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The cost of not counting adolescent girls in India

Neha Raykar 17 March 2022

Without adequate evidence collected or disaggregated on adolescents – especially girls living in urban poverty – policymakers will continue to leave them behind and exacerbate the inequalities facing India’s next generation.

Photo credit: hadynyah on iStock by Getty Images

As per the 2011 Census of India, approximately one in three Indians lives in an urban area; this population is expected to almost double by 2030 (Economic Survey, 2021). One in ten people in India live in urban poverty, often a slum, and face acute challenges in terms of access to nutritious food, availability of drinking water, sanitation, hygiene, stable employment, social protection programs, and they often face overcrowding and environmental pollution. Among people living in urban poverty, India’s adolescent population between 10 to 19 years – the largest in the world – remains particularly vulnerable. As of 2011, about one in 30 Indians was an adolescent living in an urban area (Ramadass et al., 2017). 

Despite often better access to education and economic opportunities than those in rural areas, urban youth do not have adequate nutrition, health services, or other support systems that enable them to thrive.1

Yet, there is currently little and fragmented evidence on the realities of people living in urban poverty – especially one of the most vulnerable groups: adolescent girls.

Without adequate data on adolescent girls’ interactions with government and non-government services, inequities will continue to be exacerbated and the core challenges they face will fly under the radar of policymakers. This translates into a failure to address a whole range of issues related to poor access to, and utilization of, services important for adolescent girls’ physical, sexual and mental health, nutrition, as well as their overall development. There are several reasons why evidence on adolescent girls living in urban poverty in India is relatively thin.

The urban population, and particularly the population of people in urban poverty, is likely to be underestimated in India due to the lack of a standardized definition of slums. The Government of India only recognizes slums that have legal recognition. About six out of ten slums in India -more than half – are non-notified or lack legal recognition by the government (Nolan et al., 2017). Census surveys of the government are therefore likely to undercount populations that reside in non-notified/illegal/disputed slums (Nolan, 2015). As a result, the urban population is likely to be underestimated by the Census surveys and by programs that use Census data to estimate and identify populations for targeting services. Challenges with underestimation notwithstanding, robust representative slum/non-slum data are seldom available at the disaggregated level to enable policymakers to more deeply understand the services people in urban poverty need and how those are or aren’t improving their lives.

Young adolescent girls between the ages of 10 to 14 years are not identified, targeted and or studied as a disaggregated population. National surveys, which are most common, often consider girls and women aged 15-49 years as ‘women of reproductive age,’ while girls between the ages of 10 and 14 years old are excluded or usually included as either a subset of children under the age of 18 or as a subset of adolescents between the ages of 10 and 19. Young adolescent girls are also often grouped with young adults and included as a broader category of “youth” aged 10 to 24 years (Chant et al., 2017). There is evidence, albeit limited, of differences in physical and mental health, nutrition, education, aspirations and ambitions between groups of younger (10-14 years) and older (15-19 years) adolescents (Santhya et al., 2017; WHO, 2021). Disaggregated data for the two age groups is therefore important to identify potential differences in their health behaviors, interactions with family, access to peer networks, and agency.

Such data can also throw light on factors that determine healthy transitions from childhood to adolescence and adulthood for these groups.

In practice, however, neither adolescent programming nor research distinguishes between the 10-14 and 15-19 years as two distinct age groups with different challenges and constraints. Furthermore, even if they are included in the research, the different experiences of rural and urban adolescent girls are rarely investigated, despite the growing recognition of distinct concerns and needs of girls in rural and urban areas.

On a related note, urban populations, including urban adolescents, are seldom recognized as a stand-alone category of people with special needs. Programming of health and nutrition interventions in India does not distinguish between rural and urban areas that often require varying strategies and approaches based on their distinct contexts.

For instance, community outreach services for adolescent girls in densely populated urban areas with floating groups of populations may require a different strategy than in rural areas where the community is a close-knit, fairly homogenous group.

Similarly, heavy reliance on private providers for healthcare services in urban areas may require differential programming compared to remote rural areas with greater uptake of publicly provided services.

Finally, despite the gamut of national and state programs addressing adolescent health and wellbeing in India, there is no systematic evidence on the effectiveness of these programs on adolescent outcomes in urban areas. In the early 2000s, the Government of India began to actively support adolescent health and well-being by strengthening its existing programs and systems to respond to adolescent needs. While the national strategy was primarily aimed at improving sexual and reproductive health through a clinic based approach, the focus has gradually broadened beyond sexual and reproductive health to include non-communicable diseases, mental health, nutrition, substance abuse, injuries and violence, through a combination of clinic and community-based approaches to service delivery (Barua et al., 2020). In addition, several states have also supported interventions aimed at promoting girls’ education through incentives, introducing additional information, education and communication campaigns on sexual and reproductive health and gender norms, preventing child marriages, and building life skills, among others.

Unfortunately, a lack of rigorous assessments of the reach, quality, and effectiveness of ongoing programs and initiatives, particularly in urban areas, hinders the possibility of making optimal improvements to their design and delivery.

While key programs may have set up their own monitoring systems, these are fragmented, disconnected, lack interoperability, and do not provide a comprehensive picture of coverage of the entire range of clinic, school, and community-based services for adolescent girls.

It is imperative to develop an efficient and reliable data management system that makes it possible to track essential adolescent services offered by multiple departments, through multiple delivery platforms, by age groups, gender and place of residence (urban/rural). More importantly, it is crucial to intentionally promote a culture among program officials of using data to monitor progress and identify gaps in services. National and state governments, along with funding agencies, need to invest resources in evaluations and assessments of existing programs to build evidence on what works, what doesn’t, and under what conditions, to enable adaptation and course correction of existing programs.

The COVID-19 pandemic has exacerbated all the prevalent urban inequities and related challenges for urban adolescent girls, due to massive loss of household incomes and disruption of school- and community-based health and nutrition services.

Inadequate service delivery for girls living in urban poverty is not only evidence of inequality, it also stunts their future social and economic contributions to the country.

This next generation has the potential to shape the country if policymakers can effectively tailor health, education, and economic empowerment services to address their evolving needs. They also must curb the outside forces – sexual violence and exploitation, human trafficking, and poverty – that contribute to their increased vulnerbiity.

It is undoubtedly critical to have effective services that keep girls in schools, provide quality education, nutrition and healthcare, and delay their age of pregnancy until after adulthood. It is just as urgent to invest in monitoring existing programs and build evidence for improved programming to cater to a growing population of urban adolescent girls in India so they can reach their full potential.

  1. 1. Some evidence does show that adolescent girls in urban areas fare worse on several health and nutritional outcomes compared to urban adolescent boys and rural adolescent girls (CNNS, 2016-18). Poverty affects the most vulnerable the hardest, as is the case with adolescent girls. Girls typically have high levels of anemia (Rani et al., 2018), inadequate consumption of diverse and nutritious diets (Deka et al., 2015), insufficient knowledge of sexual and reproductive health (Kadam et al., 2019), and a high risk of being overweight and obesity – early markers for non-communicable diseases such as diabetes and hypertension in later life (Ahmed et al., 2018).