DELHI — At the landmark London Summit on family planning in 2012, 69 countries pledged to enable fuller access to family planning services for an additional 120 million women globally by 2020. India committed to spending more than $2 billion toward family planning services for 48 million women by 2020, besides sustaining its existing coverage of approximately 100 million users.
India’s population of 1.3 billion consists of nearly 18 percent of the world’s total population. China ranks first in the world, with 1.4 billion people.
A recent study by the Population Foundation of India on family planning budgets and projections for meeting the so-called FP2020 commitments indicates, however, that at the current growth of the modern contraceptive prevalence rate (mCPR), the country will reach only an additional 32.8 million women, 15 million short of the target.
“Meeting the FP2020 goal is essential for India, because despite significant progress in the family planning, it is still far behind in both quantitative and qualitative terms,” said Dr. Barun Kanjilal, a professor at the Indian Institute of Health Management Research, in Jaipur, who led the study.
“The population has reached an alarmingly high level and there is an urgency to drastically reduce the fertility rate,” he said. “Increasing population implies increasing pressure on existing resources like schools, roads, water, health care and so on. Essentially, there is a huge burden or cost waiting for the future generation if some urgent and drastic steps are not taken.”
Dr. Kanjilal linked FP2020 to human rights, gender equality and empowerment by noting, “In qualitative terms, FP2020 paints a desirable scenario where women and girls have full right to decide freely, and for themselves, whether, when and how many children they want to have.”
According to the Population Foundation’s policy brief on resource requirement, which is based on the study, while states like Rajasthan, Madhya Pradesh, Himachal Pradesh and Chhattisgarh are on track toward meeting the FP2020 goal, others like Bihar, Odisha, Uttaranchal, Uttar Pradesh and Assam need to drastically improve their mCPR to meet the target.
Dr. Kanjial listed the three main challenges that must be addressed if many more Indian women are to benefit from family planning services. First, since private players dominate the “spacing” contraceptive market — the use of condoms and pills — their involvement is imperative. The private sector is expected to cater to 42.5 percent of all modern contraceptive users between 2013 and 2020. But if only nonpermanent birth-control options, like pills, condoms and IUDs, are considered, the private sector is expected to serve 76.5 percent of the users.
Trends indicate, however, that the private sector will reach only 10 million more users by 2020, 12 million short of the goal. Therefore, the government must build partnerships with the private sector to bridge the gap.
Second, the percentage share of limiting and spacing contraceptives — known as method mix — is heavily skewed toward limiting or terminal methods. Female sterilization is the preferred method of approximately 75 percent of total users. For couples with two or more children, a permanent sterilization solution may be viable. This is often not the case for younger couples, who may not have the desired number of children yet, though they still choose a permanent method because they lack access to spacing contraceptives.
“Freedom to choose the numbers and spacing between children is a basic reproductive health right of any woman,” Dr. Kanjilal said. “But the popularity of female sterilization not only impinges on that freedom, it strongly indicates poor accessibility to contraceptives and lack of information, especially for spacing.”
Indeed, it is difficult for a married woman in the hinterlands to traverse 5 to 10 kilometers, or up to six miles, to a pharmacy or health center to get birth control pills even if she is inclined to do so. Social and cultural barriers, including a husband’s reluctance to agree to spacing, as well as low awareness further curtail a woman’s choice. And if a financial incentive is provided for one method, it indirectly skews overall choices.
Dr. Sanjib Mukherjee, a gynecologist and former president of the Health Service Association, in West Bengal, has over the years closely observed the workings of the rural health care system and interacted with couples there. He thinks that when it comes to “our family planning programs, hardly any thought is given to what women and girls want.”
“They are mostly imposed from the top down, and there is rarely any input taken from doctors working in primary health centers, who are the ones actually in touch with the grassroots needs.”
Ample evidence links birth spacing to improved mother and child health; it has a special impact on child survival as well. But while the Accredited Social Health Activists distribute contraceptives in local communities, more must be done to increase coverage and affect positive behavioral change, experts say.
Dr. Nilima Thakuria Haque, who is based in Assam, said, “Intensive counseling on the use of spacing contraceptives is the need of the hour. Illiteracy, poor awareness and social taboos lead to the majority saying no to IUDs [intrauterine devices]. Most don’t know how to use condoms or take pills properly. So, unfortunately, when couples with two children are looking for birth control they almost always end up going for female sterilization instead of, say, even vasectomy.”
The third challenge concerns the quality of family planning services “offered free of charge which, in reality, are ‘freely unavailable,’ especially in rural areas,” Dr. Mukherjee said. He added that there is a tendency to medicalize family planning, but that it is equally important to “incorporate women’s education and counseling into the family welfare and family planning program for it to really work.”
“For married women interested in planning their family informed advice is hard to come by, and so it all comes down to either sterilization or abortion,” he said.
The gaps in family planning point to a need for a significant increase in government spending if women are to lead healthy, productive lives.
Dr. Kanjilal said that government spending on family planning goes in two ways: to program costs through the National Health Mission, and in-kind support and nonprogram routine costs. “So far, the focus has been on the first aspect since it is directly linked to number of users.”
Despite an increase in the government family planning budget, the total allocation for family welfare has decreased. Moreover, although the National Health Mission allocation for such services increased 47 percent to 2015-2016, from 2013 to 2014, a shortfall of about $231 million persists. So, it will be difficult for the government to reach a target of even 33 million additional users by 2020.
Effective family planning is possible when couples are aware of their options and have equitable, easy access to quality services, both of which are impossible to ensure without adequate financial resources. That means securing women’s basic reproductive rights.
“Right now, the focus has to be on investing in women and ensuring a social acceptance of their right to choice,” Dr. Kanjilal.
© Women’s Feature Service