolescents varies widely
within the region and within individual countries,
literacy and school enrolment rates among
adolescents have risen in all South Asian countries
over the past couple of decades. In Bangladesh,
India and Pakistan, for example, the proportion of
women aged 20-24 who report seven or more years
of education is dramatically higher than the
. jportion of older women aged 40-44 who do so,
as illustrated by Figure 1.
Nevertheless, according to United Nations
estimates, secondary school enrolment ratios
remain low in most South Asian countries, except
Sri Lanka, and large proportions of teenage girls
aged 15-19 remain illiterate. It is important to note
that geographic disparities are wide within individual
countries. Differences between the sexes are also
wide, particularly in Bangladesh and Pakistan
where secondary school enrolment ratios for boys
are nearly double those for girls (Table 2).
Health status of adolescents in South Asia
As noted in the global overview by Paul Van Look,
adolescence is generally a period of life free from
both childhood diseases and the ravages of ageing.
Consequently, as in other settings, mortality rates
3 majority of older South Asian adolescents are
Figure 1. Per cent of women with 7+ years of education, by generation
4 0 %
-i
3 4
3 5 %
3 0 %
2 5 ?'o
s
2 1
2 0
1 8
2 0 %
CD
1 5 %
$
8
1 0 %
7
5 %
_i__I
■W^-.____________
0 %
Bangladesh 1993-1994
I B
In dia 1992-1993
omen age 20-24
□ Among women
P a k-is ta n 1 9 9 0 - 1 9 9 1
BAmong women age 4 0 - 4 4__
Source: Demographic and Health Surveys as citedTi'Singh"S7r9T8)_AToiesc^^
a global review. Studies in Family Planning. 29(2): 117-163.
in developing countries:
Sarah Bott and Shireen J. Jejeebhoy
among adolescents and young people in this
region are generally lower than those observed at
younger and older ages. However, unlike in other
countries, adolescent and young women in the
countries of South Asia, with the exception of Sri
Lanka, experience somewhat higher mortality rates
than males at the same ages (Table 4). Disparities
are particularly evident among young people aged
!
r
Table 2. Secondary school enrolment and illiteracy rates among adolescents in South Asia and other
selected Asian countries, 1995-1997
Secondary school enrolment
ratios (% of # enrolled
to# in applicable age groups
Country
South Asia
Bangladesh
India
Nepal
Pakistan
Sri Lanka
Other Asian Countries
China
Indonesia
Philippines
Thailand
Viet Nam
Per cent of teens aged 15-19
who are illiterate
Boys
Girls
Boys
Girls
25
59
51
33
72
13
39
33
17
78
58
20
26
56
9
71
44
51
74
10
74
55
77
38
48.
67
48
78
37
46
3
2
4
1
7
8
3
1
2
7
I
Table 3. Labour force participation rates of adolescents and youth by sex and age group
Males (%)
Aged
10-14
Aged
15-19
Aged
20-24
Aged
10-14
Aged
15-19
Aged
20-24
Bangladesh (1995-96)*
28.1
47.8
58.7
37.8
65.5
82.0
India (1991)*
5.1 +
26.2
33.5
5.7+
43.8
74.7
Nepal (1991)*
28.0
49.0
54.0
18.1
49.2
80.0
Pakistan (1999)**
5.8
9.6
11.7
16.5
51.1
85.5
Sri Lanka (1999)***
3.1
21.2
50.6
3.3
35.8
87.1
China (1990)*
na
68.3
89.6
na
61.5
92.6
Indonesia (1999)
na
90.6
53.8
na
45.5
33.6
Philippines (1999)***
na
25.8
52.7
na
45.1
81.0
Thailand (1999)***
8.3++
29.1
67.9
9.0++
37.7
77.9
Viet Nam (1989)*
37.4++
73.3
88.8
29.5*+
67.4
94.4
Country and year
South Asia
Other Asian countries
* International Labour Organisation (1998) Yearbook of Labour Statistics 1998. Geneva, ILO.
** International Labour Organisation (1999) Yearbook of Labour Statistics 1999. Geneva, ILO.
***lnternational Labour Organisation (2000) Yearbook of Labour Statistics 2000. Geneva, ILO.
+ Aged 5-14; ++ aged 13-14.
na: not available.
i
I
Source: Population Reference Bureau (2000) The World's Youth 2000. Washington, DC, Population Reference
Bureau, Measure Communication.
Females (%)
!
Adolescent sexual and reproductive health in South Asia: an overview
15-19 and 20-24, and this may well be explained
by the poorer reproductive health of females in
these countries.
Gender disparities in health are particularly
significant in South Asia. In terms of food intake,
access to health care and growth patterns, girls
are worse off than their brothers. Disparities become
evident soon after birth, and, by adolescence, many
girls are grossly underweight (Jejeebhoy, 2000).
Adolescent girls contribute long hours to the
household economy, but their activities are largely
invisible and undervalued since they draw no
income. Gender roles and expectations have such
a orofound impact on the lives of adolescents that
arly every author in this collection explores
some dimension of the ways in which gender roles
affect adolescents’ lives.
Adolescent sexual and reproductive health
in South Asia
Two papers in this collection provide comprehensive
overviews of South Asian adolescents’ sexual and
reproductive health, namely, a regional overview
by Ena Singh and a national oven/iew of the Indian
situation by A.R. Nanda. Together, these papers
outline the many factors that undermine
adolescents’ ability to make informed sexual and
reproductive choices in South Asia. For example,
South Asian societies have traditionally placed
high priority on preserving young women’s chastity
before marriage—a concern that has important
implications for their education, age at marriage,
autonomy and mobility. Seclusion norms are
widespread in the region from puberty onwards.
As a result, adolescent girls in many South Asian
settings are unlikely to have much exposure or
physical access to the outside world. Few services
cater to their needs for health care, nutrition,
vocational skills, economic opportunities or
information. A sizeable proportion of women in
South Asia marry well before age 18, and early
pregnancy further exacerbates their poor
reproductive health and the poor survival chances
of the infants they bear. These papers also highlight
the factors that prevent boys from making informed
decisions, including lack of knowledge about sex
and reproduction, and social pressure to have sex
Table 4. Age-specific death rates of adolescents and youth by sex and age group
Males (%)
Females (%)
Aged
Aged
Aged
Aged
Aged
Aged
10-14
15-19
20-24
10-14
15-19
20-24
Bangladesh (1986)
1.1
2.3
3.1
1.7
2.0
2.2
India (1997-98)
1.4
2.5
3.8
1.0
1.8
2.7
Nepal (1986-87)
6.6+
4.1-
3.3+
4.3++
Pakistan (1996-97)
2.5
1.9
3.9
2.6
1.9
2.9
Sri Lanka (1995)
0.4
0.9
1.0
0.5
1.7
3.6
0.6
0.3
0.7
0.6
0.9
1.1
0.7
0.5
1.2
2.1
2.3
3.3
uuntry and year
South Asia
Other Asian countries
Philippines (1991)
Thailand (1997)
'Aged 5-14** aged 15-24, further breakdown not available.
Sources: Bangladesh: United Nations (1997) Demographic Yearbook 1995. New York, United Nat'°"s (ST/ESA/
STAT/SER R/26); Philippines, Sri Lanka, Thailand: United Nations (2000) Demographic Yearbook
.
York United Nations (ST/ESA/STAT/SER. R/29); India: International Institute for Population Sciences & Macro (ZUUU)
National Family Health Survey (NFHS-2) 1998-99: India. Mumbai, International Institute for Population Sc,enc®s.
Nepal: Central Bureau of Statistics, Nepal (1995) Population Monograph of Nepal. Kathmandu f
'
Table 1.4, p. 33; Pakistan: Hakim et al. (1998) Pakistan Fertility and Family Planning Survey 199&-97 (PbhPb).
Islamabad, Pakistan, National Institute of Population Studies (December).
Sarah Bott and Shireen J. Jejeebhoy
under unsafe conditions, placing them at risk of
sexually transmitted infections.
The other papers in this collection explore all these
dimensions in more depth, including papers from
Bangladesh, China, India, Pakistan, Nepal, Sri
Lanka and Thailand. The first half of the collection
presents empirical evidence about adolescents’
situation and needs that form the basis for
programmes and policies discussed in the second
half.
Married adolescents: the health consequences of
early marriage and childbearing
International attention on adolescent sexual activity
tends to focus on premarital sex. However, in South
Asia, sexual debut among adolescent girls occurs
largely within marriage. Despite rising age at
marriage and laws prohibiting marriage before age
18 for women and before age 21 for men in most
South Asian countries, the majority of women
marry as adolescents in Bangladesh, India and
Nepal (Figure 2 and Table 5). Correspondingly, most
South Asian women experience sexual debut as
married adolescents. Moreover, large surveys have
found that almost half of all women aged 20-24
are married by age 15 in Bangladesh, as are nearly
one-fourth (24%) in India and one-fifth (19%) in
Nepal. In contrast, South Asian boys rarely marry
as adolescents. For example, the recent National
Family Health Survey (NFHS-2) in India found that
only 6% of adolescent boys were married (Kulkarni,
this volume).
Over the past decade, adolescent fertility has
dropped in nearly all South Asian countries.
However, due to the persistence of early marriage,
pregnancy during adolescence is still common
(Figure 3 and Table 7). The 1996-1997 Bangladesh
Demographic and Health Survey found that 14%
of 15 year-old girls were either already mothers or
pregnant with their first child (Mitra et al., 1997).
Many girls become pregnant before they reach
physically maturity, which has adverse health
consequences, both for young women and their
children.
Several papers in this collection explore the social
context and health consequences of early marriage
Figure 2. Per cent of women aged 20-24 married by age 18 in South Asia and other selected Asian
countries
80% -
73
70%
60
60% ■
50
50% ■
(D
O
40%
32
31
30%
20
20%
14
12
10% •
i
•<. •
Pakistan
Nepal
<<
0%
Bangladesh
1993-1994
India
1998-1999
1990-1991
1996
9
■
■
•o
7^.
IS
.•••A--.-
’■M
Sri Lanka
Indonesia Philippines Thailand
Viet Nam
1993
1998
1993
1994
1987
Sources: National Demographic and Health Surveys from various years as noted. Figures cited in the following
sources: India: International Institute for Population Sciences & Macro (2000); Pakistan: Blanc & Way (1998);
All other countries: De Silva W (1998).
W'8 <
Adolescent sexual and reproductive health in South Asia: an overview
Table 5. Per cent of women aged 20-24 married by age 15,18 and 20 in South Asia and other selected
Asian countries
Country and year
South Asia
Bangladesh (1993-1994)
India (1998-1999)
Nepal (1996)
Pakistan (1990-1991)
Sri Lanka (1993)
Other Asian countries
Indonesia (1994)
Philippines (1993)
Thailand (1987)
Viet Nam (1998)
By age 15 (%)
By age 18 (%)
By age 20 (%)
47
24
19
na
1
73
50
60
32
12
82
na
76
na
24
9
2
2
1
31
14
20
9
48
29
37
31
na: not available.
National Demographic and Health Surveys from various years as noted.
noted Figures
Figures cited
c.teo in
m the
me following
urces ■ India:
urces:'
International Institute for Population Sciences & Macro (2000); Pak.stan: Blanc & Way (1998), All
other countries: De Silva W (1998).
Table 6. Median age at first marriage and per cent of teenage girls ever married
Country and year
South Asia
Bangladesh (1996-1997)
India (1998-1999)
Nepal (1996)
Pakistan (1990-1991)
Sri Lanka (1993)
Other Asian countries
Indonesia (1997)
Philippines (1998)
Thailand, na
Viet Nam (1998)
___________
Median age at first marriage
among women aged 20-24
Per cent of girls
aged 15-19 ever married
15
18
17
20
24*
50
34
44
25
20
na
na
22.5
■ 7
18
8
.17
8
* Among women aged 25-29; na: not available.
Sources- National Demographic and Health Surveys various years as noted. Data cited in f°J'°wing sources: Sn
Lanka: De Silva W (1997); Thailand: Population Reference Bureau (2000); All other countries.
www.measuredhs.com.
and childbearing. Kulkarni and Adhikari each
present a national profile of married adolescents’
reproductive health in papers from India and Nepal,
respectively. Kulkarni analyses data from the 1998—
1999 National Family Health Survey, India
(NFHS-2), that focus on young women aged 1519, while Adhikari draws from published and
unpublished research on women aged 15-24,
including the 1996 Nepal Family Health Survey.
These papers describe a situation applicable to
many South Asian settings (with the possible
exception of Sri Lanka). Surveys from the late
1990s suggest that over two-fifths of adolescent
girls in Nepal and nearly one-third of those in India
have ever been married. Both Adhikari and Kulkarni
present evidence that a substantial proportion of
young girls enter marriage already malnourished.
For example, a study from three rural areas of
Nepal found that 72% and 45% of girls aged 1014 and 15-18 were stunted and undernourished.
In India, the NFHS-2 found that nearly 15% of evermarried adolescent women were stunted, and
about one-fifth had moderate to severe anaemia.
fggjl
.
II
SaraIh Bott and Shireen J. Jejeebhoy
Figure 3. Per cent of married women aged 20-24 who gave birth by age 20, from national surveys in the
1990s.
70% -i
63
60% -
52
49
50% c
o
o
40% -
(D
CL
30% ’
31
16
20% ’
10% 0%
India
Bangladesh
Nepal
Pakistan
Sri Lanka
Source: Population Reference Bureau (2000) The World’s Youth 2000. Washington, DC, Population Reference
Bureau, Measure Communication.
The combination of poor nutrition and early
childbearing expose young women to serious
health risks during pregnancy and childbirth,
including damage to the reproductive tract, maternal
mortality, pregnancy complications, perinatal and
neonatal mortality and low birth weight.
International analyses suggest that, at the global
level, girls aged 15-19 are twice as likely to die
from childbirth as are women in their twenties, while
girls younger than age 15 face a risk that is five
times as great (United Nations Children’s Fund,
2001). These sources report that more adolescent
girls die from pregnancy-related causes than from
any other cause (Population Reference Bureau,'
2000). Kulkarni and Adhikari support such findings
with data from India and Nepal. For example, studies
from Nepal found higher rates of obstetric morbidity
among adolescents than among adult women, as
Table 7.Childbearing among adolescents in South Asia and other selected Asian countries
Country
South Asia
Bangladesh
India
Nepal
Pakistan
Sri Lanka
Other Asian countries
China
Indonesia
Philippines
Thailand
Viet Nam
Per cent of
women aged
20-24 who
gave birth by
aged 20*
Per cent of TFR
attributed to
births by
mothers aged
15-19*
Teenage fertility
rate (births per
1000 girls
aged 15-19)
circa 1999**
Per cent of births
to women aged 15—
19 attended by
trained personnel*
63
49
52
31
16
18
18
13
9
5
140
107
117
100
21
14
34
14
17
82
8
31
21
24
19
1
11
6
20
5
15
57
43
76
na
na
32
51
61
76
na: not available; TFR: total fertility rate
Sources: *Population Reference Bureau (2000) The World's Youth 2000. Washington, DC, Population Reference Bureau,
Measure Communication. **World Bank (2001) World Development Indicators. Washington, DC, World Bank.
I
Adolescent sexual and reproductive health in South Asia: an overview
well as a 25-66% higher incidence of low birth
weight among children of adolescent mothers. Both
authors report considerably higher rates of neonatal
and infant mortality among children of adolescent
mothers. Despite greater risks, both authors cite
evidence that adolescents do not receive more
antenatal or intrapartum care than older women.
Adhikari argues that adolescent girls in Nepal
actually receive less prenatal care than older
I
gathered retrospective data from women who
married as adolescents. Most women in these
studies reported that they were unprepared for, and
ignorant about, sexual intercourse until the first
night with their husbands. Many experienced some
form of sexual coercion, and many described their
first sexual experience as traumatic, distasteful,
painful and involving the use of physical force.
women.
The social context of early marriage
Within the age- and gender-stratified family
structure that characterizes much of South Asia,
mg, newly married women are particularly
powerless. The average adolescent bride is unlikely
to have had a say in the decision about whom or
when to marry, whether or not to have sexual
relations, and when to bear children. On the
contrary, society often places strong pressures on
young women to prove their fertility, and, in many
settings, bearing sons is the only means by which
young women can establish social acceptance and
economic security in their marital homes. Lack of
autonomy within their marital homes often means
that married girls have limited access to health
care or participation in decisions about their own
health. For example, Kulkarni notes that in some
' iian states, such as Maharashtra and Madhya
Hradesh, fewer than one-third of adolescent women
surveyed reported any involvement in decision
making about their own health.
Two papers in this collection focus on the social
context of married adolescents. Both Chowdhury
(Bangladesh) and George (India) present qualitative
findings from small-scale, in-depth studies with
select groups. Findings from these studies are not
necessarily representative of larger populations,
but they provide an important complement to the
quantitative evidence, by describing experiences
of new wives and mothers in their own words.
George highlights young wives’ lack of sexual
autonomy in a review of two qualitative studies
among poor urban women in India. Those studies
I
!
Chowdhury presents preliminary findings from a
study on first-time parents in Bangladesh. Women
reported that they did not have a choice as to whom
or when to marry, or when to begin childbearing.
As echoed by many papers in this collection (for
example, see Rashid), many male and female
respondents told researchers that they would have
liked to have waited longer before getting married.
Lack of decision-making authority permeated all
aspects of young women's lives—including food
intake during pregnancy, workload, mobility, and
access to health care. Young women reported
heavy workloads during pregnancy, which only
increased after the birth of their child, and some
expressed great unhappiness about their situation.
I
I-
Other papers in this collection explore the context
of early marriage as one among many issues that
concern adolescents. Though it was not the central
focus of their research, Waszak, Thapa and Davey
describe similar experiences involving young
married women in Nepal, based on 71 focus group
discussions. Young women suggested that young
pregnant girls often have low priority when food is
distributed in their husbands’ family. Heavy
workloads are common and supported by local
beliefs such as: “the more you work, the lighter
your body becomes and easier it is at delivery .
Newly married girls are expected to tolerate sexual
coercion from their husbands, to prove their fertility
as soon as possible after marriage, and to allow
family elders to limit their food intake and health
care during pregnancy.
Many authors in this collection argue that girls who
postpone marriage and stay in school longer are
better off than those who marry early. This is not
only because they will reach physical maturity
11
* Sarah Bott and Shireen J. Jejeebhoy
before childbearing, but also because they may
be better able to negotiate with their in-laws and
voice their own needs.
Social and economic factors behind early
marriage
Many papers in this collection examine why early
marriage persists in South Asia. Again, such
research findings tend to emerge from qualitative
studies that cannot be generalized to the
tremendously diverse population of South Asia as
a whole. Furthermore, it is important to note that
marriage trends are in flux, and average age at
which girls marry in South Asia is rising.
Nevertheless, this collection of studies offers
important insights into the factors that contribute
to early marriage among girls—in the words of both
adolescents and their parents.
Rashid presents findings that emerged from focus
group discussions in the Nilphamari district of
Bangladesh. In this district, girls still marry as
young as age 11. Mothers explained that the main
reason for early marriage was parents’ fear that
daughters would be raped, become pregnant or
elope. The knowledge that a girl has had premarital
sex (even resulting from rape) can ruin the status
and reputation of the entire family. Respondents
suggest that attitudes towards early marriage may
be changing, as parents increasingly appreciate
the value of education and the negative health
consequences of early childbearing. Nevertheless,
they noted that parents who wait too long to marry
their daughters often face community pressure,
including derogatory comments from community
elders. Chowdhury also cites evidence that early
marriage of girls in Bangladesh may stem from
financial pressures, a father's death or a large of
number of daughters.
Waszak, Thapa and Davey analysed focus group
discussions (FGDs) held in 11 districts in Nepal.
During FGDs stratified by age, sex, marital status
and residence, researchers explored gender norms
that affect work, education, marriage and
childbearing among young people aged 14-22. On
12
the one hand, respondents suggested that families
have increasingly recognized the benefits of
education for girls (though parents still generally
invest more resources in sons). On the other hand,
families face social pressure to marry their
daughters early as a way to protect their
“character”. The longer a girl stays at home, the
longer she is at risk of running away or having a
love marriage—all of which could bring dishonour
on the family. Adolescents described norms that
condone premarital sexual activity among boys,
but ruin girls who do the same. Parents’ fear about
their daughters’ sexual chastity often pressures
them to end their schooling and arrange early
marriages. Marriage usually ends a girls’
education, because her increased household
responsibilities are generally incompatible with
attending school. The respondents also described
how gender norms pose different challenges for
young men. Pressure to achieve financial stability
before marriage often forces them to delay
marriage, increasing pressures and opportunities
for young men to engage in unsafe sexual activity.
Attitudes and risk behaviours of unmarried
adolescents
Given highly conservative attitudes about sex in
South Asia, few studies have successfully elicited
information on sexual behaviour. Most explore
premarital rather than marital sex, men’s behaviour
rather than women’s, and young people’s current
experiences or retrospective experiences of adults.
Samples tend to be small and drawn from urban
areas rather than rural communities or slums.
Results, therefore, tend to be unrepresentative of
the general population. While generalization is
difficult, findings of the few available studies (see
for example, Jejeebhoy, 2000, for India; or Abraham,
this volume) generally suggest that between 20%
and 30% of young men and between 0% and 10%
of young women report premarital sexual
experience. Sexual initiation occurs earlier than
many assume, and is often unplanned and
unprotected. Moreover, as noted in many papers
in this volume, substantial proportions of young
men report having sex with sex workers—usually
without condoms.
'■
Adolescent sexual and reproductive health in South Asia: an overview
Several papers in this collection present findings
on the sexual behaviour and attitudes of South
Asian adolescents before marriage, including
studies from Bangladesh, India. Nepal, Pakistan
and Sri Lanka. Understandably, these studies are
quite diverse, having used different methodologies
among diverse populations. Study populations
included low-income urban college students in
India, young people from provincial settings in
Pakistan and a nationwide sample in Nepal.
Methodologies ranged from a combination of
qualitative and quantitative in India and Sri Lanka,
to a pilot survey in Pakistan, and focus group
discussions in Nepal and Bangladesh.
studies suggest that most South Asian
adolescents have conservative attitudes towards
marriage and sex. For example, in studies from
Bangladesh, Nepal and Sri Lanka, young people
told researchers that they generally disapprove of
love marriages, premarital sex (particularly by
girls), and often for that matter, social interaction
between unrelated women and men. In some
cases even the hint of a friendship with a boy can
ruin a girl’s reputation, her marriage prospects and
the social status of her entire family. While few
studies have considered social constraints on
adolescent boys, it is clear that their behaviour is
less closely supervised than that of girls. Many
jung people feel that society condones premarital
sexual activity among boys and even puts social
pressure on boys to become sexually active at an
early age.
Rashid presents findings from discussions with
adolescents in Bangladesh about love and
romance. Most adolescents did not approve of
“love” (prem) and instead felt that young people
should marry whomever their parents chose for
them. They described heavy sanctions and
punishments that befall girls discovered to be
involved in sexual relationships. Nevertheless,
some respondents expressed attitudes that—in
the author’s view—were “considered unthinkable
for previous generations”. For example, some had
secretly fallen “in love”. Many distinguished
between “pure" love as a relationship that leads to
marriage, and “impure” love as a relationship that
does not lead to marriage or involves sex.
Abraham presents focus group discussion and
survey data gathered among low-income, urban
college students aged 16-18 and 20-22 in
Mumbai. Young respondents reported friendships
with members of the opposite sex, despite strong
parental disapproval of such behaviour. The author
describes different categories of friendship,
including platonic (bhai-behen), romantic with the
intention of marriage (“true love”) and transitory
sexual relationships (“time pass”). The boundaries
of these categories are fuzzy, as is the extent of
physical intimacy. Authors note that many
researchers have not adequately explored different
kinds of sexual activity. While only 26% of young
men and 3% of young women reported penetrative
sex, as many as 49% and 13%, respectively,
reported other forms of physical intimacy. Young
women almost unanimously reported monogamous
and committed relationships. By contrast, young
men reported a range of partners, including sex
workers and “aunties” (older married women in the
neighbourhood).
Silva and Schensul report considerable premarital
relationships between young men and women in
Sri Lanka, according to survey data gathered,
among low-income youth and university students
aged 17-28. Contrary to what the authors
expected, this study found that university students
were somewhat more likely than less educated
young people to oppose premarital sex among
women. Similar to the study among Indian college
students, young men were considerably more
likely than young women to approve of premarital
sexual activity. Unlike the Indian case, however,
differences between women and men reporting a
“love partner" (not necessarily a sexual partner)
were marginal. Over 50% of both young women
and young men reported having such a partner.
This study found that young people generally
preferred behaviours perceived to protect female
virginity, such as inter-femoral and other forms of
non-penetrative sex. Even so, as in India, a large
.13 -
*
Sarah Bott and Shireen J. Jejeebhoy
number of young boys and men reported sexual
relations with commercial sex workers.
Bhuiya and colleagues present findings from a
community-based survey in two rural sites in
Bangladesh, which found relatively lower rates of
premarital sexual activity among 2626 unmarried
adolescents aged 13-19. In this study, 9% of 1462
boys and three of 1164 girls had ever engaged in
premarital sexual relations. (Two of the three girls
reported forced sex.) Once again, evidence
suggests that sexual relations are often unsafe
and sometimes non-consensual. Two-fifths of the
sexually experienced males reported sex with
commercial sex workers. Less than one-quarter
of sexually experienced males reported condom
use at first sex. Twelve per cent reported a sexually
transmitted infection (STI) symptom in the previous
six months, and 6% (7 adolescents) reported having
experienced coerced sex.
Non-consensual sexual activity among adolescents
As a taboo subject, sexual violence is rarely
reported or studied. Hence it is difficult to estimate
how many young people suffer from sexual abuse,
violence, coercion, incest, rape or sexual
trafficking. Nevertheless, evidence suggests that
a disturbingly large number of adolescent girls and
boys are subjected to coercion in South Asia.
Several small studies suggest that sexual coercion
and rape often occur within marriage, and
adolescents may be more likely to experience such
violence than older women. Sexual coercion can
have considerable health consequences, including
sequelae related to unsafe abortion.
Many papers in this collection cite evidence of
sexual coercion against young people, including
Waszak, Thapa and Davey (Nepal), George (India),
Bhuiya et al. (Bangladesh), and Qazi (Pakistan).
Three papers from India explore sexual coercion
in more depth, including papers by Ramakrishna
et al. among street boys in Bangalore, by Sodhi
and Verma among young people in a low-income
area of Delhi, and by Patel et al. among school
going adolescents in Goa. None of these studies
.
y. -i
14
was designed to explore sexual coercion
exclusively; instead they focused on coercion as
one of several risk behaviours. Given the sensitive
nature of the topic, researchers typically learned
the most about these experiences from in-depth
interviews rather than surveys.
As one might expect, evidence suggests that street
children are highly vulnerable to coercion.
Ramakrishna and colleagues offer insight into the
context of coercion among street boys in
Bangalore, a city with an estimated 85 000100 000 street children. Using a variety of
qualitative methods and sample recruitment
strategies, their study found that some 74 of 121
street boys aged 9-21 were sexually experienced.
Forty had their first sexual experience by age 12.
A large proportion of boys reported coercive
experiences, both as victims and perpetrators,
often involving exchange of money, gifts or other
favours, as well as physical force. Sexual coercion
is so pervasive on -the streets that street boys
rated rape and forced sex as among the most
pleasurable ways of seeking sexual
gratification. Authors argue that social
conditions, poverty and drug use shape
concepts of sexuality and coercion among
street boys.
Sodhi and Verma’s study among low-income
adolescents in Delhi, India, supplements this profile
of coercion. During 71 in-depth interviews with
youth, respondents described widespread verbal
harassment of women as well as 32 instances of
sexual coercion, including forced sex. Both girls
and boys reported experiences of coercion,
including cases in which girls were forced to
engage in sex against their will, sometimes with
multiple partners. Double standards are pervasive,
and young women who experience forced sex often
face severe reprisals should their experience be
disclosed. Some are even forced to continue
coercive relationships under threat of disclosure
from the perpetrator. Echoing other studies in this
collection, young married women also reported
widespread marital rape, which they tended to view
as “normal” male behaviour.
Adolescent sexual and reproductive health in South Asia: an overview
Patel and colleagues present the findings of a
survey that explored the prevalence and
consequences of abuse and violence among 811
students in the first year of higher secondary school
(average age 16). Researchers asked adolescents
about forced or unwanted verbal or physical sexual
coercion in the last 12 months. As many as onethird of students—both male and female—reported
a coercive experience in the past year, and 6%
reported forced sexual intercourse. Nearly half of
all adolescents who experienced coercion reported
more than one such experience. Students and
friends were the most commonly reported
perpetrators, followed by strangers, neighbours and
others; abuse by parents and teachers was also
. jported. Most suffered the abuse in silence. The
authors found strong associations between forced
sex and and a number of variables, including poor
school performance, self-reported mental and
physical health and subsequent consensual sexual
relations.
Together these studies suggest that for many young
people, homes, schools and neighbourhoods do not
provide a safe and supportive environment. Societal
norms and double standards often perpetuate
violence by condoning harassment and abuse
perpetrated by young men, while blaming victims.
Their findings suggests that researchers and
Brvice providers need to pay more attention to
factors such as violence and sexual abuse that
impact young people’s mental and emotional
health.
Adolescents’ use of condoms and contraceptives
In light of evidence that substantial proportions of
South Asian adolescents are sexually active, many
papers in this collection explored the extent to
which adolescents take measures to protect
themselves from unwanted pregnancy and STIs.
At the global level, adolescents are far less likely
than adults to use contraception, either in or out
of marriage. Not all contraceptive methods are
suitable for adolescents, and those that are
appropriate may be inaccessible or simply
unavailable. Not surprisingly therefore, a
substantial proportion of sexually active
adolescents—both married and unmarried—have
an unmet need for contraception and are at risk of
STIs, including H1V/AIDS.
While an array of contraceptive methods exists,
evidence of their suitability, safety and efficacy
among adolescents is incomplete. Questions
remain about their clinical performance and their
effects on adolescents who have not reached
physical maturity. Meirik reviews the existing
literature on these issues, which suggests that
certain
methods,
such
as
Depotmedroxyprogestrone acetate (DMPA) and the
intrauterine device (IUD), are not advisable for
adolescents. While evidence is still inconclusive,
some data suggest that DMPA may reduce
adolescents’ bone mass, thereby increasing the
risk of fracture later in life. Concerns about the
IUD arise from its possible link with increased risk
of pelvic inflammatory disease (RID), to which
young women are at higher risk than adult women.
In contrast, recent evidence demonstrates that
combined oral contraceptives do not adversely
affect either the maturation of the hypothalamicpituitary-ovarian system or the risk of breast cancer
later in life, as was previously feared. The author
argues that combined oral contraceptives and
male condoms are clearly safe for adolescents.
However, he notes that only condoms offer dual
protection against unwanted pregnancy and STIs,
including HIV.
Pachauri and Santhya’s review of available data
on married adolescents’ contraceptive use in South
Asia confirms that the proportion of married
adolescents who use contraception in these
countries remains low, even though significant
minorities of young women say they want to delay
or space births. In large surveys, 41 % of sexually
active married adolescents aged 15-19 in Nepal
reported an unmet need, as did 16% in
Bangladesh, 14% in India and 8% in Pakistan
(Table 8). In India, Nepal and Pakistan, fewer than
10% of married adolescent women or their partners
practise contraception, compared to about onequarter in Bangladesh and one-fifth in Sri Lanka
*
(I
Sarah Bott and Shireen J. Jejeebhoy
(Alan Guttmacher Institute, 1998). In addition,
discontinuation and failure rates for contraceptive
use are more pronounced among adolescents than
among older couples.The authors argue that the
unmet need for reversible methods is particularly
great. They cite the example of India where the
leading method used by married adolescents is
sterilization, a method that, by definition, cannot
be used to delay or space births.
Few studies have looked at the extent to which
adolescents protect themselves from pregnancy
or STIs during pre- or extra-marital sexual activity.
The few studies that have done so generally focus
on young men’s use of condoms, including papers
in this collection by Tamang and Nepal (Nepal)
and Abraham (India). Tamang and Nepal offer a
rare look at factors that inhibit condom use among
young, unmarried men aged 18-24 in border towns
of Nepal. That study found that nearly one-third of
respondents initiated sexual activity .before age 18,
and more than one-fourth reported “casual" sexual
relations in the previous 12 months, including with
commercial sex workers. Less than half of the
respondents who engaged in casual sex reported
condom use in their last sexual contact. Alcohol
consumption was strongly associated with
unprotected sex. When researchers asked young
men why they did not use condoms, however, the
most common responses were that they did not
feel at risk; they expressed fatalistic attitudes or
they thought that condoms would reduce pleasure.
Abraham’s study also found that male college
students in Mumbai used condoms rarely and
irregularly. Despite the fact that most sexually
experienced young men reported multiple
partnerships, fewer than one in six young men who
engaged in sexual relations with a casual partner
said that they “always" used a condom. All those
who admitted to having sex with commercial sex
workers reported having used a condom at least
once. The majority, however, used them rarely,
and not a single student reported regular use of
condoms during sex with sex workers. Meanwhile,
few young people perceived themselves to be at
risk of contracting an infection. The author notes
that young women seem oblivious to the possibility
that the unprotected sexual behaviour of their future
husbands may eventually expose them to infection,
even if they themselves practise strict abstinence
before marriage.
Numerous factors contribute to low contraceptive
use rates among adolescents, ranging from lack
of knowledge to gender imbalances that prevent
communication between partners and exclude
young women from decisions about when to have
children. Pachauri and Santhya note that while
adolescents' awareness of at least one method of
Table 8. Current contraceptive use among adolescents (aged 15-19) in South Asia and other
selected Asian countries
Country, year of survey
South Asia
Bangladesh 1997
India 1998-1999
Nepal 1996
Pakistan 1996-1997
Sri Lanka 1987
Other Asian countries
Indonesia 1997
Philippines 1998
Thailand 1997
Per cent of married
women aged 15—19
currently using any
method of contraception
Estimated per cent
of women aged 15-19
with an unmet need
for contraception
33
19
27
8
7
6
20
41
23
na
36
9
18
32
na
43
Sources: All figures from Demographic Health Surveys cited in Pachauri & Santhya (2002).
16
Adolescent sexual and reproductive health in South Asia: an overview
contraception is nearly universal in South Asian
countries (with the exception of Pakistan),
adolescents are not necessarily aware of reversible
methods that might be most appropriate for their
situation, such as oral contraceptives or condoms.
Furthermore, many young couples do not know
how to obtain such methods or understand how to
use them correctly. As many papers in this volume
illustrate, adolescents who want to protect
themselves from pregnancy and STIs/HIV face a
host of obstacles including lack of access to
services, poor quality of care, and provider attitudes
that adolescents find threatening, disrespectful or
indiscrete.
and accurate instructions, as well as efforts to raise
awareness among both potential users and
distributors about how to use EC correctly and
how to choose a contraceptive method that is
appropriate for regular or long-term use.
Unplanned births and induced abortion among
adolescents
Because so many adolescents have sex without
protection (both in and out of marriage), the
proportion of adolescent births that are unplanned,
unwanted or mistimed is relatively high, as
illustrated by Figure 4, reprinted from Pachauri and
Santhya (this volume).
w studies have explored the ways that provider
attitudes may inhibit contraceptive use among
unmarried adolescents. Two papers in this
collection shed light on this issue, including Gao
et al. (China.) and Naravage (Thailand). Gao and
colleagues provide a rare look at provider attitudes
in China. They report that as many as 40% of
providers disapproved of supplying contraceptives
to unmarried young people. Their findings suggest
that even in settings such as China, where family
planning is so well accepted, provider attitudes may
discourage sexually active unmarried youth from
using methods to protect themselves against
unwanted pregnancy or STIs.
tmergency contraception (EC) has increasingly
been recognized as a useful backup method for
adolescents who have unprotected sex, but few
studies have explored the acceptability or use of
EC among youth in South Asia. The paper by
Naravage suggests that misinformation and
barriers to access may undermine the potential
benefits of EC. The study found that both
distributors and purchasers had a poor
understanding of how to use EC correctly.
Furthermore, young women told researchers that
they were reluctant to purchase EC for fear of
disclosing the fact that they were sexually active.
Many purchasers reported using EC incorrectly or
using it on a regular basis, which is contrary to its
intended purpose. These findings suggest that the
introduction of EC must be accompanied by clear
Worldwide, many unplanned births end in induced
abortion, often under unsafe conditions. Data on
the numbers of adolescent abortions are scarce,
but estimates for developing countries range from
1 to 4.4 million (McCauley & Salter, 1995). Some
evidence suggests that adolescents—particularly
unmarried adolescents—are more likely than older
women to seek abortions from untrained providers,
to undergo second trimester abortions and to suffer
complications. Fear, shame and lack of access to
both services and resources inhibit adolescents
from seeking safe and early abortions on the one
hand, and from seeking care in case of
complications on the other (Bott, 2000).
The abortion scenario varies considerably within
South Asia. In India, abortion has been legal since
1972, but limited availability and poor service
quality keep safe abortion beyond the reach of
most poor women. In Bangladesh, abortion has
been available since 1999 for up to 12 weeks of
gestational age in the form of “menstrual
regulation", and large proportions of women use
these services. In Sri Lanka, abortion is legally
restricted, but available, and women have access
to relatively safe services. In Nepal and Pakistan,
it remains severely restricted and women who
undergo an abortion are liable to prosecution.
Few studies have explored the context of abortion
among young women in South Asia. The majority
i
i
Sarah Bott and Shireen J. Jejeebhoy
Figure 4. Per cent of births to married adolescent girls that are unplanned in selected countries of
South Asia and South-East Asia
40% i
37
35% -
32
§o
to
30
o
30% -
O
TD
CO
■o
O
25% -
29
21
CO
E
o
co
_c
•e
20% 15
13
15% -
11
•o
CD
9
c
c
10% -
c
Z)
5% -
_CO
CL
0%
Philippines
T haloid
Sri Laika
Nepd
Ba^gadesh
I nd a
Met Nan
Pcfcistcn
Incfcnesia
Sources: Figure reprinted with permission from Pachauri & Santhya, this volume, Figure 3, p. 111. Data for:
Bangladesh: National Institute of Population Research and Training et al. (1997); India: International Institute for
Population Sciences (UPS), Macro International (2000); Indonesia: Central Bureau of Statistics (CBS), Indonesia et al.
(1998); Nepal: Pradhan A et al. (1997); Pakistan and Thailand: Alan Guttmacher Institute (1998); Philippines:
National Statistics Office (NSO), Philippines et al. (1999); Sri Lanka: Department of Census and Statistics, Sri Lanka
et al. (1998); Viet Nam: National Committee for Population and Family Planning (NCPFP), Viet Nam et al. (1999).
of these studies have been hospital-based rather
than community-based, urban rather than rural, and
conducted among married women rather than all
women. Two papers in this collection, Akhter
(Bangladesh) and Ganatra & Hirve (India) present
rare data on adolescent abortion. Their evidence
paints a disturbing picture.
Akhter reviews various studies from Bangladesh.
Because abortion services are available only up to
the 12th week of pregnancy, women who want such
services must recognize their pregnancy as early
as possible. This poses a major obstacle for
adolescent girls who may not recognize their
pregnancy or find the resources to access services
in time. Akhter reports that while adolescents
constituted 9% of women who received services
from “menstrual regulation” clinics, they constituted
15% of those rejected by the clinics, presumably
because their pregnancies were too far along. As
a result, many adolescent girls are hospitalized
for complications of induced abortion after
undergoing an abortion by traditional birth
attendants or after attempting to self-induce. About
half of these girls resorted to unsafe methods such
as inserting a solid stick or rubber catheter, or
ingesting medicines. Researchers observed life
threatening complications such as severe infection,
mechanical injury to the cervix or vagina, and
evidence of a foreign body having been inserted
into the vagina, cervix or uterus. Awareness and
prior practice of contraception were found to be
limited among young women in the study.
I
Ganatra and Hirve describe a rare community
based study of abortion in a rural Indian setting.
The study found that young women age 15-24
constituted over half of all abortion-seekers in the
area. About 14% of married women who had
recently experienced an induced abortion were
younger than age 20, and another 40% were aged
21-24. Although abortion among unmarried women
in India is a highly sensitive topic, researchers were
able to identify 43 unmarried adolescents who
admitted to having had an induced abortion. Their
results suggest a number of important differences
i
i
Adolescent sexual and reproductive health in South Asia: an overview
between married adolescent and adult abortion
seekers. First, adolescents reported considerably
less decision-making authority than older abortion
seekers. They were less likely to have been allowed
a major role in the decision, more likely to have
been coerced into an abortion, and conversely,
more likely to have faced opposition from their
families. As in Bangladesh, young women’s
knowledge about and use of contraception were
limited, yet their need to space births was a leading
reason for seeking abortion. Finally, providers were
more likely to insist on spousal consent from
younger abortion-seekers than from adult women,
even though such consent is not legally required.
.,ie study found several important differences
between married and unmarried adolescent
abortion-seekers. While no evidence indicated that
married adolescents delayed seeking services
compared to older married women, it was clear
that unmarried adolescents sought abortions
further along in their pregnancy than their married
counterparts. While married adolescents preferred
the private sector, unmarried adolescent abortion
seekers reported higher use of traditional providers
as a result of less family support, less money,
and concerns about confidentiality and provider
attitudes. Adolescents tended to believe that
abortion services were not legally available to
imarried women. Researchers also found that
some providers charged unmarried women a higher
price for their services. Regardless of marital
status, however, almost three-quarters of
adolescent abortion-seekers reported post-abortion
morbidity. Drawing on findings from other studies,
the authors suggest that deaths related to
abortions and unwanted pregnancies account for
a significantly larger proportion of pregnancy-related
deaths among adolescents than among older
women. They also noted that suicides related to
unwanted pregnancy constitute a substantial
portion of maternal deaths in the area.
on AIDS in Asia and the Pacific, Peter Piot, the
Executive Director of the Joint United Nations
Programme on HIV/AIDS (UNAIDS), stated his
conviction that, “Asia and the Pacific hold the key
to the global future of the epidemic”. Compared to
the African region, many Asian countries have seen
only limited spread of HIV. Nonetheless, several
worrisome indicators suggest that South Asia is
at risk of sharp future increases in the numbers of
HIV/AIDS cases. Estimates suggest that nearly
four million people were living with HIV/AIDS in India
by the end of 2000, and some surveillance sites in
Southern India have found that more than 2% of
pregnant women are infected with HIV (Monitoring
the AIDS Pandemic & Joint United Nations
Programme on HIV/AIDS, 2001). Sex workers
throughout the region are at higher risk, as are
men who purchase sex, and their wives. As several
studies in this collection suggest, this situation
poses a serious concern for male adolescents,
young men and their future wives.
Reproductive tract and sexually transmitted
infections among adolescents
In their global overview, Mane and McCauley
discuss the physiological, behavioural and social
risk factors surrounding STIs/HIV among
adolescents. They point out that physiologically,
adolescents are more vulnerable to STIs than
adults, and girls are more vulnerable than boys.
Gender power imbalances, societal norms, poverty
and economic dependence all contribute to young
people’s risk of STIs. Many young people lack
control over the choice of their marital and sexual
partners, how many partners they have, the
circumstances and nature of sexual activity and
the extent to which sex is consensual or protected.
Many lack information about condoms or are
unaware of the risk. It is not surprising, therefore,
that global estimates suggest that more than half
of all new HIV infections occur among young people
age 15-24. Mane and McCauley note that the
pandemic also has an impact on young people
who live with an HIV-infected parent. For these
young people, adolescence ends prematurely. They
often face early withdrawal from school and entry
into economic activity, stigma, poverty and
psychological suffering from losing a parent.
In his address to the 6th International Congress
Few researchers have studied reproductive tract
9
'
f
Sarah Bott and Shireen J. Jejeebhoy
infections (RTIs) or STIs among South Asian
adolescents. Nonetheless, evidence suggests that
young people constitute a neglected but high-risk
group. The typical STI patient is a young man barely
out of adolescence (modal ages are 20-25), of
relatively low socioeconomic status. Likewise, the
proportion of young women attending STI clinics
has been, increasing (see, for example,
Ramasubban, 2000).
Girls who marry early begin sexual activity when
they are physiologically more vulnerable to
infection. Boys who have unprotected sex expose
not only themselves but also their future wives to
infection. Since discussion of sex is taboo, young
oeople often lack reliable information and
misconceptions abound. Gender imbalances
ensure that girls are particularly uninformed about
their bodies and STIs. With limited power to
negotiate safer sex, young women in South Asia
are at risk of STIs/HIV no less than young men.
Young people who experience an STI suffer not
only health consequences, but also shame and
social stigma. Fear of reprisal often prevents young
people from getting timely treatment for an STI,
thus worsening the situation and facilitating HIV
infection.
Several studies in this collection highlight the
prevalence of reproductive tract infections, including
STIs among adolescents, particularly among girls.
Kulkarni and Adhikari cite evidence from India and
Nepal that adolescent women report relatively high
rates of gynaecological morbidities—of particular
concern in settings where girls have limited access
to adequate health care. The 1998-1999 NFHS-2
in India found that nearly two in five ever-married
adolescent women reported some reproductive
health problem.
Joseph and colleagues present a rare community
based study of RTI prevalence, among 451 married
women aged 16-22 in rural Tamil Nadu, India. This
study found alarming levels of morbidity. As many
as 49% of women in the study suffered from one
or more RTI, not counting cases of infertility,
urinary tract infections and prolapse. Clinical and
20
laboratory examination diagnosed 18% with an
STI, including chlamydia, trichomoniasis and
syphilis. Researchers found that wives of truck
drivers and army personnel seemed more likely
than other women to experience sexually
transmitted morbidity, although the multivariate
analysis found that length of marriage was the only
statistically significant variable. These data clearly
suggest that husbands’ unsafe sexual behaviours
transmit infections to their young wives—an
alarming finding, given that many infected women
are asymptomatic and are unlikely to seek medical
care even when symptoms do appear. In fact, the
authors report that two-thirds of women with
symptoms did not seek care, and among those
who did, over three in four sought treatment from
unqualified sources, such as home treatment or
untrained private practitioners.
Even when adolescents seek care, a host of
barriers may prevent them from receiving
appropriate care. Ranjha and Hussain carried out
research on the Hakims who provide services at
“Sex Clinics” throughout Pakistan and much of
South Asia. These clinics are more accessible and
perceived to be less judgmental than public sector
facilities. They are often the first place that
adolescents seek care. A nongovernmental
organization (SAHIL) in the area found that more
than half of the adolescents seeking counselling
sen/ices at their centres had previously sought care
from Hakims at local sex clinics. Researchers
found that Hakims were poorly informed about
sexual and reproductive health matters and lacked
even the vocabulary to address sexual and
reproductive health issues. They knew little about
STIs, their diagnosis or treatments. Their services
reinforced myths and misinformation and bordered
on outright quackery. The medicine they prescribed
contained potentially dangerous substances such
as appetite stimulants, steroids, male and female
hormones, and narcotics. Additionally, researchers
posing as mystery clients reported incidents of
sexual harassment by the Hakims.
Awasthi, Nichter and Pande report findings from
an innovative, interactive programme designed to
i
f
I
I
t
I
!
Adolescent sexual and reproductive health in South Asia: an overview
raise awareness of risk behaviours and sexually
transmitted infection among some 377 boys
residing in a slum in Kanpur in north India. As other
studies have shown, a sizeable proportion of boys
had engaged in sexual activity, some with casual
partners and some with sex workers.
Misperceptions concerning disease transmission
were widespread, and condom use minimal. The
intervention included three educational sessions
using a host of communication strategies, such
as “teaching by analogy’’ and responding to
questions dropped anonymously in a sealed letter
box. Messages drew upon previously conducted
qualitative research with young males and used
—alogies drawn from events that were familiar to
ti.ese urban slum residents. Exposure to the
intervention succeeded in significantly reducing
misconceptions about STI transmission among
participants—for example, that one can only be
infected by having sex with a prostitute. The
intervention also raised awareness of basic facts
such as the asymptomatic nature of STIs and the
days during a woman's cycle when she is least
likely to become pregnant. The intervention made
some headway in changing the misconception that
taking medicines before or after sex, using a vaginal
birth control tablet or washing the penis after sex
with disinfectant would reduce chances of acquiring
sexually transmitted infections. In short, the study
monstrated that to be effective and acceptable
to young men, STI education requires innovative
and confidential approaches that address both
medical and cultural concerns.
Communication between adolescents and adults
about sexual and reproductive health
Adolescents in South Asia tend to be poorly
informed about their own bodies and matters related
to sexuality and health. The information they have
is often incomplete and confused. Low rates of
schooling, limited access to sex education and
attitudes that prohibit discussion of sex exacerbate
their ignorance. As gatekeepers who should play
a central role in enabling adolescents to protect
their health, parents often obstruct rather than
facilitate informed choice. Adolescents commonly
report that discussions with parents about sex or
reproduction are taboo. In both rural areas and
urban slums, parents often want and expect their
adolescent children, particularly daughters, to
remain uninformed about sex. Educational systems
also tend to be ambivalent about sex education,
though this has begun to change in' the wake of
the HIV/AIDS pandemic. In many cases, sex
education continues to stress biological and
scientific information over broader issues of
sexuality. Teachers often find the topic
embarrassing or shameful, and may avoid such
issues, even in schools that supposedly teach a
family life/sex education curriculum. As a result of
adults’ reticence to address these issues, young
people tend to rely on peers and mass media for
information about sex, reproduction and STIs
including HIV/AIDS.
Qazi presents data from a pilot survey in Pakistan
that explored knowledge about sex and
reproduction among adolescents aged 13-21 . The
survey found that adolescents’ knowledge tended
to be limited, with many misconceptions regarding
pregnancy, contraception and STIs (including HIV/
AIDS). The study also found that although sex and
pregnancy were considered taboo topics of
discussion, many young people do indeed discuss
them, often with peers. Qazi points out that in the
conservative setting of Pakistan, parents are often
reluctant to discuss matters of sex and
reproductive health with their adolescent children,
and many young people do not turn to their parents
for such information.
Bhuiya and colleagues cite similar survey data
suggesting that communication between parents
and children on topics of sexuality and reproduction
in Bangladesh is limited—particularly between parents
and boys. The study found that although a majority of
girls had discussed reproductive health issues with
their mothers, very few boys had discussed such
matters with their parents or other family members,
(2% with fathers, 3% with mothers and 6% with
other family members).
Three papers, namely those by Rashid
r
k
k
3
Sarah Bott and Shireen J. Jejeebhoy
(Bangladesh), ul Haque and Faizunnisa (Pakistan)
and Masilamani (India), explore communication
between adolescents and adults based on focus
group discussions in Bangladesh and Pakistan,
and more informal discussions and programme
experience in India. In all three settings, parents
reported embarrassment about discussing issues
with adolescent children—including menstruation.
They generally preferred to leave this responsibility
to textbooks, teachers and others. In all three
settings, parents argued that they themselves
lacked the knowledge and even the vocabulary to
discuss such sensitive issues. As a result, Rashid
reports that many young girls knew nothing about
menstruation before it began. Unable to ask for
help from their parents, many believed that they
were sick or dying. Concern for the sexual security
and chastity of daughters dominates parental
relationships with adolescent girls. This concern
leads to close supervision of daughters and strict
limits on their mobility. In contrast, sexual activity
among adolescent sons tends to be condoned. In
many cases, as Masilamani notes, parents believe
that talking to adolescents about these matters
will imply approval of premarital sexual activity.
Adolescents perceive discussions with parents
about sexual and reproductive topics to be taboo
and express embarrassment at the prospect. As
a result, adolescents tend to get their information
from peers and the media, despite the fact that
adolescents often express a desire to be able to
turn to parents for information and counsel. These
papers clearly suggest a need for educators and
parents to improve their ability to communicate with
young people.
A fourth paper describes family relationships and
the extent to which these can be dominated by
fear and violence. Bella Patel Uttekar and
colleagues present findings from a study of
domestic violence in the homes of 382 adolescents
aged 10-19 living in a slum area of Allahabad,
India. The authors describe a situation in which
adolescents’ home environments are frequently
characterized by high levels of physical and verbal
violence perpetrated by fathers against mothers
and children. As many as 49% of boysand 16% of
girls reported that they themselves had been beaten by
theirfathers, and a quarter reported that their mothers
were verbally abused or beaten. Clearly, intra-family
dynamics of this nature can severely impede the
ability and willingness of adolescents to
communicate with parents on any threatening
topic, let alone sexual issues.
Programmes that address the sexual and
reproductive health of adolescents
Equipping adolescents to make informed sexualand reproductive choices requires multi-pronged
activities, including efforts to enhance knowledge
and awareness, change attitudes and strengthen
skills, such as the ability to negotiate with peers,
partners and family members. At the facility level,
programmes have tried to design “youth-friendly”
services. At the household and community level,
programmes have tried to enhance parents’ ability
and willingness to communicate with adolescents.
Through a multitude of ways, programmes have
tried to educate young people, build life skills and
address the myriad of concerns that young people
express that go beyond sexual and reproductive
health.
Authors in this collection-highlight several broad,
but important lessons learned from adolescent
programmes. First, evidence suggests that youth
are reluctant to patronize clinics. Hence, the
programmes that do not reach out beyond the clinic
facility are unlikely to reach many young people.
Second, in the process of preparing for adulthood,
young people face a plethora of challenges and
concerns, and projects intended to enhance the
exercise of informed sexual and reproductive
choices among them need to be delivered within
the context of other issues that adolescents
consider to be relevant to their immediate needs.
Finally, effective programmes need to use multiple
strategies. Most effective programmes have not
limited themselves to family planning, clinical
services or education alone. They combined
multiple strategies, including education,
counselling, and building links with services, to
22
«
Adolescent sexual and reproductive health in South Asia: an overview
name but a few. The rest of this chapter reviews
the papers in this collection that focus on
programme experiences and recommendations.
affordable fees, and specially trained staff, central
elements of programmes aiming to communicate
with youth are anonymity and drop-in hours.
Family life end sex education programmes
Rashid describes the efforts of BRAC, an NGO in
Bangladesh that provides reproductive health
education in conjunction with a three-year nonformal education programme conducted for
adolescents who have never attended school.
Introduced in the last year of the three-year
programme (and corresponding to the government
secondary school programme), the curriculum
informs adolescents about puberty, reproduction
and contraception and sensitizes them about
gender equity and responsible relationships.
Tiedemann and DasGupta describe similar efforts
among youth organizations (namely the Scouts
and Guides Associations) in West Bengal, India.
This programme is designed to use the “learningby-doing” approach of the Associations. The
programme involves providing education, building
links with local health providers and training Scouts
and Guides to become peer leaders. Since large
numbers of youth sign up to become Scouts and
Guides in West Bengal, the programme hopes to
reach thousands of young people.
A variety of educational programmes are underway
in the region, implemented by both the public and
nongOVernmental sectors. According to a recent
UNAI DS report, in the wake of new epidemiological
evidence about the spread of HIV/AIDS, as many
as 25% of schools in India will have launched AIDS
education programmes by 2001 (Monitoring the
AIDS Pandemic-MAP & the Joint United Nations
Programme on HIV/AIDS, 2001). Chakrabarti
, cviews population and sex education programmes
within the formal and informal educational sectors
in India. With UNFPA funding and government
collaboration, the National Population Education
Project reached about 154 million students in 2000.
She argues that such programmes must
complement sex education with strategies such
as telephone counselling, peer counselling, life
skills education, health camps, and efforts to
change attitudes and awareness among teachers
and parents.
In addition to governmental efforts to educate youth,
the nongovernmental sector has designed many
novative sexuality education programmes
throughout South Asia, many of which use the
strategies that Chakrabarti recommends. Case
studies in this collection illustrate such efforts,
including programmes run by Indian
nongovernmental organizations (NGOs), such as
the Family Planning Association of India
(Brahmbhatt) and Parivar Seva Sanstha (Tewari &
Taneja), that work in schools, colleges, non-formal
education sectors and community-based centres.
Activities include counselling centres that offer
services individually, in groups, by correspondence,
telephone hotlines and a variety of peer-led
activities. In addition, they direct their programmes
at gatekeepers, such as parents, teachers and
sen/ice providers. Both programmes underscore
the importance of flexibility to youth-friendly
services. Aside from convenient locations,
In short, all these programmes include a range of
activities intended to enhance young people’s
knowledge and communication skills, change
attitudes, dispel misconceptions, prevent risky
behaviour and address traditional gender norms. A
typical curriculum addresses physiological
changes during puberty, menstrual hygiene,
reproduction, contraception, gender equity, and
skills needed to manage relationships. In
communities where early marriage for girls is
common, programmes often provide premarital
counselling and sensitization on responsible
parenthood. Nearly all organize peer education,
along with strategies to reach parents, teachers
and service providers. Many emphasize
counselling services, including face-to-face
counselling, written correspondence and telephone
counselling. They all aim to communicate with
young people in direct, non-judgmental yet
culturally sensitive ways.
Sarah Bott and Shireen J. Jejeebhoy
A number of papers in this collection describe
evaluations of programmes that inform adolescents
about sexual and reproductive health issues.
Tiedemann and DasGupta describe the evaluation
pians—including a study/control design—that will
be used to evaluate the programme among Scouts
and Guides in West Bengal. Papers by Teiwari &
Taneja and by Rashid report tentative observations
of changes in awareness among adolescents
exposed to education programmes. Both report a
considerable increase in awareness of issues
relating to sex, contraception and infection. In
addition, Rashid describes how adolescents
exposed to the programme reported improved
menstrual hygiene as well as attempts to break
down communication barriers between themselves
and their parents—in particular about their request
to delaying early marriage. Nevertheless, several
conference participants noted that programme
evaluation remains a weakness of many NGOs.
They argued that policy-makers and donors need
rigorous evidence about which strategies have
produced results and are therefore worth scaling
up.
Building self-efficacy among adolescents
Many programmes include “life skills” either as one
component or as the central focus of their work. In
the early 1990s, the World Health Organization
defined life skills (World Health Organization, 1993;
1994) as the “abilities for adaptive and positive
behaviour that enable individuals to deal effectively
with the demands and challenges of everyday life”.
WHO identified a group of core life skills that
include problem-solving, decision-making, goal
setting, critical and creative thinking, values
clarification, communication skills, inter-personal
and negotiation skills, as well as self-awareness,
self-esteem and understanding how to cope with
stress.
Papers by Seth, and Levitt-Dayal and colleagues
describe life skills programmes in India. Seth
describes a programme that trains teachers to
conduct life skills programmes among youth in
rural Rajasthan. Anecdotal feedback from
24
participating teachers suggested that such training
|
empowered trainers to communicate sexual and |
reproductive health information more effectively and ’
with fewer inhibitions. Preliminary observations also
suggest that such training may benefit teachers
themselves, as well as young people. Levitt-Dayal
et al. describe programmes in rural Gujarat, rural
Madhya Pradesh and periurban areas of Delhi that
aim to enhance life skills among young women.
These programmes use a combination of
nonformal, family life and vocational education,
combined with the provision of services. They give ]
young women the opportunity to learn to use banks
and public transport, to participate in recreational
activities and to receive leadership training. These
programmes are among the few that have evaluated
the impact of their efforts by gathering follow-up
data among their alumnae and among a control
group of girls who did not participate in their
programmes. Compared to controls, alumnae were
more likely to remain in school and to have greater
decision-making authority within their families,
particularly with respect to decisions about when
to marry and whether to continue their education.
The alumnae demonstrated higher levels of selfesteem, assertiveness, mobility and exposure to
media and new ideas. Married alumnae were also
more likely to have married at age 18 years or
older, and were more likely to obtain appropriate
care during pregnancy, compared to those who
had not participated in the programmes.
Making health services accessible and friendly
While the need to provide accessible and friendly
services to youth is generally acknowledged, there
is less clarity about what is meant by “youth
friendly” services. What is evident is that in most
settings, adolescents face obstacles in accessing
health services. Reviewing the global situation,
Epstein, and Chandra Mouli highlight the many
obstacles that may discourage young people from
seeking health care. These include an inability to
access services independently from their families,
fear of discovery by family or community members,
inconvenient locations and hours, long waits at
clinics, high costs, and providers whom
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Adolescent sexual and reproductive health in South Asia: an overview
adolescents perceive to be threatening, judgmental
or unwilling to respect their confidentiality. Using
survey data from Bangladesh, Bhuiya and
colleagues underline adolescents’ reluctance to
use health services. They hold the perceived
unfriendliness of providers responsible for much of
thiS reluctance. Only 1 % of adolescents surveyed
had visited a facility in the prior six months, and
concerns about how they would be treated were
clearly an issue. Only 15% of boys and 1% of
girls believed that providers would treat them with
respect if they sought contraceptive services, and
26% and 7%, respectively, believed that providers
would treat them respectfully if they sought care
£-r STI symptoms. The adolescents’ perceptions
vl pharmacies were similar, if not worse.
The literature often mentions the need for services
to be “youth-friendly”, but this term is not always
clearly defined. However many authors (such as
Epstein, Mehta, Poonkhum, Brahmbhatt, Tewari
& Taneja and Chandra Mouli) note that, when
asked, adolescents generally cite a number of
fundamental characteristics that make services
“youth-friendly”. These include special hours or
settings for adolescents, convenient access, a
place that does not look like a clinic, a place used
by their peers, affordable fees, drop-in hours, staff
who are empathetic, knowledgeable and
jstworthy, staff that are non-judgmental and nonpunitive, and services geared towards young
people’s needs and interests. Epstein points to
adolescents’ need for related services such as
counselling in managing friendships, partner and
family relationships, and life skills development
activities that help young people develop practical
and applied skills in many areas of life.
Few organizations in South Asia have
implemented, let alone evaluated, models for
delivering such “youth-friendly services although
such efforts seem to be on the rise. Chandra Mouli
describes a number of models of youth-friendly
services: integrated comprehensive services that
offer a range of services including sexual and
reproductive; community-based health facilities
that provide stand-alone sexual and reproductive
health services (such as those offered by Marie
Stopes International or Profamilia) orthose that
are offered through a district or municipal health
system; community-based centres that offer an
array of personal development activities and a
limited health focus; and outreach activities
designed to enhance access to services. Chandra
Mouli stresses that priorities in adolescent-friendly
health services need to vary according to the
nature of the health services provided and to the
specific adolescent group to be reached. For
example, approaches that make services friendly
to sexually active males may not be wholly
adaptable to girls in their early adolescent years.
In short, programmes must be tailored to meet
the special needs of the adolescents who are being
addressed, keeping in mind such issues as social
and cultural sensitivities, feasibility and
sustainability. Clearly, strategies should be adapted
to different sociocultural and programme settings,
but what is needed are supportive policies,
involvement of the community and adolescents in
the design of services, and competent and
committed providers.
This volume includes several case studies of youth
friendly services. Bhuiya and colleagues describe
efforts to establish “youth-friendly’’ services in
existing NGO clinics, complemented with other
outreach efforts in north-west Bangladesh. That
project introduced designated hours for adolescent
clients, strengthened privacy and confidentiality,
expanded the range of services offered, and made
an effort to ensure that physicians have the skills
to provided counselling. They supplemented these
services with efforts to educate community
members, provide telephone counselling and
establish community-based reproductive health
programmes for young people.
Two case studies from Thailand (Poonkhum) and
India (Mehta) describe efforts to set up “youth
friendly” services in specially designated areas
within government hospitals. These programmes
involved remarkably similar preparatory steps,
activities and experiences. Both designed the
projects based on discussions with adolescents.
S2W8
* Sarah Bott and Shireen J. Jejeebhoy
Counselling on a variety of topics was the
cornerstone of the projects. To avoid using the term
“clinic”, the project in Thailand delivered services
in “adolescent-friendly rooms”. Services were free
and offered during extended hours. Both maintained
confidentiality through anonymous record-keeping.
The projects developed training materials and fact
sheets (India) or manuals containing frequently
asked questions (Thailand). In addition, they
trained peers, teachers and parents on reproductive
health knowledge and life skills. In Thailand, the
project promoted its services with the help of radio
DJs who had a wide following among adolescents.
Preliminary findings from both interventions
suggest that establishing adolescent-friendly
services at government hospitals is feasible and
sustainable. However, both found it difficult to
attract adolescents to the hospital setting, despite
efforts to promote the services widely. Both found
that adolescents preferred telephone counselling
rather than face-to-face services, probably because
it provided greater privacy and anonymity. In
Thailand, the Department of Health has considered
setting up services in sites outside hospitals that
would be more acceptable to adolescents.
Reflecting on lessons learned from experiences
around the world, Epstein suggests that the public
sector may not be the best entity to deliver such
services. In many settings, adolescents perceive
NGO services to be less threatening and more
acceptable than public services. Furthermore, the
public sector tends to take the clinic-based
approach, the limitations of which are illustrated
by examples in this collection. Several innovative
programmes have explored alternatives in the
private and NGO sectors, such as training
pharmacists or doctors in the private, for-profit
sector to serve adolescents, providing counselling
and contraceptive services at workplaces and
military sites, setting up emergency drop-in
centres, offering special hours or facilities for boys,
developing long-term adult/adolescent mentoring
programmes, and providing discussion
opportunities for young couples on marriage and
parenthood. Given the limited success of public
26
sector programmes, Epstein argues for a model
in which governments support NGOs to scale up
successful adolescent reproductive health services.
1
Regardless of the approach used, Epstein argues
that cross-referrals are crucial, because
adolescents’ needs go beyond the capacity of any
one sector. For example, hotline services need to
establish formal agreements with other services,
such as pharmacies, private physicians,
neighbourhood depot holders, abuse/violence crisis
centres, mental health counsellors, lawyers and
legal services centres, micro-credit facilities, or job
training programmes in order to best serve the
needsofadolescents. Such cross-referrals require
considerable cooperation across public and private
sectors and between organizations that provide
different services to youth.
Finally, Epstein points out that existing
programmes are rarely designed in ways that
facilitate rigorous evaluation. Evaluations of
adolescent programmes tend to rely on pre- and
post-intervention assessments of reproductive
health awareness. Because most programmes
focus on small populations and evaluations do not
include comparisons or controls, it remains difficult
to determine whether an outcome is directly
attributable to the programme alone, and therefore,
whether a finding has programme or policy
implications. Furthermore, while many
programmes measure changes in knowledge, few
are able to measure behaviour change, which would
be a more important indicator of success. Epstein
argues for building rigorous evaluations into all
stages of programmes—a recommendation that
has major implications for those who fund
programmes, because it would require investing
substantial resources in evaluation.
Conclusions
This overview has sought to provide a profile of the
sociodemographic and sexual and reproductive
health situation of adolescents in South Asia. More
significantly, it has attempted to record the
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Adolescent sexual and reproductive health in South Asia: an overview
evidence and insights that emerged at the
onference and to synthesize from these a
c
summary of what is currently known about the
sexual and reproductive health risks and challenges
faCed by adolescents and young people in the
region. The findings generally emphasize the
considerable risks that adolescents continue to
face extending from unsafe or unwanted sexual
activity to such consequences as unwanted
pregnancy, abortion and infection, and from
misperceptions to a lack of life skills and wide
gender power imbalances. They also underscore
the vast obstacles that must be overcome in order
to access contraceptive and other reproductive
aalth information and services.
At the same time, however, several encouraging
signs are evident. The sexual and reproductive
health needs of adolescents and young people are
firmly on national agendas in the South Asian
region. There is growing recognition that
adolescents themselves must be given a role in
articulating and designing such programmes.
Finally, a growing number of programme
experiences already exist that appear to respond
successfully to young people’s sexual and
reproductive health needs in innovative and
acceptable ways.
Nonetheless, throughout this volume, authors
suggest ways in which policy-makers, programme
managers, researchers and service providers could
do more to improve the lives of South Asian
adolescents. The final chapter of this collection
summarizes their recommendations —both for
research and programmes. These recommenda
tions should be seen as a call to action by all
those who care about the well-being of the next
generation.
References
Alan Guttmacher Institute (1998) Into a New World:
Young Women’s Sexual and Reproductive Lives. New
York, Alan Guttmacher Institute.
Blanc A, Way A (1998) Sexual behavior and
contraceptive knowledge and use among
adolescents in developing countries. Studies in
Family Planning, 29(2): 106-116.
Bott S (2000) Unwanted pregnancy and induced
abortion among adolescents in developing countries:
Findings from WHO case studies. In. Puri CP and
Van Look PFA, eds. Sexual and Reproductive Health:
Recent Advances, Future Directions. Mumbai, New
Age International (P) Limited, Publishers.
Brown A, Jejeebhoy SJ, Shah I, Yount KM (2001)
Sexual Relations Among Young People in
Developing Countries: Evidence from WHO Case
Studies. Geneva, World Health Organization, Department
of Reproductive Health and Research (WHO/RHR/
01.8).
Central Bureau of Statistics (CBS), Indonesia et al.
(1998) Indonesia Demograhic and Health Survey
1997. Calverton MD, USA, Macro International.
De Silva W (1997) The Ireland of Asia: Trends in
marriage timing in Sri Lanka. Asia-Pacific Population
Journal, 12(2):3-24.
De Silva W (1998) Socio-economic change and
adolescent issues in the Asian and Pacific region,
Report and Recommendations of the Expert Group
Meeting on Adolescents: Implications of Population
Trends, Environment, and Development. Bangkok,
ESCAP (Asian Population Studies Series, No. 149).
Department of Census and Statistics, Sri Lanka
(1988) Sri Lanka Demographic and Health Survey
1987. Columbia MD, USA, Institute for Resource
Development/Westing house.
Department of Census and Statistics, Sri Lanka
(1995) Demographic and Health Survey 1993 Sri
Lanka. Colombo, Department of Census and
Statistics, Sri Lanka.
Hakim A, Cleland J, Bhatti MH (1998) Pakistan Fertility
and Family Planning Survey 1996-1997. Preliminary
Report. Islamabad, Pakistan, National Institute of
Population Studies and London School of Hygiene
and Tropical Medicine.
International Institute for Population Sciences, Macro
(2000) National Family Health Survey (NFHS-2)
1998-1999: India. Mumbai, International Institute for
Population Sciences.
Sarah Bott and Shireen J. Jejeebhoy
International Labour Organisation (1998) Yearbook
of Labour Statistics 1998. Geneva, International
Labour Organisation.
International Labour Organisation (1999) Yearbook
of Labour Statistics 1999. Geneva, International
Labour Organisation.
International Labour Organisation (2000) Yearbook
of Labour Statistics 2000. Geneva, International
Labour Organisation.
Jejeebhoy S (1993) Family size, outcomes for children
and gender disparities: A case of rural Maharashtra.
Economic and Political Weekly, 28(35):1811-1822.
Jejeebhoy S (2000) Adolescent sexual and
reproductive behaviour: A review of the evidence from
dia. In: Ramasubban R, Jejeebhoy S, eds. Women’s
Reproductive Health in India. Jaipur, Rawat
Publications.
Macro International (2002) Demographic Health
Surveys, Stat Compiler [Online data base available at
http://www.measuredhs.com ].
McCauley AP, Salter C (1995) Meeting the needs of
young adults. Population Reports, Series J, No. 41,
Vol. XXIII, 3 (October).
Mitra SN, Al-Sabir A, Cross AR, Jamil K (1997)
Bangladesh Demographic and Health Survey 19961997. Dhaka, Bangladesh, National Institute of
Population Research and Training (NIPORT).
Monitoring the AIDS Pandemic (MAP), Joint United
ations Programme on HIV/AIDS (2001) The Status
and Trends of HIV/AIDS/STI Epidemics in Asia and
the Pacific, Provisional Report. Melbourne, Australia,
MAP, UNAIDS. [Available at: www.unaids.org/
hivaidsinfo/statistics/MAP/index.html]
National Statistics Office (NSO), Republic of the
Philippines (1999) Philippines National Demographic
and Health Survey 1998, Manila, NSO and Macro
International.
National Committee for Population and Family
Planning (NCPFP), Viet Nam (1999) Viet Nam
Demographic and Health Survey 1997. Hanoi,
NCPFP.
Pachauri S, Santhya KG (2002) Reproductive choices
for Asian adolescents: a focus on contraceptive
behaviour.
International Family Planning
Perspectives, 28(4):186-195.
j
|
j
s
Population Reference Bureau (2000) The World’s
?
Youth 2000. Washington, DC, Population Reference
Bureau, Measure Communication.
■
Pradhan A et al. (1997) Nepal Family Health Survey
1996. Kathmandu and Calverton, MD, Nepal Ministry
of Health, New ERA and Macro International, Inc.
Ramasubban R (2000) Women’s vulnerability: The
recent evidence on sexually transmitted infections.
In: Ramasubban R, Jejeebhoy S, eds. Women’s
Reproductive Health in India. Jaipur, Rawat
Publications:280-330.
Singh S (1998) Adolescent childbearing in developing
countries: a global review. Studies in Family Planning,
29(2):117-163.
United Nations (1997) Demographic Yearbook 1995.
New York, United Nations (ST/ESA/STAT/SER. R/26).
United Nations (1999) World Population Prospects:
the 1998 Revision. Volume II: The Sex and Age
Distribution of the World Population. New York, United
Nations.
United Nations (2000) Demographic Yearbook 1998.
New York, United Nations (ST/ESA/STAT/SER. R/29).
United Nations Children’s Fund (2001) The Progress
of Nations 2001. New York, UNICEF.
World Health Organization (1993) Increasing the
Relevance of Education for Health Professionals.
Geneva, World Health Organization (WHO Technical
Report Series, No. 838).
World Health Organization (1994) The Development
and Dissemination of Life Skills Education: an
Overview. Geneva, World Health Organization (MNH/
PSF/94.7).
i
Nepal Central Bureau of Statistics (1995) Population
Monograph of Nepal. Kathmandu, Central Bureau of
Statistics.
fi
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