With an estimated 253 million adolescents, India has the largest population of adolescents in the world (1). These young individuals face multiple challenges that influence their physical, psychological, and social well-being. The major health issues faced by the adolescents include substance abuse, nutritional (malnutrition and obesity), mental disorders including stress, suicide, sexual and reproductive disorders, injuries and violence. The health problems experienced by adolescents not only affect their well-being during this critical life stage but also have long-term implications for their transition into adulthood (2).

According to the National Family Health Survey 5 (NFHS 5), the prevalence of anemia in adolescents (in the age group of 15–19), is 31.1% and 59.1% in boys and girls respectively (3). Similarly, the NFHS 5 also suggests that the prevalence of teen-age pregnancy is 6.8% among the age group of 15–19 years with a higher share in rural areas. Hence it is imperative to design comprehensive interventions to promote their overall well-being and address the health needs of adolescents to ensure their smooth transition into productive adulthood and reduce the burden on healthcare systems in the future (4, 5). To tackle the multifaceted health challenges faced by adolescents, various programmes have been designed in India. The government has prioritized the adolescent population through programmes focusing on Reproductive, Maternal, New born, Child and Adolescent Health (RMNCH + A)(6). Additionally, the National Adolescent Health Programme (Rashtriya Kishor Swasthya Karyakram or RKSK) was launched in 2014 by the Ministry of Health, Government of India as a comprehensive approach to address the health needs of all adolescents, beyond sexual and reproductive health(7). The programme is unique in terms of its approach to address the health care needs of the adolescents. The programme expands the scope of adolescent health and now includes in its ambit nutrition, injuries and violence (including gender-based violence), non-communicable diseases, mental health and substance misuse. The three major approaches included in the progarmme are school-based, facility based and community-based approach. A key component of RKSK is the involvement of Peer Educators (PE), recognizing the unique influence and relatability of peers in adolescent health promotion (8, 9). The Peer Education Programme within the Rashtriya Swasthya Kishor Karyakram (RKSK) is a community-based strategy where the PEs are selected from the community and trained on different adolescent related health issues. They sensitize adolescents on their health problems and inform them about existing adolescent friendly health services. Under each PE, there is a provision of 15–20 adolescents who form a group called the PE group (9). PE’s are adolescents selected through the RKSK peer-education program and trained to educate their peers, either in groups or on a one-on-one basis. They serve as intermediaries between the program and the adolescents enrolled under them (“adolescent enrolled under peer educators” (AEPs). The PEs are mandated to undergo 6 days of training following the structured session plan outlined in the PE’s training manual. The training is delivered by medical officers, Auxiliary Nurse and Midwifes (ANM), or non-governmental organization (NGO) mentors, who have been trained at the regional level.

Estimating the cost of health care interventions holds significant importance within the health system as it provides vital insights to the policymakers regarding the utilization of scarce resources and assesses the potential for utilization of the resources in a better way to improve the health system performance. Further, the programme cost data provides a benchmark to make price negotiations to purchase services from the private sector. Importantly, costs can be used to assess efficiency questions and guide the scaling up decisions to a large population and different geographical locations (10).

In India, the Government Spending on health was 1.35% of its Gross Domestic Product (GDP) and the out of -pocket expenditure constituted about 47.1% of total health expenditure (NHA 2019-20)(11). Given the constraints on government resources for healthcare, these limited resources need to be judiciously spent. In this context, economic evaluation studies assume significance to provide insight to policymakers about optimal allocation of scarce resources by comparing costs and their associated outcomes against available alternatives. There have been several studies, which investigated the costs related to various health care services, programmes and utilization in India (12–20). However, evidence on costing studies related to adolescent healthcare in India are limited. A recent study in Rajasthan, one of the Northern states of India, compared the cost and benefit of three interventions: delaying child marriage in Rajasthan by providing incentives, preventing anemia among adolescent girls through iron and folic acid supplementation and school-based behavioral screening and further mental health services for the adolescents. The findings suggest that the total cost of delaying child marriage is 2000 Crores (INR 20 billion) over a period of four years and the programme is expected to reduce child marriage from the existing 35% to 26.6%. Similarly, the iron and folic acid supplementation programme are estimated to reduce the prevalence rate of anemia from 81 % to 47% aerting 25 lakh cases of anemia among the target population with a total annual cost of 83 Crores (INR 830 million) (21). Further, there are numerous studies in India focusing on cost and cost effectiveness of adolescent health interventions (22),(23),(24)(25). However, we need to produce more evidence on costing of various adolescent health programmes using micro costing approach to inform the policymakers.

Given this, the study aimed to estimate the resource utilization and implementation cost of the PE programme under RKSK in two Indian states, namely Madhya Pradesh and Maharashtra using micro costing approach which breaks down activities, sub activities and determines the cost collecting data from each small unit. This approach produces detailed and accurate estimation of cost of an intervention based upon the actual resources utilized in the programme and provides a better guide for future resource allocation decisions.

This study was undertaken using a provider’s perspective to estimate the total cost of services provided through the Peer Education programme in each state. Cost data was collected retrospectively for the two financial years 2019-20 and 2020-21 to examine resource use and the cost of implementing the programme. We used the micro-costing approach (bottom-up costing or activity costing), where all relevant resources/inputs used for the programme were identified, the unit cost were determined and subsequently estimated their costs. This method looks into each input for each activity ( training, meeting, workshop, material development, human resources) and determines the cost based upon the resource use and number of units consumed in particular time period. For all these items, the actual cost incurred in the particular activity was estimated and attention was given to collect detailed disaggregated cost. The data was collected using a standardized costing tool developed specifically for this study. It included different items on costs -Human Resources (HR), monitoring, meetings, trainings, incentives and Peer Educator Kits. The human resource part presents a certain level of complexity, as it involves individuals who are engaged entirely (providing 100% of their time), while others make partial contributions to the progarmme due to their multiple engagements. The broad costing principles involved here is the apportioning the costs according to the time they contributed for the programme in various activities. In the HR, the cost includes the salary of the NGO coordinators, medical officer at the primary health centers, ASHA (Accredited Social Health Activist) and Auxiliary nurse midwife (ANM). Monitoring cost includes the cost of travel, per diem and accommodation used by the staff to monitor the peer educator programme. Training cost covers the cost of food, accommodation, venue and material used in the training activities.

In Madhya Pradesh, the implementation is done by the NGO. The states have the responsibility to select the NGOs for the programme implementation. The responsibility of the NGOs includes provision of the counsellors for the Adolescent Friendly Health Clinics (AFHC), selection, training, mentoring support of Peer Educator Programme. Under this model, there is a provision of 2–3 training mentors providing supportive supervision to the Peer Educators by visiting 15–20 villages in a month. In Maharashtra, the Department of Health and Family Welfare implements the programme. This includes selection of the PE (konwn ‘Saathiya’) by the ASHAs to the moderation of Adolescent Friendly Clubs (AFC) meetings by the ANMs/MHWs and conduction of Adolescent Health Days (AHDs) by the Block Adolescent Health Coordinators with oversight provided by the medical Officer in charge of the Primary Health Centre (PHC).

We also estimated the per capita cost of providing peer led education programme across two states separately. The per capita cost was estimated by diving total cost with the number of PEs and AEPs (adolescents enrolled under PE) at the block level separately. The per capita cost at the district level was estimated by calculating the average of per capita cost of all the blocks under the study estimated separately. Similarly, the per capita cost of the adolescents enrolled and continued with learning activities under the peer educator was estimated. All costs data were collected in the current prices. For training and meeting cost, disaggregated cost data were not available for different heads - hired cost for trainer, Traveling Allowance (TA), venue cost and food. Hence, we included the lumpsum amount under training as reported by the NGOs. One may refer to the additional methodological note submitted as annex files. (Details are given in Annex 5).

Our findings suggest that the total programme cost was INR 1092968 (95% CI: 608344–1577592) and INR 412990 (95% CI: 246728–579252) in Madhya Pradesh and Maharashtra on an average for a block respectively in the year 2020-21 (Table 1)(28). The per capita cost of creating a PE in Madhya Pradesh was INR 2935 (95% CI: 2509–3362) against 1818 (95% CI: 1122–2515) in Maharashtra in 2020-21. Similarly, the per capita cost of services provided for an adolescent enrolled under the peer educator (AEP) in the year 2020-21 was INR 262 in Madhya Pradesh while this was INR 168 in Maharashtra.

While examining the share of different components of the programme cost in the total programme cost, it was observed that monitoring constituted around 59% followed by HR costs (19%), PE incentive cost (16%) and administrative cost (6.4%) in Madhya Pradesh. Whereas, in Maharashtra, the share of HR cost was 45%, the highest, followed by PE incentive cost (24%), training (18%) and meeting cost (11%) in the financial year 2020-21.

In between the states, the monitoring costs were higher in Madhya Pradesh as compared to Maharashtra and formed the highest share (58%) in the total programme cost. The variations in cost were largely due to the costs associated with the NGO trainers/mentors who are involved in programme monitoring in Madhya Pradesh. In Maharashtra, the HR formed the highest share in the total programme cost. The training cost is more in Maharashtra and there were no trainings conducted in Madhya Pradesh in 2020-21 due to COVID-19 restrictions.

Block definition – it is an administrative unit under the district created to implement and monitor developmental activities in the rural areas aligned to rural development and panchayat raj institutes in the state

For making resource allocation decisions, cost-effectiveness studies are important. In India, studies related cost of providing services especially, adolescent health are limited. The Peer Education Programme is a key component of RKSK. By engaging adolescents in the peer-led discussions, programme become more accessible, reliable and effective, as the peers can understand and empathize with their counterparts' experiences and challenges. In order to expand the programme for a larger population, resource allocations decisions are critical. Further, for making resource allocation decisions, the cost effectiveness studies are important. However, within the cost-effectiveness framework, albeit effectiveness indicators, we need total and per capita cost of providing services. These costing studies provide crucial information about the cost of providing services in the public health systems and help scaling up the information. This also provides information on the cost effectiveness analysis. Some other studies (21–25) generated evidence on cost and cost effectiveness of other adolescent interventions. However, to our knowledge, this is the first study using robust costing and methodology covering four districts of two diverse states of India generated evidence on the total cost as well as per capita cost of peer education programme, one of the important pillars of RKSK. This study also presented detailed costing data in a disaggregated fashion to explain the resource use in the programme. The bottom-up costing methodology though is resource intensive, but it provides a lot of insight on the resource use pattern and output generated in the health system. The approach used in this study may encourage undertaking similar studies in public health systems which will guide resource allocation decisions as well as efficiency in the use of resources. Since this study based upon economic cost analysed each input required to produce the output, known here as peer educator led adolescent health delivery, this is relevant to improve the programme efficiency.

Overall, our findings suggest that per capita cost of creating a PE in Madhya Pradesh is INR 2935 against INR 1818 in Maharashtra in 2020-21. Similarly, the per capita cost of adolescents enrolled under PE in the year 2020-21 is INR 262 in Madhya Pradesh and this is INR 168 in Maharashtra. Further, the per capita cost of PEs and adolescents taken together which is defined as the progarmme output is INR 236 in Madhya Pradesh compared to INR 152 in Maharashtra in the same year. These cost information needs to be presented in proper perspective to draw significant policy inferences. These cost indicators are crucial information for both programme implementation and for understanding the efficiency of the programme. Before examining the efficiency question, it is pertinent to understand the implementation modalities, distinct components of the total costs and their variations across the two states included in this study. The two states included in this study are diverse in terms of implementation modalities – Madhya Pradesh an NGO implementation model and Maharashtra, a direct implementation model. The per capita cost is relatively higher in Madhya Pradesh, which implemented the programme through the NGOs compared to Maharashtra. While examining different components of the total cost, the costs associated with monitoring formed the highest share in Madhya Pradesh. The analysis further indicates that the monitoring activity is largely undertaken by the mentors appointed by the NGOs and hence the apportioned costs increase the monitoring costs in the state.

Another difference in cost is due to the different role played by different government officials involved in the implementation of the programme. In Madhya Pradesh, the staff involved in training included the ASHA, ASHA Facilitators, NGO mentors, Counsellors, Block Programme Manager (BPM) and Block Community Mobilizer (BCM). The training of Peer Educators is conducted by the NGO. In Maharashtra, the staff involved in training includes the Medical Officers, ANM, ASHA and ASHA facilitator. Our study findings further suggest that monitoring cost constitutes the highest share in total cost in Madhya Pradesh whereas, HR cost is the major cost in Maharashtra.

Though the study concluded the total programme cost and per capita cost of creating a PE as well as adolescent enrolled and trained under PE are more in Madhya Pradesh compared to Maharashtra, the differences in the per capita cost between the two states should not be examined in isolation. There are many programmatic advantages, which Madhya Pradesh has experienced due to involving an NGO that needs to be diligently presented to draw meaningful inferences of the cost findings. In Madhya Pradesh, the PE training was found to be aligned with the operational framework of RKSK, including the recommended number of training days and the provision of educational/training kits to Peer Educators (26). Further, the frequency of sessions conducted at the village level was consistently maintained due to the supportive supervision provided by the dedicated NGO Trainer/Mentor. Madhya Pradesh has also developed dedicated resources in the form of comic books, videos on different themes of RKSK, which helps them make PE sessions interactive and interesting. Additionally, the programme has started in Maharashtra in the year 2018-19, which, was, followed by the years of pandemic that affected the health systems. The COVID- 19 pandemic also contributed to the delay of some the programme activities in both the states. Hence, it would not be fair to draw out conclusion based on costing alone on the performance of the different models of implementation in the states. Moreover, a cost effectiveness study can be conducted on the different modes of implementation of the programmes once the programme has matured sufficiently in one of the selected states (Maharashtra).

To our knowledge, there are hardly any study done on the programme cost analysis of the PE programme in India except some studies that focused on the cost-effectiveness of various adolescent health interventions. Therefore, it is difficult to compare and contrast our findings.

The study concludes that there are differences between the programme costs in both the states because of difference in implementation models. The total programme cost in the NGO implementation model in Madhya Pradesh is higher than the government run model in Maharashtra. The cost differences between the two states needs to be presented in proper perspective and should not be examined in isolation without reference to the quality of progarmme. In Madhya Pradesh, despite having higher cost, the progarmme is matured and there is higher consistency in the implementation of the programme. This study holds significance as it would guide the resource allocation decision of adolescent health programmes. The bottom up costing methodology used in this study are important to guide and encourage similar health system based costing studies. Finally, the study findings provide many crucial inputs for future cost effectiveness analysis of adolescent health interventions, which has been gradually recognized as an important tool in government decision-making process.