If there's one country that has no shortage of adolescents, it's India. With a population of over 1 billion people, half of that population is under the age of 25. And that means that there are over 250 million adolescents in India. And as we've been hearing about over this course, their health needs are changing rapidly. It's pretty exciting that the Indian government recently has introduced a new program that aims to improve the health of India's young people known as RKSK. And I'm particularly pleased that today we have with us Professor Harish Pemde, who is a Professor of Pediatrics at the Lady Harding Medical College in New Delhi in India. And also a senior figure in pediatrics and adolescent health and medicine in India, whose been generous enough to share some of his time with us. Good afternoon Harish. >> Good afternoon and thank you very much for inviting me to this very important initiative regarding adolescent health. >> Thank you. Tell me what do you think are the greatest challenges affecting India's young people growing up today? >> See, you very, very clearly said India has the largest population of adolescents in the world. And challenges faced by Indian adolescents are similar to the challenges faced by adolescents around the world. They also have issue with related to the independence, issues related to their own establishment of identity. And there too concerns of their future, their career. And there are issues related to risk factors for non-communicable diseases. Issues related to substance use, misuse, body image issues, but they also face similar issues. And their challenges are a little more because our health services are still not tuned to provide services to them, to deliver the same for these various issues. So that is why the introduction of the new national health programs becomes very, very important step from the government of India to prepare the health services of India for providing adolescent friendly health services. And that is the reason government has launched this new adolescent health program known as Rashtriya Kishor Swasthya Karyakram in the local, our national language Hindi, RKSK. And this had been launched in last year generally. And the strategy for the program is based on quite a bit everyday base strategy is there. And experts from around the world have been involved in making this program. So I am very hopeful that this program will be very, very successful and will certainly make some dent in the well-being and health of adolescents of India. >> So can I ask you what the plans are then to be how is it expected that Indian health services will be responding to these changing health needs. You've talked about what those needs are and you've mentioned the importance of a policy. What are the implications for health services? >> See, through this program we are aiming to have adolescent friendly health clinics to all the government hospitals. >> Sir, can I push you there, what do you mean by adolescent friendly health clinics? Because I know that in India there has been a history recently of stand alone adolescent reproductive and sexual health services. Is that what you mean, or do you mean something else? >> Yes, before this new national program, we have some other program by the name of Adolescent Reproductive and Sexual Health Program. It was that in many states of India and through that program, some ARSS clinics were established. Maybe by the friendly and unfriendly states. But ministers kept this name, ARSS clinic. So attendance in those clinics were very, very low. Again, reasons may be the name was Adolescent Reproductive and Sexual health clinics. To understand this low attendance, we must consider the values and cultures prevalent in India. In the Indian community, sex outside marriage is looked at very bad thing. People do not even consider it something which is normal. Although, sex outside marriage is quite prevalent, it is increasing. But it still at a societal level it is not acceptable. So if an adolescent is going to those clinics who is not married again, he will think that I will be viewed as someone who is having some sexual illness related to having sex outside marriage. So that is the reason that unmarried persons are not going. As far as reproductive services are concerned, we are very, very friendly to the married persons. There can be married adolescents also. So they had no fear of going to those services. But married adolescents are very less in number. Many services have to be unmarried adolescents, which is a big number, but they were not going to those clinics. Now under the new program, the name will be changed. Under the earlier one there were no dedicated individuals manning those ARSS clinics. Under the new program, for reason is there, that in every clinic there will be two counselors dedicated to that clinic only. They will not be doing any of their work. One male and one female adolescent health counselors will be there. But they will be trained properly in adolescent friendliness. So now in the new services, they will be coordinating the care of adolescence through these clinics. And an attempt will also be made to orient the other staff of that particular health setting to become adolescent friendly. They must have the attitude of helping adolescents. They must not be prejudiced with their own thinking and beliefs. So that they treat adolescent with respect or they will become it. So that attitudanal change has to be brought in to make the service adolescent friendly. Certainly when we get all services adolescent friendly, there should be a flexibility of time, flexibility of appointments and comprehensive services should be available through one place only. >> So, am I right in thinking that this is a very dramatic shift from a focus that has been previously primarily around adolescent reproductive and sexual health services for married adolescents to a focus on continuing to provide and offer sexual and reproductive health services? But including a much more comprehensive suite of services and not being titled sexual and reproductive health? >> Yes. >> But rather having a broader frame and presumably the expectation is from what you're saying that that will be far less stigmatizing and with greater staff training will be more welcoming of young people who are expected to participate much more. Is that the case? >> Yes, certainly like this only earlier services were also for unmarried adolescents, but they were not availing those services. >> Yes. >> Okay, and in the new services the scope has been broadened. Like mental health issues have been brought in. Noncommunicable destructors had been brought in. >> Mm-hm. >> Substantial missiles had been brought in. >> Mm-hm. >> So all the important issues have come in. Nutritionists have come in. They were there a little bit earlier also but focus was not there. >> Mm-hm. >> Now the main focus is on nutrition, mental health services Noncommunicable diseases, gendered race issues, along with the product demand also. So and someone is going to avail those services. >> Mm-hm. I must say it sounds like an incredibly exciting opportunity- >> Yes. >> For India. But equally challenging in terms of the capacity that is needing to be built within Indian health professionals. How are you thinking that this is going to happen? >> In India, the health and provide services. So from the central government, from the government of India, what we have done. We have in rated the key percents from all these states of India. And we have printed them as master tables. So I coordinated technically and academically those trainings. >> Mm-hm. >> So we have trained people, from four to six people from every state of India. That's what has been done. Though they are supposed to train more doctors from the estate. So this training isn´t going on right now. >> Mm-hm. >> And we expect that around 8,000 medical officers, medical doctors will be trained, in coming years. This is one part, then we also plan to train nurses. I mean, three times more this number than nurses we've trained around the country. Then there is a provision of counseling that I explained earlier. So they will also be trained because they will be manning those clinics. For the very important component is there of PR educators. So this new national program has a provision of having PR educators in the community, provision is there that for every 2000 population, there will be four peer educators. So in 2000 population, around 45, 42%, around 400 adolescents will be there. >> Mm-hm. >> So likelihood is there that for every hundred adolescent, one peer educator will be there. >> Can you tell us how these peer educators will be selected or recruited, and obviously, they will need training and supervision as well. How is expected that, that will occur? >> Yes, peer educators will belong to those communities only. >> Mm-hm. >> One boy and one girl from the school site, and one boy and one girl will come from among those who are not going to school. Not going to school. So, we have to catch up with time also. >> Mm-hm. >> So, maybe the local head workers, the field hand worker. Especially in that hours we have a very good system that have been giving a defined population, and given area. We also have a system of ASHA, that is Accredited Social Health Activist. They also look after a small population. So, through them, we shall identify these peer educators. We shall train them. And they will go to the community, to their age mates, and spread the messages of the program. And every three months they would be having a meeting and we would be discussing the various issues they found during that time. And someone, some doctor or nurse, would also appear in those meetings. They would further educate them about the about the various current issues. So this ongoing planning, ongoing education will forever. >> Mm-hm. >> And they'll grow up more than 18-19 years. New persons will join. This very good system has been planned. So through this the government and the health services are going to the services. Because what we feel that not all the are having issues. Come with the health festivities. And not all of them are saying not all patients come to facilities. Around 35, 40% only they come to the government facilities and some of them go to private organizations that this program will not reach. So to reach every this had been emphasized. And we are also looking at it quite excitingly, that how it rolls up and how it influences the health of adolescents. Because this is catering to the adolescent who are otherwise healthy. The good notion is that, if you fall sick, then only you visit the hospital. If you are healthy, you don't go to hospital. But to remain healthy also, one needs some health and support from health services. >> Sure. >> So that is the purpose, to keep our young people healthy so that they can become a productive adult and add to the productive of the nation. >> So really trying to have a focus on prevention. >> Yes. >> In changing the paradigm, rather than simple acute care. >> Yes. This is very much based on the provincial science principals. >> Yup. >> We are trying to have primordial prevention rather than prevention. >> Yup. This program sounds very exciting. There's obviously a piece which is looking at capacity building for health services themselves. And a piece that is focusing on young people as peer educators. I'm also interested, Horatio, in whether there is a component which is looking at building the acceptability within communities, and obviously, particularly, by parents building their understanding of the changing nature of health in young Indians. And the value and opportunities provided from preventive approaches end and date from health services. >> Certainly, parents are a very very important component. Because they influence the life of adolescence greatly. And they need to be that these are doing, so to address those things, certainly when parents come with some issue with other they would welcome those health centers. But all the parents in the county, they will be accessed through various medias like a radio, like print media, like television. In there were some like serious were made on that other issues. Sponsored by Government of India and UNICEF some Syrians were there. >> Mm-hm. >> But Prime Minister he is having regular radio programs. He says it is indeed it means talking from heart. >> Mm-hm. >> Okay he also addressed this a few months ago so the first from the gourmet side reach though he of the community through various media, through print medio, through television, through radio. And through social media, also. >> Mm-hm. >> Our prime minister and the government is becoming more and more active on social media, also. >> Mm-hm. >> So to whatever media it is there, there will be access to and explained various issues that are related to adolescence, to adolescent parenting. Are related to for example. But backward related to exercise related to. All these messages are illegal. >> Mm-hm. >> But they will also come to know what is happening around. >> One of the things that we've been discussing throughout this MOOC Has been the context of health, and in terms of the opportunities for regulatory frameworks to be promoting the health of young people. I'm aware that a very significant number of young Indians become pregnant each year. My understanding of the figures, that it's at least 2 million Indian children, or young adolescents under the age of 15, become pregnant each year. One of the things obviously that that raises in terms of a question is, what's the legal age of marriage in India? >> Yeah, this is quite interesting. The legal age of marriage in India is 18 years for a girl and 21 year for boys. But all the regulations have to be viewed in context with culture and values society has. >> Mm-hm. >> In several communities, in several places, having marriage below those age groups are quite acceptable. So large number of child marriages that we can say then aren't happening. Because it is culturally accepted society accepts them. So generally, regulatory agencies do not take any action on that because they are viewed as something which is very acceptable and normal thing. So when child marriages occur, certainly pregnancies will also occur. So almost all of those pregnancies, very few occur outside of the marriage, very few, rarely. But all of those pregnancies and childbirth aren't happening in marriage. Yes, government is doing lots of education and activities, lots of publicity, for the consequences of child marriages. Certainly we do not promote child marriages and we tend to reduce the number of child marriages. But fact is that they are happening, and certainly not supported by any regulations. >> What do you think the opportunities are for education in those communities, and if it's to try to promote continued participation in education for girls? >> Yes, we also feel that educating a girl child is the strongest intervention which anyone can make. So a girl child who is educated is much less likely to get married. And several of the steps, initiatives, are being taken by the government. You will find it very small issue, but is a great issue that not having proper, adequate toilets in a school becomes one thing where girls do not go to school. So, our Prime Minister has this initiative of providing proper toilets in the schools so that school attendance improves, especially for the girl child. So such initiatives are being taken to make them educated. So once they have education, probably they will not be, I cannot say, but a victim of child marriage. >> Clearly, one of the most important layers within a health service is primary care. But I'm aware that in India there's also a growing focus on specialist services and hospital services for adolescents. And I'm interested in what your thoughts are about what the priorities should be within specialist health services in terms of improving the quality of care that's delivered to adolescents in India. >> Yes, currently focuses on to have primary physicians for adolescents. >> Mm-hm. >> And certainly when primary services are being provided, then we do need secondary and tertiary services for adolescents. So, time has come that government should also focus on providing, especially services toward adolescents. The program itself does not have that component of providing specialist services. But yes, as a health care professional, I think the need will soon be there to have specialist services. And people like me and those who are entrusted in developing themselves as an adolescent health expert. So they will have to take their own initiative to learn more about it and provide specialist services. And through various academies and the professional associations, efforts are being made to train people, to educate them, and to bring them to the level of adolescent health specialists, so that they can provide services, either in government or in private. One very important step for making, especially with health services, will be, and it should be and it will be, having some kind of post graduation, regular post graduation course in order to send help. So if for next three, four years, this will be my personal attempt to have an accredited course, post graduation course, in medical education, and probably in nursing education also, so that we can have our own adolescent experts being trained in the country. So as we start, we can spread it, and we can then have our own adolescent health experts. >> And do you think that there would be support for that type of accredited post graduate course within India's medical organizations, for example? >> This newness in the program strategy already has as a policy that adolescent health will be included in the graduate and post graduate curriculum. So once we have a policy of making it, we have to turn into some program and bring it to the light, so that we have some actual programs running for making adolescent health experts. >> Well, it certainly doesn't sound like you're going to be short of activity over the next few years to be rolling that out. So I certainly wish you well with that. >> Thank you so [INAUDIBLE] >> As we all know, tobacco smoking is a very major problem in terms of the health of adults in many countries. And the concern for countries like India is that the rapid increase in the proportion of young Indians who are smoking will have dramatic consequences in terms of the adult burden of disease and the costs to the healthcare system in India. I confess to being incredibly excited that one of the, if you like, pillars of the new Indian government's policy or program on adolescent health, the RKSK program, has as its basis the desire to prevent the onset of non-communicable diseases by focusing on risk factors. >> Yes. >> Obviously, one of the ways that we have available to do that is through taxation on certain behaviors or practices, and in terms of tobacco, making tobacco and cigarettes more expensive through taxation has been a major plank of a lot of policies in high income countries. Are you able to share with us whether in India as well, taxation of tobacco has also been viewed as a mechanism to be reducing access in adolescents, and if so, how successful has that approach been? >> Yes, the rollover, including the taxation, has been viewed as a very important policy of controlling tobacco consumption. In India also, government almost every year, they raise taxes on cigarettes, mainly. >> Mm-hm. >> But in addition to the taxation there are certain other regulations that also there. Like tobacco products cannot officially be sold to any individual who's below 19 years. Tobacco products cannot be sold for merely 100 to 200 meters around the educational institutions, okay? And I know that the shops that were selling tobacco, they had to stop, they had to change their business because they were near to university campuses. So they say very, very important things. When tobacco availability is not there, where the residents are congregating, probably this also has some affect. But that's not certainly. They're very well aware of it. And they always increase, almost every year they increase taxation and make cigarettes costlier. >> Mm-hm. >> Recently tobacco chewing is an area they showed. So certain companies were looking tobacco in various products. They make fancy products which has tobacco we can be used for chewing. >> Mm-hm. >> We call it in local language [FOREIGN]. So these products were very, very popular. And recent regulation is that government has decided that nobody can put tobacco mixed with something else. >> Mm-hm. >> So tobacco mixing has been stopped, but company there is smart so they are selling tobacco separately than the product. But still the conception has gotten less after these regulations. Government is trying their best to stop, to reduce tobacco chewing as well as tobacco smoking it shows. >> Well I wish the Indian government well because as we know it's such a major problem for young people around the globe. >> Certainly. >> I understand that Indian doctors have greatly embraced the WHO tool, what's going on is the adolescent job aid that has been very much targeted for primary care professionals. Havish, could you share with us how the job aid is being used by Indian doctors? >> See and that the new mission the recent health program was for the training of medical officers, we have incorporated almost everything given the recent job aid. It just simplified many mental issues coming with various issues including mental health issues. We plan that these are of the same job rate, which has been renamed as physician child aid for another sense. This will be given to all primary care physicians. So about 8,000 physicians will get it. >> Mm-hm. >> So when adolescents come to them, they're going to use it for managing those conditions that are given in the job aid. >> Mm-hm. >> Or in the physician chart booklet. >> Mm-hm. >> And I believe that this will make management of those issues unified, standard, and easy for the physicians, and ultimately adolescents will benefit from the system. >> So can I clarify then that in terms of the WHO tool that in India this is now been translated into different languages, is that right? >> Yes, yes, yes. >> And that you're suggesting that it's been modified or expanded to have a stronger focus on mental health? Is that also correct? >> See we reviewed all of the algorithms. >> Yeah. >> So we made all the redundant consonants with other national health programs, little bit modifications were done. And then on this end, job aid, particular the book, it doesn't have the mental health algorithms. WHO has made them separately. They were provide it to us, so we have included those algorithms also that are not otherwise available in the world physician chart booklet. So our doctors will get all algorithms, including mental health algorithms also, and this will certainly facilitate management of children coming with anxiety, coming with depression, and coming with psychosis. >> Harish, thank you so much for sharing your expertise with us and with our audience today and I really do very genuinely wish you and your Indian colleagues all of the best in terms of what is a very big job ahead of you. But in certainly hearing from you today I have no doubt you've got the skills and enthusiasm to get down to work so, good luck. >> Thank you, thank you very much for giving me the opportunity to be part of Mook Global Adolescent Health Program. Thank you. >> Thanks.
