Will Budget 2016 prioritize family planning?

At the recent International Conference on Family Planning, Indian health ministry officials committed to make available better quality family planning services and expanding contraceptive choices. How much of that will translate into action will depend on the money allocated to health care in this budget.

India has promised to meet the FP2020 goal of providing 48 million additional women and girls in the country with access to modern contraceptives by 2020. Family Planning 2020 is a global partnership that is working with governments, civil society, donors and the private sector to enable 120 million women and girls to decide for themselves, whether, when, and how many children they want.

Reaching 48 million, however, seems like a tall order. India spends just 1.3% of the GDP on health care, which is lower than other countries. China, for instance, spends 2.8% and South Africa 4.1%. Budget 2014-15 saw an 87% drop in funds allocated to family welfare and this was reduced even further by 34% in 2015-16.

The low priority is baffling given that India has among the worst maternal and infant mortality rates in the world. The role family planning plays in achieving broader development goals, including poverty reduction has been well documented.

Population Foundation of India figures show that 46% couples in India do not practise family planning, About 21% of births every year are unplanned, due to lack of access to contraceptives. The cost of unplanned children, according to a PFI study ranges from 2% of state GDP in Tamil Nadu to 14% in Bihar.

In this context, the Health Ministry’s decision to introduce injectable contraceptives in government health centres is a welcome move. The decision was pending for nearly 15 years due to protests from many women’s rights groups. It also plans to promote spacing methods and improve quality of care.

“Meeting the FP2020 goal would need an investment of approximately Rs 13500 crore over seven years (2014 to 2020)”, points out Poonam Muttreja, Executive Director, Population Foundation of India. An additional Rs 11,150 crore would be needed over the next four years, which is Rs 2800 crore per year, adds Muttreja.

Supplying injectables alone will not is be enough say experts. The government needs to rethink its approach towards family planning.

“If you are talking of FP2020 goals, a lot depends on involving men”, says Ashok Dyalchand, Director, Institute of Health Management in Pachod, Maharashtra. “Not enough has been done to involve men and you have a significant proportion of women using contraception without their husbands’ knowledge.”

“The emphasis has been largely on methods for women historically”, adds Muttreja. “The public health system, FP programmes and communication strategies have to change to encourage male engagement”.

For decades India has depended on female sterilization as a means of contraception. It conducts the highest number of tubal ligations – nearly five million in a year. Data from the first phase of the National Family Health Survey (NFHS-4) shows that female sterilisation accounts for 34% of modern contraceptive methods, while less than 1% men go for a vasectomy

One of the main reasons for the low prevalence are the many myths and misconceptions relating to vasectomy says Emily Jane Sullivan from the London School of Hygiene and Tropical Medicines.

“A tubal ligation is a more complicated, costly, and risky procedure than vasectomy”, says Sullivan. “However, in India, more than 1 in 3 women choose to have a tubal ligation while only 1 in 100 men choose to have a vasectomy.”

Countries like Bhutan, Brazil, Nepal, and Rwanda have countered these myths effectively through campaigns that frame men who choose vasectomy as responsible and caring towards their families.

“There is an opportunity for these countries to share their ‘lessons learned’ with other national family planning programs that are looking to thoughtfully, ethically, and effectively promote vasectomy”, says Sullivan.

India needs to look at similar approaches instead of simply adding more to the basket of choices say experts.

“The only addition to the basket is injectables. We do not have male contraceptives. I am in favour of injectables but whether diligence will go into administering it in the government sector is a concern. There is also the question of a strong provider preference towards tubectomies”, cautions Dyalchand.

For decades India has followed a targets and incentives based approach towards family planning. Achieving the FP2020 goal involves a shift away from that. It is not just about technical solutions or contraception, but also about women’s agency, choice, quality of reproductive health services and dignity.

Thie article was published in The Indian Express here

 

 

 

Zika virus disease: Lessons for India

The fear and panic over the spread of the Zika virus disease has helped highlight the inadequacies many countries face in providing family planning and reproductive health services. The outbreak may be far from India’s shores, but those lessons hold true for us as well.

Zika has been declared a global public health emergency. There are fears, not entirely proven, that it is linked to birth defects in babies whose mothers contract the virus during pregnancy. Over 3000 cases of microcephaly—an oddly small head and an immature brain—have been reported in Brazil.

Given that the virus is spreading rapidly, with no proven vaccine in the horizon, women who are pregnant, or are likely to become pregnant, are in a spot.

In many of the countries affected, abortion is illegal. In some regions, contraceptives are in short supply. But going by the statements coming from political leaders, the onus seems to be entirely on women.

In El Salvador, women have been told to postpone getting pregnant for up to two years. How will they given that it’s not always accessible?

The public health system in many of these countries is in a poor state, much like in India. Rural areas, which are understaffed, are worse off. Again, much like in India. There is also great stigma attached to contraception.

Like India, the societies in many Latin American countries are deeply patriarchal. Cases of rape, including marital rape, are high. So where is the question of women exercising the choice to not get pregnant?

Zika is already out of the headlines, swept away by another crisis in another part of the world. But the outbreak has thrown up relevant questions. Like the need to build a strong public health infrastructure, make available a range of contraceptive choices, and most important, empower women to exercise those choices.

This article was published in the blog healthyurbanworld here. 

Why India needs a sex positive approach

At 1.8 billion adolescents and youth form a significant part of the world’s population; the numbers are expected to grow even faster in the developing world. Which makes it critical that we invest in their education and health, and that includes sexual and reproductive health.

 

About 16 million adolescents in developing countries between the ages of 15-19 years give birth annually; many of them are unplanned pregnancies. One-third of girls are married before 18 years, and 12% by the age of 15. An estimated 33 million young women between 15-24 years have an unmet need for contraception.

The global consensus statement at the recently concluded International Conference on seeking to expand contraceptive choices, even long acting reversible contraceptives, for young people acknowledges this critical gap. A significant number of adolescents and youth are sexually active and want to prevent or delay a pregnancy. But access to contraception and ability to choose from a variety of methods is limited.

“I believe the terminology “family planning” needs to be modified”, says Dr C.M Purandare, president of the International Federation of Gynecology and Obstetrics, FIGO. “Because adolescents are not family planning—they have no family. But they are looking at contraception. When the terminology was decided, maybe 20 years ago, the situation was different. Then, we were talking about population reduction”.

The statement calls for providing evidence-based information to policymakers, ministry officials, service providers, communities, family members and young people on the benefits of contraceptive options.

At its very core, it demands a rethink in how many countries, including India, approach sexuality education.

With one fourth of our population between 10-19 years, India is the youngest country in the world. We are likely to have 358 million young people in the next three decades.  Young people, by accident or design, are experimenting with sex but is there enough being done to ensure that they are informed about it in an appropriate manner?

Findings from the latest National Family Health Survey findings are not very promising. Data collected from the 13 states surveyed in Phase 1 show that 82% women and 70% men lacked comprehensive information about HIV/AIDS and safe sex practices.

Sexuality education, as defined by UNESCO, “provides opportunities to… build decision-making, communication and risk reduction skills about many aspects of sexuality.  The term encompasses the full range of information, skills and values to enable young people to exercise their sexual and reproductive rights and to make decisions about their health and sexuality”.

However, in India, the subject of sexuality education has been a controversial one. In 2007 when the  Centre, along with the NACO, NCERT and UN agencies announced the launch of the Adolescence Education Programme in schools, 13 states announced an immediate ban who felt comprehensive sexuality education is against Indian culture. Presently there is a ban on AEP in five states across India, and there is no unformity in the way the subject is approached.

Successful sexuality education programmes start with children between the ages of 5-8 years. Children are curious about their bodies, and ideas of shame and silence are internalized at a young age. It is important, say experts, to educate children early on on the need to understand issues of consent, body image/shame, preventing abuse, establishing good communication skills and gender norms.

There is a need to adopt a “sex positive approach” and go beyond looking at sexuality education as a “means of controlling adolescent fertility because we want to reduce unwanted pregnancies or make sure families are planned better”, says Ishita Choudhry, Ashoka Fellow and Founder of The YP Foundation, a youth-led organization that has worked with adolescents and young people in India in settings, both urban and rural, on many development issues, which include sexual and reproductive health and rights.

“The fact is that adolescents are discovering their bodies and this is a joyful, exciting process for them”, says Dr V Chandramouli, scientist at the WHO Department of Health and Reproductive Research. “They need information that will help them make safe, informed choices and this is not to be always framed in the context of HIV”.

But most parents do not talk to their kids about sex and believe they will figure it out by themselves at some stage. They fear that incorporating it in the school curriculum will encourage promiscuity although innumerable studies show otherwise.

“From our experience we find that most adolescents are getting to know about sex from porn videos”, says Ramya Jawahar, Vice Chair, International Youth Alliance for Family Planning. “These videos don’t talk about safe sex or respecting boundaries so the messages going out to these adolescents is that its OK to not wear a condom or treat women in a disrespctful manner”.

Policymakers and the government, says Jawahar, have to start looking at sexuality education as a health, development and human rights issue and not through a morality prism.

“It is high time we move past our individual discomfort in acknowledging sexuality as a human desire and started considering adolescents as people with agency”, says Chaudhry. “Until then we will keep looking at ways of regulating sexuality across different health outcomes instead of empowerment.”

This article was published in the Business Standard. To read click here