Family Planning plays an important role in achieving multiple development targets and goals set under the Sustainable Development Goals ( SDGs), Goal 3 – Good health and well-being and Goal 5 – Gender equality, call for reduced maternal mortality, reduced premature, neonatal and child deaths and universal access to sexual and reproductive health care and rights, including family planning information and education.
In 2012 the ‘London Summit on Family Planning’ was held to ensure focus on family planning globally. It was a watershed event in the history of family planning worldwide wherein countries and donors pledged around $2 billion (INR12000 crores) annually and all-around efforts to reach 120 million (12 crores) women with lifesaving family planning information, services and supplies, a sizeable 48 million (4.8 crores) of who are Indians. Needless to emphasise that the London Summit on Family Planning provided a much-needed impetus to the national agenda in order to revolutionise the vision of protecting children and mothers dying due to unhealthy spacing and lack of access to family planning choices.
Access to safe, voluntary family planning is a human right. Family planning is central to gender equality and women’s empowerment and is a key factor in reducing poverty. The lack of women’s autonomy in reproductive decision-making, compounded by poor male involvement in sexual and reproductive health matters, is a fundamental issue yet to be addressed. Recognising the urgency and importance of family planning from a rights-based framework, the Government of India (GoI) announced the expansion of the basket of contraceptive choice for women with the introduction of injectables and improved quality health care in the country. India is a country with very high unmet needs. Various studies show the reasons for unmet needs are little-perceived risks of pregnancy, fear of side effects, lack of information, lack of access, objection from family /husband and also high costs (UNFPA 2016).
The data from NFHS shows the use of any/modern family planning method by currently married women (15-49 age group) has meagrely declined from NFHS3 to NFHS4 (56.3 % to 53.5% and 48.5 to 47.8 %) and there has been just a marginal decline in total unmet need from 13.9 to 12.9. Approximately 13 percent of currently married women between the ages of 15 and 49 in India have a total unmet need for contraception (NFHS 4) and 5.7 % have an unmet need of spacing method calls for every stakeholder to share the responsibilities of addressing the gap. India is committed to increasing demand satisfied by modern contraceptives to 74% by 2020 (Vision FP 2020).
Improving the quality of care in family planning services is key to improve use of family planning services in India, both by attracting new contraceptive users and by maintaining existing users (i.e. ensuring continued engagement with services). The quality indicators for family planning as measured in the national family health survey have not shown significant improvement for over a decade. The data reflects that current users receiving information on side effects of the current method have slightly improved from 34.4% (NFHS-3 ) to 46.5% ( NFHS-4) and Health worker talking to female nonusers about family planning has just improved from 10.1 % (NFHS- 3) to 17.7 % ( NFHS-4). These are areas of concern.
Quality improvement is an unending process. Monitoring and constant assessment are very essential for providing quality services which are also a major thrust area under National Health Mission. The basket of choices under the family planning program has extended beyond sterilisation but sterilisation continues to be the preferred and widely accepted method among couples adopting family planning methods. The government has been actively pursuing improvement in the quality of sterilisation services provided through the states’ fixed day static centers as well as camp outlets.
The need to strengthen infrastructure, human resources management, accountability and governance of the public health system has been repeatedly emphasised (Pachauri, Sexual and reproductive health services: Priorities for South and East Asia, 2011) as these are major impediments to the effective delivery of health and family planning services ((UNDP), 2014). But it is not enough to only ensure availability and geographical and economic access to family planning services. Quality of services (perceived or real) strongly predicts the choice of provider as well as the decision to use family planning. At other times, poor quality may lead to loss of return to follow-up or even discontinuation of use of family planning.
Focused and frequent quality assessments will provide actionable data to program managers. Identifying, and then acting upon, systematic barriers to low FP service quality will decrease the unmet need for contraception and lead to important gains in women’s health. There is also a need to have standardized Family Planning assessment tools, quality indicators and methodologies for data analyses to help identify gaps in service provision, community barriers as well as potential points for intervention.
Moreover, family planning programs function not in isolation but within the broader context of social relations in a setting. Within India, these relations are determined largely on the basis of caste, social class, and gender. Within such systems, the poor, especially poor women, have traditionally been accorded few rights—including the right to receive sympathetic and respectful treatment. It is essential to focus attention on strengthening the health system’s capacity to reach the poor and unreached. Also, the integration of men into the ambit of family planning is essential.
To realise SDGs and India’s commitment to FP2020 goals of reaching to 48 million additional users of modern family planning methods by 2020 (compared to 2012) and increased financial commitment on family planning to more than US $2 billion (Rs. 13,000 crores) from 2012 to2020, it becomes imperative to work on quality of care. The first, and perhaps, the most important strategy that must be underscored is the need to translate within the national programme, the fundamental concept of informed contraceptive choice which, despite much rhetoric, has remained a mirage for the people of India. It is imperative that the principle of “the rights of couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so”, is operationalised within the national programme.