FP UHC Blog Series: Ensuring Equitable Access to Family Planning in India’s Health Care System

Family Planning has been recognized as one of the most cost-effective solutions for achieving gender equality and equity as it empowers women with the knowledge and agency to control their bodies and reproductive choices¹. It is an investment with a cross-sectoral impact, which has a bearing on all 17 goals of the Sustainable Development Goals (SDGs) either directly or indirectly. Unintended pregnancies, unsafe abortions, and maternal deaths would drop by about two-thirds if all women in low and middle-income countries who want to avoid pregnancy were to use modern contraceptives and all pregnant women were to receive needed care².

India has been a member of the FP2030, formerly FP2020 global partnership instituted in 2012. It was a signatory to the FP2030, formerly FP2020 commitments and stood by its commitment to increase the modern contraceptive prevalence rate, reduce the unmet need for family planning, meet the demands for family planning through modern contraceptives, and increase spending on family planning. As countries made their FP2030 commitments last year, India, along with other commitments, has prioritised assuring quality family planning services in hard-to-reach areas aligned with its commitments to “leave no one behind.”

Efforts of the Indian government toward increasing access to contraceptives can be summed up in three critical strategies implemented in the National Family Planning Programme in 2016-17.

• The launch of Mission Parivar Vikas (MPV) Programme, a flagship programme of the Ministry of Health and Family Welfare, Government of India, to increase access to contraceptives and family planning services in 146 high fertility districts in 7 high-focus states (Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh Jharkhand and Assam). Given the success of the programme, the government has scaled it up to all other non-MPV districts in the seven high focus states and all the six North- Eastern states.
• The introduction of three new contraceptives — Injectable Contraceptive – Medroxyprogesterone Acetate (MPA) Centchroman, Progestin Only Pills* (POPs) [*on a pilot basis]
• Implementation of Family Planning Logistics Management Information System (FP-LMIS) to ensure a better supply chain of family planning commodities.

A comparison between the Fourth & Fifth National Family Health Surveys (NFHS) reveals that India has significantly improved its health and fertility outcomes. The country has achieved the replacement level of fertility rate of 2.0, that shows that India is on course to population stabilization and we must steer away from coercive measures of population control. The use of modern contraceptives increased to 56.4% in 2019-21 from 47.8% in 2015-16. Although the unmet need for family planning for married women (15-49 years) decreased to 9.4%, it is still high, which means that many women are still not able to use family planning services. This could be because services are not available or they do not have the agency to access and use the services.

India’s FP2030 commitment also aims at ensuring access to and expanding the range of contraceptives with the addition of new contraceptive choices (Implants and Sub-cutaneous MPA), improving Healthy Timing and Spacing of Pregnancies (HTSP) through Postpartum Family Planning, including in urban areas under MPV, intensifying social and behavioural change communication for all age groups, especially young people, and engaging civil society organizations for awareness generation and increasing community engagement for family planning³, all of which contribute significantly toward meeting the goal of universal health coverage.

Persistent challenges

Despite the efforts, challenges of inequity in healthcare coverage, outcomes, and financial protection still prevail. The Modern Contraceptive Prevalence Rate (mCPR) differs according to where people live (urban: 58.5% and rural: 55.5%), and on the basis of wealth, (50.7% for people in the lowest wealth quartile and at 58.7% in the highest wealth quartile). Access to family planning services is also dependent on education. The Total Fertility Rate (TFR) of women with more than 12 years of schooling is 1.78, while for women with no education it is 2.82. All of this suggests underprivileged, less educated, and rural low-income people are at a disadvantage when it comes to managing their fertility.

Adolescents, in particular, have substantial unmet needs for sexual and reproductive health (SRH) care⁴. According to NFHS-5, the unmet need among adolescents (15-19 years) is 17.8% and for young adults (20-24 years) is 17.3%. Many adolescents and youth feel that public health care services are not intended for them due to a perceived or real lack of respect, privacy, and confidentiality; fear of stigma; discrimination; and imposition of health care providers’ moral values⁵.

The way forward

In order to ensure last-mile coverage of the family planning programme in India, the following measures are recommended:

1. A strong primary healthcare system could be instrumental in maximizing the range and reach of available contraceptive options for all, and the foundation for achieving universal health coverage. Through counselling and information sharing, primary healthcare providers should be able to dispel existing myths around family planning methods and help in making informed contraceptive choices, especially through the use of Long Acting Reversible Contraceptives.
2. Survey and research data are the building blocks of governance, policy and program decisions. Data needs to be utilised effectively by policymakers through regular exchange and dialogue with researchers, civil society organisations working at the grassroots and functionaries who implement programmes, to promote positive family planning and SRH outcomes for all. Strengthening the Health Management Information System, under the National Health Mission and using its data for decision-making could help design programmes that address specific needs and issues of communities as identified by data.
3. The policy and programmatic response need to factor in socio-cultural variables and their impact on access to family planning and SRH services. Without adequately considering and addressing the social determinants of health, one cannot bridge the inequities between individuals, couples, and families, which is the biggest threat to achieving universal health coverage. The use of targeted social and behavioural change communication strategies and interventions on issues of family planning, adolescent health and SRH to address social and gender norms can help achieve equity and reach for all.

Conclusion

Family planning is a powerful tool for fulfilling people’s reproductive health and fertility needs and has rightly been at the heart of political and programmatic interventions in India as well as globally. However, India’s family planning programme, despite its numerous successes, has had to contend with misconceptions, lack of information around contraceptives, and a continuing gap in public perception on the importance and need for family planning. Various rounds of National Family Health Survey shows persisting unmet need for family planning, which can be a barrier to women’s realisation of their optimal reproductive health and fertility needs. Various factors contributing to women’s unmet need for family planning include access to quality of care, level of information about contraceptives, quality of counselling, and sociocultural norms that hinder contraceptive use.

Going forward, the programme planners and implementers should focus on the following measures:

• Quality of care, including a mix of contraceptive methods, needs to be made easily accessible especially in regions and within communities that report high unmet need.
• India should further expand the basket of contraceptive choices to include additional methods for spacing to improve the last-mile reach of quality reproductive healthcare services in underserved regions.
• Several research studies have documented a general lack of comprehensive knowledge about contraceptives among clients as well as providers across developing countries. These concerns can be addressed by providing effective counselling services and capacity building of frontline workers, that can enable clients to choose a method of their choice, address women’s lack of knowledge and fears regarding the side effects of contraceptives
• The government must focus on targeted social and behaviour change communication to address anticipated social opposition from husbands, families, communities, and religious leaders, to the use of contraceptives and to women’s desire to regulate fertility.
• Concerted efforts are required to systematically introduce comprehensive sexuality education, that includes information on conception, contraception, and reproductive health among other aspects.

¹ https://www.ghspjournal.org/content/4/2/191?__hstc=175320440.4b44870ec4a577029c49e44b73bd3bee.1671408000146.1671408000147.1671408000148.1&__hssc=175320440.1.1671408000149&__hsfp=3515293548
² https://www.guttmacher.org/article/2021/07/sexual-and-reproductive-health-care-key-achieving-universal-health-coverage
³ https://fp2030.org/india
⁴ https://www.guttmacher.org/report/adding-it-up-investing-in-sexual-reproductive-health-2019
⁵ https://www.prb.org/resources/adolescents-and-youth-are-key-to-fully-achieving-universal-health-coverage/