Cost of providing Peer Education programme in the National Adolescent Health programme and its variations across two states of India.

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Sarit Kumar Rout, Priya Amrit, Shalini Bassi, Deepika Bahl, Monika Arora This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8470187/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Health system cost entails the cost incurred by the health care provider to deliver services and these costing studies are critical for budgeting and price setting of essential health interventions. Moreover, cost information is used for evaluating cost effectiveness of various interventions, which guide resource allocation decisions. In India, though these studies bear significance because of low public spending on health care, there are scant evidence on health system costs of various interventions. The present study was undertaken to estimate the resource use and implementation cost of the Peer Educator (PE) programme, a community-based intervention, under the Rashtriya Kishor Swasthya Karyakram (RKSK) within the National Adolescent Health Programme in India. Methods This study was undertaken using a provider perspective to estimate the unit cost of service provided through the PE programme in the two states of India namely Madhya Pradesh and Maharashtra. We used the micro-costing approach (bottom-up costing), where all relevant resources used for the programme were identified and subsequently, costs were estimated. We estimated the total programme cost, the per capita cost of creating a peer educator and an adolescent enrolled and trained under PE. The per capita cost was estimated separately for the Peer educators and adolescents enrolled under the PE. The programme is run by a Non-Government Organization (NGO) in Madhya Pradesh, while, it is implemented by the government, known as government-led model in Maharashtra. The cost data was collected retrospectively for the two financial years: 2019-20 and 2020-21 respectively from 16 blocks covering 4 districts across the two states. Results The total programme cost was found to be Indian National Rupee (INR) 1092968 (95% CI: 608344–1577592) in the NGO-led model in Madhya Pradesh and INR 412990 (95% CI: 246728–579252) in the government-led model in Maharashtra in 2020-21. The share of human resource cost was 45% of total cost and was the major driver of the overall cost in Maharashtra while monitoring cost formed the highest share (59%) in the total programme cost in Madhya Pradesh. The per capita cost of creating a Peer Educator in Madhya Pradesh was INR 2935 (95% CI: 2509–3362) compared to INR 1818 (95% CI: 1122–2515) in Maharashtra in 2020-21. Similarly, the per capita cost of proving the Peer Education intervention to the adolescents enrolled under the PE known as adolescents enrolled under PE (AEP) in the year 2020-21 is INR 262 in Madhya Pradesh and INR 168 in Maharashtra. Conclusion This study generates evidence on the total programme cost, the per capita cost of providing the peer educator programme and its variations across two states of India. The findings suggest that the per capita cost of adolescents trained on various aspects adolescent health and the resource use pattern varies between the two states. The findings of the study could help the policy makers for future planning and budgeting of adolescent health programmes. Peer Educator programme provider cost cost of peer educator programme micro costing adolescents health India Background 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. Methods Study Setting and Sampling This study forms a part of the I-Saathiya study conducted in the two states of India namely Madhya Pradesh and Maharashtra to understand and knowledge, attitude and practice of adolescents and PE involved in this programme and implementation challenges of PE progarmme ( 26 ). These two states were selected in consultation with the Ministry of Health and Family Welfare, Government of India. From the selected states, two districts were selected in consultation with the State Health Department of Madhya Pradesh (Panna and Damoh) and Maharashtra (Nashik and Yavatmal). These two districts were selected based on their implementation status of RKSK and Peer Education programs, that is, one district where the peer-education program has just started and the other, where it has been implemented for many years. The criteria for state selection has been described in another publication ( 27 ). We have used a multi stage cluster sampling for the study. From each state, two districts namely Panna and Damoh in Madhya Pradesh and Nashik and Yavatmal in Maharashtra were selected. Four blocks from each district were selected. A block 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 the selection of blocks, the sampling frame of blocks were stratified into two strata namely less developed and more developed blocks based on their tribal population and female literacy. From each stratum, two blocks were selected, through PPS (Probability Proportionate to Size) sampling, thus four blocks in each district formed the sample. The blocks in Nashik are Nandagaon, Dindori, Sinner and Surgana and in Yavatmal are Babhulgaon, Zari Jamani, Pusad and Yavatmal. The selected blocks in Damoh are Damoh, Jabera, Pathariya and Patera and in Panna, are Ajaygarh, Devendranagar, Pawai and Shahnagar. These blocks are the unit of study for the cost analysis. Costing Methodology 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). Results 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. Table 1 Average Programme cost in Madhya Pradesh and Maharashtra (FY 2020-21) Madhya Pradesh (8 Blocks) Maharashtra (8 Blocks) Programme Activity Mean Cost (in INR) 95% C.I. Mean Cost (in INR) 95% C.I. Human Resource (HR) Cost 208352 (19.1%) 134696–282007 186125 (45.1%) 145890–226361 Monitoring 642510 (58.8%) 365435–919584 6427 (1.6%) 5526–7328 Meeting 1077 (0.1%) 497–1657 46000 (11.1%) 32699–59302 Administrative cost 69500 (6.4%) 38906–100094 NA PE Incentives Cost 171530 (15.6%) 67343–275715 99437 (24.1%) 55354–143521 Training 0 0 75000 (18.1%) -51518 -201518 Average Total cost 1092968 608344–1577592 412990 246728–579252 Average no. of Peer Educators (blocks under the study) 356 247 Average no. Adolescents enrolled under Peer Educator 5629 3346 Per capita Cost (PE + AEP) 236 168–304 152 61–243 Per capita Cost (AEP) 262 178–347 168 63–272 Per capita Cost (PE) 2935 2509–3362 1818 1122–2515 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 AEP = Adolescent enrolled under Peer Educator PE = Peer Educator The cost of creating a peer educator in a state was estimated by calculating the average of individual per capita cost of all the 8 blocks within a state. Same methodology was adopted all other per capita costs, Additionally see annex 1, 2 3 and 4 for detailed cost data In the district level analysis, the total Programme costs in Panna was INR 1619051.5 and it was INR 566884.9 in Damoh in 2020-21 (Table 2 ). Of the different programme activities, the cost of monitoring formed the highest share in both the districts. It was 58.4% and 59.8% of the total programme costs in Panna and Damoh, respectively. The other important driver of the programme cost was the HR cost, which constituted 18% in Panna and 23% in Damoh. Overall, the cost of creating a peer educator was found to be INR 3379.6 in Panna and INR 2490.6 in Damoh 2020-21. The cost of providing the peer educator programme for the beneficiaries, peer educators and adolescents combined was INR 160.9 in Panna and INR 311 in Damoh. The per capita cost for adolescents enrolled under the programme and trained on various issues of adolescent health was around INR 169 in Panna against INR 356 in Damoh. The major difference in the total programme cost between the two districts in Madhya Pradesh is due to the monitoring costs. The number of mentors involved in the programme for supportive supervision in Panna is more as compared to Damoh. Hence, the resultant apportioned costs for HR, monitoring and the administrative cost increased in Panna as compared to Damoh. Moreover, the cost incurred for the incentives for Peer Educators is also higher in Panna as the number of Peer Educators are more as the programme is operational since 2016 in Panna whereas in Damoh, it began in the assessment year of the study − 2020-21. The total programme cost in Panna was INR 1746051.0 in 2019-20. Of the different programme activity cost, monitoring formed the highest share (54%) of the total programme costs. It was followed by HR cost (13.1%), incentives to Peer Educators (10%), meetings cost (9.8%), administrative cost (6.5%), training costs (5.7%) and costs associated with Peer Educator Kits (0.9%). In between the two years, in Panna, the HR costs increased by 25% in FY 2020-21 compared to 2019-20. The Peer Educator incentives cost also showed an increase of 61.5% in the year 2020-21. There was a sharp decrease in the meeting activity cost in 2021 by 99.5% as the AFC meetings were discontinued due to the Covid 19. The administrative cost show a decrease by 8.8%. The decrease is attributed to the fact that the total administrative costs in FY 2019-20 also consisted 10% of the training activity costs, which did not take place in 2020-21 due to Covid 19. Overall, there is a decrease of 7.3% in the total programme costs. Table 2 Average Programme costs in both districts in Madhya Pradesh (2020-21) (2019-20) Programme Activity Panna Mean cost INR) % Share Damoh (Mean Cost INR) % Share Panna (Mean cost INR) % Share Human Resource (HR) Cost 286437.5 17.7 130265.6 23.0 228479.2 13.1 Monitoring 945742.4 58.4 339277.1 59.8 942934.4 54.0 Meetings 812.5 0.1 1342.2 0.2 170933.8 9.8 Training 0.0 0.0 0.0 0.0 99346.3 5.7 Administrative cost 103000.0 6.4 36000.0 6.4 112934.5 6.5 PE Kits Costs 0.0 0.0 0.0 0.0 16125.0 0.9 Total PE incentive 283059.1 17.5 60000.0 10.6 175297.9 10.0 Total Average cost 1619051.5 566884.9 1746051.0 per capita cost (PE + AEP) 160.9 311.3 202.2 Per capita cost (AEP) 169.0 356.0 211.2 Per capita cost (PE) 3379.6 2490.6 4946.7 * The programme was not started in Damoh in the year 2019-20 AEP = Adolescent enrolled under Peer Educator PE = Peer Educator Additionally see annex 1, 2 for detailed cost data of the district In Nashik, the total programme cost was INR 336339.2 in 2020-21 whereas it was INR 489640.7 in Yavatmal (Table 3 ). A marked difference in the share of different components of the cost in total cost was observed between the districts. For HR, the share was 52% in Nashik against 40% in Yavatmal. Similarly, for meetings this varied from 15% in Nashik to 9% in Yavatmal. The cost of creating a PE was INR 1456 in Nashik whereas this was INR 2181 in Yavatmal. The cost of providing the PE programme for beneficiaries (PEs + AEPs) was INR 80.9 in Nashik compared to INR 222 in Yavatmal. The per capita cost of adolescents trained and educated on different aspects of adolescent health was around INR 86 in Nashik compared to INR 250 in Yavatmal. In the year 2019-20, total programme costs in Nashik and Yavatmal was INR 206776.9 and INR 234711.9 respectively. Of the different programme cost- HR formed the highest share (57.2%) of the total programme costs in Nashik and 53.3% in Yavatmal. It was followed by costs associated with incentives to the PE’s (33.5%), meetings cost (6.2%), and monitoring cost (3.1%) in Nashik whereas in Yavatmal, the cost of training of PE’s was (30.8%), meetings cost (7%), incentives to Peer Educators (6.3%), and monitoring cost (2.6%). In both the districts, the share of HR was highest in the total programme cost in both the years. Moreover, trainings were not conducted in Nashik in both the years whereas this was held in Yavatmal. Even in Maharashtra, the trainings were conducted in only two blocks (in Yavatmal). There has been an increase in the total programme cost in both districts in Maharashtra 2020-21 from the year 2019-20. Given the fact that the programme was newly started in 2018 in Maharashtra, some of the programme activities like the AFC meetings were held in 2020-21 in all the four blocks. Till 2019, only two out of the four blocks were conducting the AFC meetings in both the districts. By 2020-21, all the four blocks were gradually covered. Since, in Maharashtra, the medical officers were attending the AFCs in all the blocks and the AFCs were moderated by the ANMs, hence the time contribution and resultant apportioned cost of the HR- Medical Officers and ANMs in the following year − 2020-21 increased compared to 2019-21. Similarly, the Peer Educator incentives were also disbursed in 2020-21 in all the blocks in both the districts, as opposed to just two blocks in each district. All these factors contribute to a higher total programme cost in 2020-21 compared to 2019-20. Additionally block-wise total programme costs were also calculated and can found separately for both the states in the supplementary table (annexed as supplementary file). We have also uploaded all the raw costing data sheets in excel format for further understanding of the readers. Table 3 Average Programme costs in both districts in Maharashtra (2020-21) (2019-20) Programme Activity Nashik %Share Yavatmal % Share Nashik % Share Yavatmal % Share Mean Cost (INR) Mean Cost (INR) Mean Cost (INR) Mean Cost (INR) Human Resource (HR) Cost 175785.0 52.3 196465.6 40.1 118277.4 57.2 125177.5 53.3 Monitoring 6554.2 1.9 6300.1 1.3 6374.5 3.1 6016.1 2.6 Meetings 49500.0 14.7 42500.0 8.7 12875.0 6.2 16500.0 7.0 Training 0.0 0.0 150000.0 30.6 0.0 0.0 72183.3 30.8 Total PE incentive 104500.0 31.1 94375.0 19.3 69250.0 33.5 14835.0 6.3 Total Average cost 336339.2 489640.7 206776.9 234711.9 Per capita cost (PE + AEP) 80.9 222.4 49.7 115.0 Per capita cost (AEP) 85.6 249.7 52.6 128.9 Per capita cost (PE) 1455.8 2181.1 894.5 1134.0 AEP = Adolescent enrolled under Peer Educator PE = Peer Educator , Additionally see annex 3 and 4 for detailed cost data of the district Discussion 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. Study limitation This study is based upon the bottom-up costing where different costs incurred on activities were collected and added up to obtain total cost. The disaggregate cost on training heads- hired cost for trainer, travelling allowance, venue cost and food were not available and hence we included the lumpsum amount under training as reported by the NGOs. Further, in one of the selected districts, Nashik, there were no trainings conducted in the reference period of the study. Similarly, the detailed meeting cost-venue, vehicle hiring was not available and we included the lumpsum amounts. Further, IEC (Information, Education and Communication) and training material development costs were not available at the district level and hence could not be considered in the costing exercise. This however will not influence the result significantly as the total cost for these items have been appropriately estimated. Conclusion 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. Abbreviations RKSK Rashtriya Swasthya Kishor Karyakram NGO Non- Government Organizations INR Indian Rupee CI Confidence Interval NFHS National Family Health Survey RMNCH + A Reproductive, Maternal, New born, Child, and Adolescent Health PE Peer Educator GDP Gross Domestic Product NHA National Health accounts QALY Quality Adjusted Life Years RCT Randomized Controlled Trial IFA Iron and Folic Acid PPS Probability Proportionate to Size AFHC Adolescent Friendly Health Clinics AFC Adolescent Friendly Club AEP Adolescents enrolled under Peer Educator AHD Adolescent Health Days HR Human Resource ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activists PHC Primary Health Centre BPM Block Programme Manager BCM Block Community Mobilizer IEC Information, Education and Communication Declarations Ethics approval: Ethics approval for the research was obtained from the Institutional Ethics Committee of the Public Health Foundation of India (Reference # TRC-IEC-342.1/17). This study has also been approved by the Indian Health Ministry's Screening Committee (HMSC). (HMSC Ref no. 2017-2250). Consent to participate: Not Applicable Consent for publication: Not Applicable Availability of data and materials: The data used for the analysis is attached in the supplementary file. Competing interests : The authors declare that they have no competing interests. Funding: This research was undertaken as part of the study, evaluating the implementation of the Peer Educator Intervention for improving adolescent health in India’s National Adolescent Health Programme. The study is supported by grant number MC_PC_MR/P011446/1 awarded to the principal investigator Monika Arora by the Medical Research Council, UK. Authors' contributions: Conceived and designed the study: SKR, PA, MA Acquisition and analysis of data: SKR, PA, SB Interpretation of Data: SKR, PA Substantially revised the manuscript: MA, SB, DB, SKR, PA Drafted the manuscript: SKR, PA Acknowledgements: The authors acknowledge the financial support provided by the Medical Research Council, UK for the study. Authors' information Sarit Kumar Rout ( Corresponding Author ) Indian Institute of Public Health, Bhubaneswar, PHFI New Delhi ORCID: https://orcid.org/0000-0003-0831-789X Priya Amrit Public Health Foundation of India, Gurugram, Haryana, India ORCID ID 0009-0001-7720-6475 Shalini Bassi Public Health Foundation of India, Gurugram, Haryana, India ORCID ID 0000-0001-6348-3335 Deepika Bahl Public Health Foundation of India, Gurugram, Haryana, India ORCID ID 0000-0003-3222-5143 Monika Arora Public Health Foundation of India, Gurugram, Haryana, India ORCID ID 0000-0001-9987-3933 References Wadhwa R, Chaudhary N, Bisht N, Gupta A, Behera N, Verma A, et al. Improving adolescent health services across high priority districts in 6 states of India: Learnings from an integrated reproductive maternal newborn child and adolescent health project. Indian J Community Med. 2018;43(5):S6–11. Global Accelerated Action for the Health of Adolescents (AA-HA!). Guidance to Support Country Implementation [Internet]. Available from: https://www.who.int/publications/i/item/9789241512343 International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019-21: India. Mumbai; 2021. Sheehan P, Sweeny K, Rasmussen B, Wils A, Friedman HS, Mahon J et al. Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents. Lancet [Internet]. 2017;390(10104):1792–806. Available from: https://pubmed.ncbi.nlm.nih.gov/28433259/ Patton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, et al. Our future: a Lancet commission on adolescent health and wellbeing. The Lancet. Volume 387. Lancet Publishing Group; 2016. pp. 2423–78. A Strategic Approach to Reporoductive, Maternal, Newborn, Child and Adolescent Health (RMNCH + A) in India. 2013. Operational Guidelines for Peer Education Programme National. Health Mission Department of Health and Family Welfare Government of Odisha. Adolescent Health Division Ministry of Health. and Family Welfare Government of India operational framework translating strategy into programmes. 2014. Implementation Guidelines Rashtriya Kishor Swasthya Karyakram (RKSK). Ministry of Health and Family Welfare Government of India. 2018. Johns B, Baltussen R, Hutubessy R. Programme costs in the economic evaluation of health interventions. Cost Effectiveness and Resource Allocation [Internet]. 2003 Feb 26 [cited 2023 Aug 16];1(1):1–10. Available from: https://resource-allocation.biomedcentral.com/articles/ 10.1186/1478-7547-1-1 National Health Systems Resource Centre. Ministry of Health and Family Welfare (MoHFW) Government of India. National Health Account Estimates for India 2019-20. 2023. Prinja S, Gupta A, Bahuguna P, Nimesh R. Cost analysis of implementing mHealth intervention for maternal, newborn & child health care through community health workers: Assessment of ReMIND program in Uttar Pradesh, India. BMC Pregnancy Childbirth. 2018;18(1). Rout SK, Gabhale YR, Dutta A, Balakrishnan S, Lala MM, Setia MS et al. Can telemedicine initiative be an effective intervention strategy for improving treatment compliance for pediatric HIV patients: Evidences on costs and improvement in treatment compliance from Maharashtra, India. PLoS ONE. 2019;14(10). Prinja S, Jeet G, Verma R, Kumar D, Bahuguna P, Kaur M et al. Economic analysis of delivering primary health care services through community health workers in 3 North Indian states. PLoS ONE. 2014;9(3). Monga D, Verma R, Kumar D, Grover G, Chauhan A, Lakshmi PVM, et al. Cost of National Vector Borne Disease Control Programme in North India. Indian J Med Res. 2022;155(1):22–33. Dhamania M, Gaur K, Pankaj JP, Sharma DK, Yadav R, Raj D. Cost Analysis of Intranatal Care Services at a Tertiary Care Public Sector Hospital in Rajasthan, India. Cureus. 2023. Prinja S, Gupta A, Verma R, Bahuguna P, Kumar D, Kaur M et al. Cost of delivering health care services in public sector primary and community health centres in north India. PLoS ONE 2016;11(8). Prinja S, Singh MP, Guinness L, Rajsekar K, Bhargava B. Establishing reference costs for the health benefit packages under universal health coverage in India: cost of health services in India (CHSI) protocol. BMJ Open. 2020;10(7):e035170. Prinja S, Sharma Y, Dixit J, Thingnam SKS, Kumar R. Cost of Treatment of Valvular Heart Disease at a Tertiary Hospital in North India: Policy Implications. Pharmacoecon Open. 2019;3(3):391–402. Bahuguna P, Guinness L, Sharma S, Chauhan AS, Downey L, Prinja S. Estimating the Unit Costs of Healthcare Service Delivery in India: Addressing Information Gaps for Price Setting and Health Technology Assessment. Appl Health Econ Health Policy. 2020;18(5):699–711. Mangal DK, Hossain M, Sharma N, Sodani PR, Gupta SD. Cost Benefit Analysis of Adolescent Health Interventions for Rajasthan [Internet]. Jaipur; 2018. Available from: www.copenhagenconsensus.com. Hossain M, Gupta SD, Sharma N, Sodani PR, Mangal DK, Hossain M. Cost-benefit analysis of adolescent health interventions in Andhra Pradesh [Internet]. 2018. Available from: www.copenhagenconsensus.com. Brown HS, Stigler M, Perry C, Dhavan P, Arora M, Reddy KS. The cost-effectiveness of a school-based smoking prevention program in India. Health Promot Int. 2013;28(2):178–86. Malik K, Michelson D, Doyle AM, Weiss HA, Greco G, Sahu R et al. Effectiveness and costs associated with a lay counselor–delivered, brief problem-solving mental health intervention for adolescents in urban, low-income schools in India: 12-month outcomes of a randomized controlled trial. PLoS Med. 2021;18(9). Kapoor A, Yadav C, Kapoor M. Investing in Adolescent Development: A Case Study for India. Institute for Competitiveness, India. New Delhi; 2021. Bassi S, Bahl D, Maity H, Dringus S, Rizvi ZA, Kumar D et al. Engagement of Peer Educators from India’s National Adolescent Health Programme for the COVID-19 response activities: Qualitative findings from i-Saathiya study. Available from: http://bmjopen.bmj.com/ Arora M, Dringus S, Bahl D, Rizvi Z, Maity H, Lama S et al. Engagement of health workers and peer educators from the National Adolescent Health Programme-Rashtriya Kishor Swasthya Karyakram during the COVID-19 pandemic: Findings from a situational analysis. PLoS ONE. 2022;17(9 September). Exploring Implementation of the Peer Education Programme for Improving Adolescent Health in India’s National Adolescent Health Strategy i-Saathiya Study Report. 2023. Available from: https://phfi.org/wp-content/uploads/2023/08/i-Saathiya-Study-Report-2023-1.pdf Additional Declarations No competing interests reported. Supplementary Files DetailedcostingPannaAnnex1.xlsx DetailedCostingExcelDamohAnnex2.xlsx DetaledcostingNashikNashikAnnex3.xlsx DetaledcostingYavatmalAnnex4.xlsx Annex5.MicroCosts.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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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 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the National Family Health Survey 5 (NFHS 5), the prevalence of anemia in adolescents (in the age group of 15\u0026ndash;19), is 31.1% and 59.1% in boys and girls respectively (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Similarly, the NFHS 5 also suggests that the prevalence of teen-age pregnancy is 6.8% among the age group of 15\u0026ndash;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 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). 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\u0026thinsp;+\u0026thinsp;A)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). 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(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). 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 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). 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\u0026ndash;20 adolescents who form a group called the PE group (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). PE\u0026rsquo;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 (\u0026ldquo;adolescent enrolled under peer educators\u0026rdquo; (AEPs). The PEs are mandated to undergo 6 days of training following the structured session plan outlined in the PE\u0026rsquo;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.\u003c/p\u003e \u003cp\u003eEstimating 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 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 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)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). 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 (\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). 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\u0026nbsp;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\u0026nbsp;million) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Further, there are numerous studies in India focusing on cost and cost effectiveness of adolescent health interventions (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e),(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e),(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). However, we need to produce more evidence on costing of various adolescent health programmes using micro costing approach to inform the policymakers.\u003c/p\u003e \u003cp\u003eGiven 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.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting and Sampling\u003c/h2\u003e \u003cp\u003eThis study forms a part of the I-Saathiya study conducted in the two states of India namely Madhya Pradesh and Maharashtra to understand and knowledge, attitude and practice of adolescents and PE involved in this programme and implementation challenges of PE progarmme (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). These two states were selected in consultation with the Ministry of Health and Family Welfare, Government of India. From the selected states, two districts were selected in consultation with the State Health Department of Madhya Pradesh (Panna and Damoh) and Maharashtra (Nashik and Yavatmal). These two districts were selected based on their implementation status of RKSK and Peer Education programs, that is, one district where the peer-education program has just started and the other, where it has been implemented for many years. The criteria for state selection has been described in another publication (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). We have used a multi stage cluster sampling for the study. From each state, two districts namely Panna and Damoh in Madhya Pradesh and Nashik and Yavatmal in Maharashtra were selected. Four blocks from each district were selected. A block 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 the selection of blocks, the sampling frame of blocks were stratified into two strata namely less developed and more developed blocks based on their tribal population and female literacy. From each stratum, two blocks were selected, through PPS (Probability Proportionate to Size) sampling, thus four blocks in each district formed the sample. The blocks in Nashik are Nandagaon, Dindori, Sinner and Surgana and in Yavatmal are Babhulgaon, Zari Jamani, Pusad and Yavatmal. The selected blocks in Damoh are Damoh, Jabera, Pathariya and Patera and in Panna, are Ajaygarh, Devendranagar, Pawai and Shahnagar. These blocks are the unit of study for the cost analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCosting Methodology\u003c/h3\u003e\n\u003cp\u003eThis study was undertaken using a provider\u0026rsquo;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.\u003c/p\u003e \u003cp\u003eIn 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\u0026ndash;3 training mentors providing supportive supervision to the Peer Educators by visiting 15\u0026ndash;20 villages in a month. In Maharashtra, the Department of Health and Family Welfare implements the programme. This includes selection of the PE (konwn \u0026lsquo;Saathiya\u0026rsquo;) 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).\u003c/p\u003e \u003cp\u003eWe 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).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur findings suggest that the total programme cost was INR 1092968 (95% CI: 608344\u0026ndash;1577592) and INR 412990 (95% CI: 246728\u0026ndash;579252) in Madhya Pradesh and Maharashtra on an average for a block respectively in the year 2020-21 (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The per capita cost of creating a PE in Madhya Pradesh was INR 2935 (95% CI: 2509\u0026ndash;3362) against 1818 (95% CI: 1122\u0026ndash;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.\u003c/p\u003e \u003cp\u003eWhile 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.\u003c/p\u003e \u003cp\u003eIn 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.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Average Programme cost in Madhya Pradesh and Maharashtra (FY 2020-21)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMadhya Pradesh (8 Blocks)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMaharashtra (8 Blocks)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgramme Activity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Cost (in INR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% C.I.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Cost (in INR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% C.I.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHuman Resource (HR) Cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208352 (19.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134696\u0026ndash;282007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e186125 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e145890\u0026ndash;226361\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonitoring\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e642510 (58.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e365435\u0026ndash;919584\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6427 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5526\u0026ndash;7328\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeeting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1077 (0.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e497\u0026ndash;1657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46000 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32699\u0026ndash;59302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdministrative cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69500 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38906\u0026ndash;100094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePE Incentives Cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171530 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67343\u0026ndash;275715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99437 (24.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55354\u0026ndash;143521\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75000 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-51518 -201518\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage Total cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1092968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e608344\u0026ndash;1577592\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e412990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e246728\u0026ndash;579252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage no. of Peer Educators (blocks under the study)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage no. Adolescents enrolled under Peer Educator\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5629\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita Cost (PE\u0026thinsp;+\u0026thinsp;AEP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168\u0026ndash;304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61\u0026ndash;243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita Cost (AEP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e178\u0026ndash;347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63\u0026ndash;272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita Cost (PE)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2935\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2509\u0026ndash;3362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1818\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1122\u0026ndash;2515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eBlock definition \u0026ndash;\u003c/b\u003e 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\u003c/p\u003e\n\u003ch3\u003eAEP = Adolescent enrolled under Peer Educator\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePE\u0026thinsp;=\u0026thinsp;Peer Educator\u003c/h2\u003e \u003cp\u003eThe cost of creating a peer educator in a state was estimated by calculating the average of individual per capita cost of all the 8 blocks within a state. Same methodology was adopted all other per capita costs,\u003c/p\u003e \u003cp\u003eAdditionally see annex 1, 2 3 and 4 for detailed cost data\u003c/p\u003e \u003cp\u003eIn the district level analysis, the total Programme costs in Panna was INR 1619051.5 and it was INR 566884.9 in Damoh in 2020-21 (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of the different programme activities, the cost of monitoring formed the highest share in both the districts. It was 58.4% and 59.8% of the total programme costs in Panna and Damoh, respectively. The other important driver of the programme cost was the HR cost, which constituted 18% in Panna and 23% in Damoh. Overall, the cost of creating a peer educator was found to be INR 3379.6 in Panna and INR 2490.6 in Damoh 2020-21. The cost of providing the peer educator programme for the beneficiaries, peer educators and adolescents combined was INR 160.9 in Panna and INR 311 in Damoh. The per capita cost for adolescents enrolled under the programme and trained on various issues of adolescent health was around INR 169 in Panna against INR 356 in Damoh.\u003c/p\u003e \u003cp\u003eThe major difference in the total programme cost between the two districts in Madhya Pradesh is due to the monitoring costs. The number of mentors involved in the programme for supportive supervision in Panna is more as compared to Damoh. Hence, the resultant apportioned costs for HR, monitoring and the administrative cost increased in Panna as compared to Damoh. Moreover, the cost incurred for the incentives for Peer Educators is also higher in Panna as the number of Peer Educators are more as the programme is operational since 2016 in Panna whereas in Damoh, it began in the assessment year of the study \u0026minus;\u0026thinsp;2020-21.\u003c/p\u003e \u003cp\u003eThe total programme cost in Panna was INR 1746051.0 in 2019-20. Of the different programme activity cost, monitoring formed the highest share (54%) of the total programme costs. It was followed by HR cost (13.1%), incentives to Peer Educators (10%), meetings cost (9.8%), administrative cost (6.5%), training costs (5.7%) and costs associated with Peer Educator Kits (0.9%).\u003c/p\u003e \u003cp\u003eIn between the two years, in Panna, the HR costs increased by 25% in FY 2020-21 compared to 2019-20. The Peer Educator incentives cost also showed an increase of 61.5% in the year 2020-21. There was a sharp decrease in the meeting activity cost in 2021 by 99.5% as the AFC meetings were discontinued due to the Covid 19. The administrative cost show a decrease by 8.8%. The decrease is attributed to the fact that the total administrative costs in FY 2019-20 also consisted 10% of the training activity costs, which did not take place in 2020-21 due to Covid 19. Overall, there is a decrease of 7.3% in the total programme costs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAverage Programme costs in both districts in Madhya Pradesh\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e(2020-21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e(2019-20)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgramme Activity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePanna Mean cost INR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003cp\u003eShare\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDamoh\u003c/p\u003e \u003cp\u003e(Mean Cost INR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% Share\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePanna\u003c/p\u003e \u003cp\u003e(Mean cost INR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% Share\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHuman Resource (HR) Cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e286437.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130265.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e228479.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonitoring\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e945742.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e58.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e339277.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e942934.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e54.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeetings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e812.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1342.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e170933.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e99346.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdministrative cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103000.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36000.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e112934.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePE Kits Costs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16125.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal PE incentive\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e283059.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60000.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e175297.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Average cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1619051.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e566884.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e1746051.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eper capita cost (PE\u0026thinsp;+\u0026thinsp;AEP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e311.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e202.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita cost (AEP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e356.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e211.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita cost (PE)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3379.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2490.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4946.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e* The programme was not started in Damoh in the year 2019-20\u003c/p\u003e \u003cp\u003e\u003cb\u003eAEP\u0026thinsp;=\u0026thinsp;Adolescent enrolled under Peer Educator PE\u0026thinsp;=\u0026thinsp;Peer Educator\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAdditionally see annex 1, 2 for detailed cost data of the district\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn Nashik, the total programme cost was INR 336339.2 in 2020-21 whereas it was INR 489640.7 in Yavatmal (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A marked difference in the share of different components of the cost in total cost was observed between the districts. For HR, the share was 52% in Nashik against 40% in Yavatmal. Similarly, for meetings this varied from 15% in Nashik to 9% in Yavatmal.\u003c/p\u003e \u003cp\u003eThe cost of creating a PE was INR 1456 in Nashik whereas this was INR 2181 in Yavatmal. The cost of providing the PE programme for beneficiaries (PEs\u0026thinsp;+\u0026thinsp;AEPs) was INR 80.9 in Nashik compared to INR 222 in Yavatmal. The per capita cost of adolescents trained and educated on different aspects of adolescent health was around INR 86 in Nashik compared to INR 250 in Yavatmal.\u003c/p\u003e \u003cp\u003eIn the year 2019-20, total programme costs in Nashik and Yavatmal was INR 206776.9 and INR 234711.9 respectively. Of the different programme cost- HR formed the highest share (57.2%) of the total programme costs in Nashik and 53.3% in Yavatmal. It was followed by costs associated with incentives to the PE\u0026rsquo;s (33.5%), meetings cost (6.2%), and monitoring cost (3.1%) in Nashik whereas in Yavatmal, the cost of training of PE\u0026rsquo;s was (30.8%), meetings cost (7%), incentives to Peer Educators (6.3%), and monitoring cost (2.6%). In both the districts, the share of HR was highest in the total programme cost in both the years. Moreover, trainings were not conducted in Nashik in both the years whereas this was held in Yavatmal. Even in Maharashtra, the trainings were conducted in only two blocks (in Yavatmal).\u003c/p\u003e \u003cp\u003eThere has been an increase in the total programme cost in both districts in Maharashtra 2020-21 from the year 2019-20. Given the fact that the programme was newly started in 2018 in Maharashtra, some of the programme activities like the AFC meetings were held in 2020-21 in all the four blocks. Till 2019, only two out of the four blocks were conducting the AFC meetings in both the districts. By 2020-21, all the four blocks were gradually covered. Since, in Maharashtra, the medical officers were attending the AFCs in all the blocks and the AFCs were moderated by the ANMs, hence the time contribution and resultant apportioned cost of the HR- Medical Officers and ANMs in the following year \u0026minus;\u0026thinsp;2020-21 increased compared to 2019-21. Similarly, the Peer Educator incentives were also disbursed in 2020-21 in all the blocks in both the districts, as opposed to just two blocks in each district. All these factors contribute to a higher total programme cost in 2020-21 compared to 2019-20. Additionally block-wise total programme costs were also calculated and can found separately for both the states in the supplementary table (annexed as supplementary file). We have also uploaded all the raw costing data sheets in excel format for further understanding of the readers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Average Programme costs in both districts in Maharashtra\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e(2020-21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e(2019-20)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgramme Activity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNashik\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%Share\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYavatmal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e% Share\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNashik\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e% Share\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYavatmal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e% Share\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Cost (INR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean Cost (INR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean Cost (INR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMean Cost (INR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHuman Resource (HR) Cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175785.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e196465.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e118277.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e57.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e125177.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonitoring\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6554.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6300.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6374.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6016.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeetings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49500.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42500.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12875.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16500.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTraining\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150000.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e72183.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal PE incentive\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104500.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94375.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e69250.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14835.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Average cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e336339.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e489640.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e206776.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e234711.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita cost (PE\u0026thinsp;+\u0026thinsp;AEP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e222.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e115.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita cost (AEP)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e249.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e128.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePer capita cost (PE)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1455.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2181.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e894.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1134.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAEP\u0026thinsp;=\u0026thinsp;Adolescent enrolled under Peer Educator\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePE\u0026thinsp;=\u0026thinsp;Peer Educator\u003c/b\u003e, Additionally see annex 3 and 4 for detailed cost data of the district\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFor 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 (\u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) 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.\u003c/p\u003e \u003cp\u003eOverall, 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 \u0026ndash; 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.\u003c/p\u003e \u003cp\u003eAnother 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.\u003c/p\u003e \u003cp\u003eThough 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 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). 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).\u003c/p\u003e \u003cp\u003eTo 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.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy limitation\u003c/strong\u003e \u003cp\u003eThis study is based upon the bottom-up costing where different costs incurred on activities were collected and added up to obtain total cost. The disaggregate cost on training heads- hired cost for trainer, travelling allowance, venue cost and food were not available and hence we included the lumpsum amount under training as reported by the NGOs. Further, in one of the selected districts, Nashik, there were no trainings conducted in the reference period of the study. Similarly, the detailed meeting cost-venue, vehicle hiring was not available and we included the lumpsum amounts. Further, IEC (Information, Education and Communication) and training material development costs were not available at the district level and hence could not be considered in the costing exercise. This however will not influence the result significantly as the total cost for these items have been appropriately estimated.\u003c/p\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe 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.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRKSK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRashtriya Swasthya Kishor Karyakram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon- Government Organizations\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eINR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIndian Rupee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNFHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Family Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMNCH\u0026thinsp;+\u0026thinsp;A\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReproductive, Maternal, New born, Child, and Adolescent Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeer Educator\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGross Domestic Product\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health accounts\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQALY\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality Adjusted Life Years\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized Controlled Trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIron and Folic Acid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProbability Proportionate to Size\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAFHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdolescent Friendly Health Clinics\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAFC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdolescent Friendly Club\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAEP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdolescents enrolled under Peer Educator\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdolescent Health Days\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman Resource\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAuxiliary Nurse Midwife\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAccredited Social Health Activists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Health Centre\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBPM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlock Programme Manager\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlock Community Mobilizer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIEC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInformation, Education and Communication\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eEthics approval for the research was obtained from the Institutional Ethics Committee of the Public Health Foundation of India (Reference # TRC-IEC-342.1/17). This study has also been approved by the Indian Health Ministry\u0026apos;s Screening Committee (HMSC). (HMSC Ref no. 2017-2250).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data used for the analysis is attached in the supplementary file.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e:\u0026nbsp;The authors declare\u0026nbsp;that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research was undertaken as part of the study, evaluating the implementation of the Peer Educator Intervention for improving adolescent health in India\u0026rsquo;s National Adolescent Health Programme. The study is supported by grant number MC_PC_MR/P011446/1 awarded to the principal investigator Monika Arora by the Medical Research Council, UK.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceived and designed the study: SKR, PA, MA\u003c/p\u003e\n\u003cp\u003eAcquisition and analysis of data: SKR, PA, SB\u003c/p\u003e\n\u003cp\u003eInterpretation of Data: SKR, PA\u003c/p\u003e\n\u003cp\u003eSubstantially revised the manuscript: MA, SB, DB, SKR, PA\u003c/p\u003e\n\u003cp\u003eDrafted the manuscript: SKR, PA\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors acknowledge the financial support provided by the Medical Research Council, UK for the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSarit Kumar Rout (\u003cstrong\u003eCorresponding Author\u003c/strong\u003e)\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eIndian\u0026nbsp;Institute of Public Health, Bhubaneswar, PHFI New Delhi\u003c/p\u003e\n\u003cp\u003eORCID: https://orcid.org/0000-0003-0831-789X\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003ePriya Amrit\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ePublic Health Foundation of India, Gurugram, Haryana, India\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eORCID ID \u003cstrong\u003e0009-0001-7720-6475\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003eShalini Bassi\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ePublic Health Foundation of India, Gurugram, Haryana, India\u003c/p\u003e\n\u003cp\u003eORCID ID 0000-0001-6348-3335\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003eDeepika Bahl\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ePublic Health Foundation of India, Gurugram, Haryana, India\u003c/p\u003e\n\u003cp\u003eORCID ID 0000-0003-3222-5143\u003c/p\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003eMonika Arora\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ePublic Health Foundation of India, Gurugram, Haryana, India\u003c/p\u003e\n\u003cp\u003eORCID ID 0000-0001-9987-3933\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWadhwa R, Chaudhary N, Bisht N, Gupta A, Behera N, Verma A, et al. Improving adolescent health services across high priority districts in 6 states of India: Learnings from an integrated reproductive maternal newborn child and adolescent health project. Indian J Community Med. 2018;43(5):S6\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal Accelerated Action for the Health of Adolescents (AA-HA!). Guidance to Support Country Implementation [Internet]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789241512343\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789241512343\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019-21: India. Mumbai; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheehan P, Sweeny K, Rasmussen B, Wils A, Friedman HS, Mahon J et al. Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents. Lancet [Internet]. 2017;390(10104):1792\u0026ndash;806. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/28433259/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/28433259/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatton GC, Sawyer SM, Santelli JS, Ross DA, Afifi R, Allen NB, et al. Our future: a Lancet commission on adolescent health and wellbeing. The Lancet. Volume 387. Lancet Publishing Group; 2016. pp. 2423\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eA Strategic Approach to Reporoductive, Maternal, Newborn, Child and Adolescent Health (RMNCH\u0026thinsp;+\u0026thinsp;A) in India. 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOperational Guidelines for Peer Education Programme National. Health Mission Department of Health and Family Welfare Government of Odisha.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdolescent Health Division Ministry of Health. and Family Welfare Government of India operational framework translating strategy into programmes. 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImplementation Guidelines Rashtriya Kishor Swasthya Karyakram (RKSK). Ministry of Health and Family Welfare Government of India. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohns B, Baltussen R, Hutubessy R. Programme costs in the economic evaluation of health interventions. Cost Effectiveness and Resource Allocation [Internet]. 2003 Feb 26 [cited 2023 Aug 16];1(1):1\u0026ndash;10. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://resource-allocation.biomedcentral.com/articles/\u003c/span\u003e\u003cspan address=\"https://resource-allocation.biomedcentral.com/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1478-7547-1-1\u003c/span\u003e\u003cspan address=\"10.1186/1478-7547-1-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Health Systems Resource Centre. Ministry of Health and Family Welfare (MoHFW) Government of India. National Health Account Estimates for India 2019-20. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrinja S, Gupta A, Bahuguna P, Nimesh R. Cost analysis of implementing mHealth intervention for maternal, newborn \u0026amp; child health care through community health workers: Assessment of ReMIND program in Uttar Pradesh, India. BMC Pregnancy Childbirth. 2018;18(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRout SK, Gabhale YR, Dutta A, Balakrishnan S, Lala MM, Setia MS et al. Can telemedicine initiative be an effective intervention strategy for improving treatment compliance for pediatric HIV patients: Evidences on costs and improvement in treatment compliance from Maharashtra, India. PLoS ONE. 2019;14(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrinja S, Jeet G, Verma R, Kumar D, Bahuguna P, Kaur M et al. Economic analysis of delivering primary health care services through community health workers in 3 North Indian states. PLoS ONE. 2014;9(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonga D, Verma R, Kumar D, Grover G, Chauhan A, Lakshmi PVM, et al. Cost of National Vector Borne Disease Control Programme in North India. Indian J Med Res. 2022;155(1):22\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhamania M, Gaur K, Pankaj JP, Sharma DK, Yadav R, Raj D. Cost Analysis of Intranatal Care Services at a Tertiary Care Public Sector Hospital in Rajasthan, India. Cureus. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrinja S, Gupta A, Verma R, Bahuguna P, Kumar D, Kaur M et al. Cost of delivering health care services in public sector primary and community health centres in north India. PLoS ONE 2016;11(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrinja S, Singh MP, Guinness L, Rajsekar K, Bhargava B. Establishing reference costs for the health benefit packages under universal health coverage in India: cost of health services in India (CHSI) protocol. BMJ Open. 2020;10(7):e035170.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrinja S, Sharma Y, Dixit J, Thingnam SKS, Kumar R. Cost of Treatment of Valvular Heart Disease at a Tertiary Hospital in North India: Policy Implications. Pharmacoecon Open. 2019;3(3):391\u0026ndash;402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahuguna P, Guinness L, Sharma S, Chauhan AS, Downey L, Prinja S. Estimating the Unit Costs of Healthcare Service Delivery in India: Addressing Information Gaps for Price Setting and Health Technology Assessment. Appl Health Econ Health Policy. 2020;18(5):699\u0026ndash;711.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMangal DK, Hossain M, Sharma N, Sodani PR, Gupta SD. Cost Benefit Analysis of Adolescent Health Interventions for Rajasthan [Internet]. Jaipur; 2018. Available from: www.copenhagenconsensus.com.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHossain M, Gupta SD, Sharma N, Sodani PR, Mangal DK, Hossain M. Cost-benefit analysis of adolescent health interventions in Andhra Pradesh [Internet]. 2018. Available from: www.copenhagenconsensus.com.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown HS, Stigler M, Perry C, Dhavan P, Arora M, Reddy KS. The cost-effectiveness of a school-based smoking prevention program in India. Health Promot Int. 2013;28(2):178\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalik K, Michelson D, Doyle AM, Weiss HA, Greco G, Sahu R et al. Effectiveness and costs associated with a lay counselor\u0026ndash;delivered, brief problem-solving mental health intervention for adolescents in urban, low-income schools in India: 12-month outcomes of a randomized controlled trial. PLoS Med. 2021;18(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKapoor A, Yadav C, Kapoor M. Investing in Adolescent Development: A Case Study for India. Institute for Competitiveness, India. New Delhi; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBassi S, Bahl D, Maity H, Dringus S, Rizvi ZA, Kumar D et al. Engagement of Peer Educators from India\u0026rsquo;s National Adolescent Health Programme for the COVID-19 response activities: Qualitative findings from i-Saathiya study. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://bmjopen.bmj.com/\u003c/span\u003e\u003cspan address=\"http://bmjopen.bmj.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArora M, Dringus S, Bahl D, Rizvi Z, Maity H, Lama S et al. Engagement of health workers and peer educators from the National Adolescent Health Programme-Rashtriya Kishor Swasthya Karyakram during the COVID-19 pandemic: Findings from a situational analysis. PLoS ONE. 2022;17(9 September).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eExploring Implementation of the Peer Education Programme for Improving Adolescent Health in India\u0026rsquo;s National Adolescent Health Strategy i-Saathiya Study Report. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://phfi.org/wp-content/uploads/2023/08/i-Saathiya-Study-Report-2023-1.pdf\u003c/span\u003e\u003cspan address=\"https://phfi.org/wp-content/uploads/2023/08/i-Saathiya-Study-Report-2023-1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Peer Educator programme, provider cost, cost of peer educator programme, micro costing, adolescents health, India","lastPublishedDoi":"10.21203/rs.3.rs-8470187/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8470187/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealth system cost entails the cost incurred by the health care provider to deliver services and these costing studies are critical for budgeting and price setting of essential health interventions. Moreover, cost information is used for evaluating cost effectiveness of various interventions, which guide resource allocation decisions. In India, though these studies bear significance because of low public spending on health care, there are scant evidence on health system costs of various interventions. The present study was undertaken to estimate the resource use and implementation cost of the Peer Educator (PE) programme, a community-based intervention, under the Rashtriya Kishor Swasthya Karyakram (RKSK) within the National Adolescent Health Programme in India.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study was undertaken using a provider perspective to estimate the unit cost of service provided through the PE programme in the two states of India namely Madhya Pradesh and Maharashtra. We used the micro-costing approach (bottom-up costing), where all relevant resources used for the programme were identified and subsequently, costs were estimated. We estimated the total programme cost, the per capita cost of creating a peer educator and an adolescent enrolled and trained under PE. The per capita cost was estimated separately for the Peer educators and adolescents enrolled under the PE. The programme is run by a Non-Government Organization (NGO) in Madhya Pradesh, while, it is implemented by the government, known as government-led model in Maharashtra. The cost data was collected retrospectively for the two financial years: 2019-20 and 2020-21 respectively from 16 blocks covering 4 districts across the two states.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe total programme cost was found to be Indian National Rupee (INR) 1092968 (95% CI: 608344\u0026ndash;1577592) in the NGO-led model in Madhya Pradesh and INR 412990 (95% CI: 246728\u0026ndash;579252) in the government-led model in Maharashtra in 2020-21. The share of human resource cost was 45% of total cost and was the major driver of the overall cost in Maharashtra while monitoring cost formed the highest share (59%) in the total programme cost in Madhya Pradesh. The per capita cost of creating a Peer Educator in Madhya Pradesh was INR 2935 (95% CI: 2509\u0026ndash;3362) compared to INR 1818 (95% CI: 1122\u0026ndash;2515) in Maharashtra in 2020-21. Similarly, the per capita cost of proving the Peer Education intervention to the adolescents enrolled under the PE known as adolescents enrolled under PE (AEP) in the year 2020-21 is INR 262 in Madhya Pradesh and INR 168 in Maharashtra.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study generates evidence on the total programme cost, the per capita cost of providing the peer educator programme and its variations across two states of India. The findings suggest that the per capita cost of adolescents trained on various aspects adolescent health and the resource use pattern varies between the two states. The findings of the study could help the policy makers for future planning and budgeting of adolescent health programmes.\u003c/p\u003e","manuscriptTitle":"Cost of providing Peer Education programme in the National Adolescent Health programme and its variations across two states of India.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 18:58:36","doi":"10.21203/rs.3.rs-8470187/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93375239-e2da-41a1-8b31-a8207284f6ce","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-13T08:43:27+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T09:01:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 18:58:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8470187","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8470187","identity":"rs-8470187","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}