Back in 2012 at the landmark London summit on family planning, 69 countries pledged to facilitate access to family planning services for an additional 120 million women globally by 2020. India committed to spending more than two billion dollars towards this end for 48 million women by 2020, in addition to sustaining its existing coverage of approximately 100 million users.
However, a recent study on family planning budget and projections for meeting FP2020 commitments by the Population Foundation of India indicates that at the current growth in the modern Contraceptive Prevalence Rate, the country will only have reached out to an additional 32.8 million women, 15 million short of the committed target.
“Meeting the FP2020 goal is essential for India, because, despite significant progress in family planning, it is still far behind in both quantitative and qualitative terms,” says Dr Barun Kanjilal, professor at the Indian Institute of Health Management Research, Jaipur, who led the PFI study. “The population has reached an alarmingly high level and there is an urgency to drastically reduce the fertility rate. Increasing population implies increasing pressure on existing resources like schools, roads, water, healthcare 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,” he warns.
He links FP2020 to human rights, gender equality and empowerment by adding that “in qualitative terms, FP2020 paints a desirable scenario where women and girls have the full right to decide freely, and for themselves, whether, when and how many children they want to have”.
According to the PFI&’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 towards meeting the FP2020 goal, others like Bihar, Odisha, Uttaranchal, Uttar Pradesh and Assam need to drastically improve their mCPR to meet the target. Professor Kanjilal enumerates the three key challenges that must be addressed if many more Indian women are to benefit from the availability of family planning services. First, since private players dominate the spacing contraceptive market, their involvement is imperative. The private sector is expected to cater to 42.5 per cent of all modern contraceptive users between 2013 and 2020, but if only non-permanent birth control options like pills, condoms and IUDs are considered, the private sector is expected to serve 76.5 per cent of the users. The current trend, however, indicates that the private sector will by 2020 only reach an additional 10 million users, 12 million short. Therefore, the government has to work towards building effective 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 towards limiting terminal methods. Female sterilisation is the “preferred” method of approximately 75 per cent of total users. But where a permanent sterilisation solution may be viable for couples with two or more children, this often isn’t the case with younger couples who may not have the desired number of children but still go in for a permanent method because they lack access to spacing contraceptives like condoms and pills.
“The freedom to choose the numbers and spacing between children is a basic reproductive health right of any woman. But the popularity of female sterilisation not only impinges on that freedom, it also strongly indicates poor accessibility to contraceptives and a lack of information, especially for spacing,” says Professor Kanjilal.
Indeed, it is difficult for a married woman in the hinterland to traverse five to 10 km to get to a pharmacy or health centre for birth control pills, even if she is so inclined. Then again, social and cultural barriers, including a husband&’s reluctance to go in for spacing, as well as low awareness combine to curtail an exercise of choice. And if financial incentive is provided for one particular method, it indirectly results in shaping skewed choices.
As someone who has closely observed the workings of the rural healthcare system and interacted with several couples over the years, Dr Sanjib Mukherjee, gynaecological consultant and former president of the Health Service Association, West Bengal, believes that when it comes to “our family planning programmes, hardly any thought is given to what women and girls want”. He elaborates, “They are mostly imposed from the top down and there is rarely any input taken from doctors working in primary health centres, who are the ones actually in touch with the grassroots needs.”
There is ample evidence linking birth spacing to improved mother and child health — in fact, it has a particular impact on child survival as well. But while the Accredited Social Health Activists do distribute contraceptives in local communities, more has to be done to step up coverage and also affect positive behavioural change. Dr Nilima Thakuria Haque, subdivisional medical officer, Sonapur District Hospital, Assam, says, “Intensive counselling 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. 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 sterilisation instead of, say, even vasectomy.”
The third challenge concerns “the quality of FP services offered free of charge that, in reality, are ‘freely unavailable’, especially in rural areas”. As per Dr Mukherjee, there is a tendency to medicalise family planning where it is important to “incorporate women&’s education and counselling into the family welfare and family planning programmes for it to really work”. He says, “For married women interested in planning their family, informed advice is hard to come by, so it all comes down to either sterilisation or abortion.”
Today, if the gaps and needs in family planning are clearly evident, what is also undeniable is that there has to be a significant increase in government spending if women are to lead healthy, productive lives, which is their right.
Professor Kanjilal explains that the government spends on family planning in two ways: programme costs, through the National Health Mission, and in-kind support and non-programme routine costs. “So far, the focus has been on the first aspect since it is directly linked to a number of users,” he says.
Number crunching done as part of the PFI study has put together a figure of Rs 15,800 crore, if not more, to enable the country to meet its commitment of providing FP services through public-funded providers. Targeting low-progress states like Bihar, Jharkhand, Assam and Uttar Pradesh, and diverting money towards improving availability of commodities such as contraceptives and lifting demand will have an added impact. Current spending trends, nonetheless, show that the government will shell out only about Rs 11,600 crore during 2013-2020.
Notwithstanding the reality that there has been an increase in the family planning budget, the fact is that the total allocation for family welfare has decreased. Moreover, although the National Health Mission allocation for FP services increased by 47 per cent from 2013-14 to 2015-16, a shortfall of about $231 million persists. Consequently, it will be difficult to reach a target of even 33 million additional users by 2020.
Effective family planning happens when couples are duly aware of their options and have equitable, easy access to quality services — both of which are impossible to ensure without adequate financial resources. It really comes down to one smart decision: investing in the future of people by 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,” says Professor Kanjilal.
Women&’s Feature Service