MARCH 2025

Country context: Taking stock of family planning and reproductive health

India is a lower-middle-income country with the largest population in the world, at over 1.44 billion people. The Indian government has prioritized family planning throughout the entire post-independence period. Since the 1950s, early family planning strategies focused on significantly reducing the birth rate, including by coercive means, and with an emphasis on male and female sterilization. Consequently, India achieved its target of a total fertility rate of two births per woman in 2021, although significant disparities among state-level fertility rates remain, and the population is projected to continue growing and surpass 1.5 billion people by 2030. India’s early family planning and reproductive health strategies laid the groundwork for advancements in population health. However, addressing the enduring legacy of son-preference, which has influenced the gender ratio and continues to impact gender equality, presents an opportunity to further empower women with greater access to and control over reproductive decision-making. Recognizing this challenge, since 2012, the government’s strategy has shifted toward a rights-based approach, which enshrines the right of all individuals and families to choose not only the number, timing, and spacing of children but also the means to do so safely.

Expanding modern contraceptive prevalence

India’s contemporary rights-based approach focuses heavily on providing accurate information and access to modern contraception. In 2021, unmet need for family planning dropped to 9.4 percent, leaving an estimated 47 million Indian women with an unmet need for contraception. India’s National Family Planning program makes six spacing and two permanent contraceptive methods available free of cost: IUDs (copper or hormonal), injectables, implants, oral contraceptive pills (combined or non-steroidal), condoms, and male and female sterilization. As of 2023, India’s national modern contraceptive prevalence rate (mCPR) sits at 59 percent, however, access to modern contraceptives varies significantly among regions and groups, and some contraceptives have a much higher penetration than others. Condoms and contraceptive pills, for example, are accessible by 79 percent and 72 percent of the national population, respectively, compared to implants—which can be accessed by just 9 percent of the population—injectables—at 53 percent—and IUDs—at 68 percent.

Despite a shift in global family planning policy toward reversible methods, and their availability through the public health system, female sterilization remains the primary contraceptive method in India, accounting for around 38 percent of all contraception as of 2022. This high prevalence may be linked to the legacy of government coercion and compensation for sterilization, which—according to some sources—continued until as recently as 2012. As an irreversible method, sterilization removes women’s autonomy over birth- and pregnancy-related decisions, and women from marginalized groups, such as scheduled castes, are more likely to undergo sterilization, factors that undermine India’s rights-based approach to family planning. Expanding the uptake of modern reversible methods is therefore key to ensuring the protection of all Indian women’s sexual and reproductive rights.

Ensuring access to family planning and reproductive health care

India is committed to achieving universal health coverage (UHC), under which family planning services are intended to be free for all. However, across India, a combination of structural, cultural, and historical barriers hampers equitable access to family planning and reproductive health services, and to information. These challenges include meeting the needs of the hardest-to-reach populations, particularly women and girls in slums and rural areas, those without a formal education, and those of marginalized caste and religious identities. Access—both physical and financial—to health facilities is another barrier: as of 2019, 82 percent of women did not give birth in a formal health facility, which can lead to higher health risks for both mothers and babies. Relatedly, health outcomes across different states remain uneven due to the decentralized administration of health policy, through which the national government disburses funds for state governments to implement state-level strategies. In practice, this means that access to the full range of contraceptive methods and to community-based health care programs is highly dependent on geographical location, including across urban-rural divides and from state to state. As a result, family planning services are not yet free or freely available to all, and supplementary actors, such as private health facilities, are needed to fill gaps in reproductive health care coverage.

Despite these challenges, India has made significant progress. Maternal mortality decreased by 77 percent between 2005 and 2021, compared to a global average of 43 percent, representing a critical victory and reliable progress toward meeting SDG 3.1. As of 2020, the most recent year for which WHO data is available, the maternal mortality ratio was 103 per 100,000 live births. There has also been a 55 percent increase in modern contraceptive usage over the past three decades, with almost one-third of this increase taking place within the FP2020 policy period from 2012 to 2020. This success demonstrates the critical role that government leadership can play in galvanizing stakeholders and achieving significant results.

Preventing and managing reproductive cancers and diseases

Reproductive illnesses remain a challenge to India’s public health and sustainable development as they have not been prioritized through policies or funding in the same ways as family planning. Breast and cervical cancers have high mortality and incidence rates, while screening uptake remains low, despite the rollout of a population-level screening program in 2016. Incidence and mortality for cervical cancer, for example, as of 2022 were 17.7 per 100,000 and 11.2 per 100,000 people, respectively, compared to average incidence across Asia of 13.9 and mortality of 6.7 per 100,000. While the government is publicly optimistic about progress toward the goal of universal screening, independent research and data collection, and the testimonies of community health workers, indicate that progress is slow and patchy, due to a mistrust of the screening process and accessibility of diagnostics, among other factors. Meanwhile, as of 2021, India had the third-highest burden of HIV globally, at 2.3 million people, with 42,000 deaths attributed to HIV/AIDS that year. However, HIV prevalence and mortality have decreased substantially in India as a result of a government-led focus on prevention and early diagnosis. This progress is important for reducing unwanted pregnancies, including those involving maternal-neonatal transmission of HIV.

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Policies and programs: Assessing multistakeholder efforts

At the highest level, India’s health policy and interventions fall under the umbrella of the National Health Mission (NHM), which lays out objectives and goals for public health to be implemented at the state level. The NHM seeks to increase access to and improve the quality of care, and ensure UHC, including by expanding health infrastructure and workforce in rural and hard-to-reach areas. The NHM covers family planning and reproductive health services, which are supposed to be free to access for all, and is supplemented by a wide range of government-led programs, including the Mission Parivar Vikas, the Janani Suraksha Yojana, and the Rashtriya Kishor Swasthva Karyakram. While India does not have a single, overarching family planning policy or strategy document, goals and objectives are articulated across a range of documents, including the 2000 National Population Policy, the 2017 National Health Policy, and multilateral agreements such as the SDGs and ICPD. Family planning goals in these documents are relatively high-level. The National Health Policy, for example, articulates the goals of immunizing over 90 percent of newborns, sustaining antenatal care and skilled attendance at birth for over 90 percent of pregnancies, and meeting 90 percent of all family planning needs at the national and subnational levels by 2025. These goals are not accompanied by detailed policy plans or strategies, but their inclusion in the government’s active health policy document indicates their prioritization at the national level.

India’s family planning commitments are also aligned with, and monitored by, multilateral partnerships, such as the FP2030 strategy and UNFPA’s Programme of Action, both of which lay out clear, data-driven goals for the government and other stakeholders, such as the private sector, to undertake. India’s FP2030 strategy was produced in consultation with the non-governmental organization FP2030, and domestic and international stakeholders, including medical professionals, civil society organizations, and patient advocates. The UNFPA programme, meanwhile, has committed USD 60 million to be spent over five years, with half of that funding specifically coming from new or innovative co-financing pathways. Priorities include scaling up rights-based family planning services, improving data collection and monitoring, and implementing digital solutions.

Funding and coordinating family planning and reproductive health

Investing in family planning and reproductive health is one of the most important ways to drive social development and economic growth in India. Estimates suggest that meeting all unmet need for modern contraception, maternal, newborn, and infant care, and post-abortion care would cost just USD 5.41 (INR 397) per capita per year, or a total of USD 7.4 billion (INR 542 billion) annually. Given the direct and indirect impact that reproductive health and family planning services can have on economic development, health security, gender equity, environmental sustainability, and more, prioritizing investments in these services will require cross-sectoral collaboration and yield dividends for generations to come.

Progress in improving access to contraceptives has been steady, undertaken via a combination of government-led and multi-stakeholder efforts. Government policies include the Mission Parivar Vikas (MPV), launched in 2017, and the mobilization of Accredited Social Health Activists (ASHAs)—community-based health care workers—to disseminate information and deliver contraceptives. The MPV specifically aims to improve family planning and reproductive health in low-performing and hard-to-reach communities. Initially targeting 146 districts in seven states with the highest birth rates and lowest uptake of modern contraceptives, since its launch 137 out of 146 target districts showed an increase in modern contraceptive use, and 124 districts demonstrated a decline in unmet need for contraceptives. The MPV is now being expanded, with the support of UNFPA and other stakeholders.

In addition to these government-led interventions, multisectoral partnerships are working to improve contraceptive supply chains, particularly to remote and rural regions of the country. According to UNFPA India Representative Andrea Wojnar, UNFPA has partnered with private pharmaceutical companies, including Bayer, to reduce stockouts by training ASHAs to record the contraceptive needs of their patients within the National Family Planning Logistics Management Information System. This project helps pharmacies to ensure they are stocked for the needs of local clients, and identify supply-side bottlenecks, which is crucial to ensuring access, as the private sector currently provides 45 percent of contraceptive pills, 24 percent of IUDs, and 40 percent of condoms distributed across India. Although family planning services are meant to be free to access via the public health system, in practice the private sector plays an important role, addressing supply-side challenges to contraceptive distribution and overcoming accessibility challenges in rural and hard-to-reach areas. Certain groups, including adolescent girls, and women from religious minorities or scheduled castes, also often choose to use private health facilities, to avoid discrimination and stigma and to ensure privacy. Indeed, harnessing the capacity of the private sector to close gaps in unmet need is a priority for India’s FP2030 goals and UNFPA strategy.

Strengthening maternal and newborn care

India’s reduction in maternal mortality is a noted success of its public health, family planning, and reproductive services, and was highlighted by multiple interviewees, including experts at the Asian Development Bank, UNFPA, and relevant NGOs. The Indian national government prioritizes maternal health within the Janani Suraksha Yojana (JSY) safe motherhood intervention program. Under the JSY, nearly one million ASHAs have been mobilized, with a remit including outreach to pregnant women for services including antenatal and post-natal care, organizing newborn vaccination schedules, registering births and deaths, breastfeeding support, and socializing the need for, and accuracy of, breast and cervical cancer screenings. The JSY also seeks to encourage maternal health-seeking behaviors by providing cash benefits to women who attend antenatal check-ups and opt for delivery in a health facility. The program’s penetration is significant, growing from one million mothers in 2005 to over 10 million by 2021. The Mission Parivar Vikas addresses drivers of maternal mortality by targeting newlyweds, new mothers, and mothers-in-law to address cultural expectations around childbearing, spacing, and son preference. This outreach focuses on shifting ingrained cultural and societal expectations, and building intergenerational support and solidarity between older and younger women.

Increased family planning services, and particularly expanded access to the full basket of contraceptive methods, is key to strengthening maternal and newborn care, and reducing maternal mortality. A 2019 Guttmacher Institute report found that fulfilling all unmet needs for contraception, pregnancy-related and newborn care, and STI treatment in India would lead to 14,000 fewer maternal and 403,000 fewer newborn deaths annually, as well as 16 million fewer unintended pregnancies and 10 million fewer unsafe abortions. Indeed, access to safe, legal abortion can also support maternal and newborn health by reducing the number of unsafe pregnancies and addressing maternal mortality. In 2021, India liberalized its existing abortion law, through The Medical Termination of Pregnancy (Amendment) Act, 2021—abortions are legal for unmarried and married women up to 24 weeks of pregnancy, with the consultation of doctors. While this represents significant progress, a 2024 UN Human Rights Committee review found that significant barriers remain to access that impede women’s human rights. The committee recommends addressing the lack of clarity in the language of the law, continued fear of prosecution by abortion providers, and severe restrictions in accessing abortion after 20 weeks.

Anticipating and targeting demographic blind spots

India faces a significant youth bulge, with over one-quarter of its population aged 10 to 24 years of age. These children, adolescents, and youth represent the next generation, and ensuring that they have access to accurate information, high-quality care, and a range of modern contraceptive methods will be central to securing India’s health, human, and economic development over the coming decades. A significant part of this challenge relates to girls’ education: UNFPA has found that girls with 12 years of schooling are twice as likely to use hygienic menstruation management methods, and four times less likely to begin childbearing in adolescence as girls without schooling. As of 2020, India recorded the highest number of child marriages worldwide, with 222.4 million women aged 20-24 married or in a union before turning 18. Securing the reproductive health and well-being of adolescent girls across their life course will also be crucial to protecting the health of older adults. As Indians live longer, UNFPA projects that people aged over 60 years will represent 20 percent of the population by 2050. Reproductive health across the life course, including during menopause, will have direct and indirect impacts on health, economic outcomes, and overall well-being.

Reflective of this challenge, India’s FP2030 and UNFPA strategies include an explicit focus on reaching adolescents and youth with services and accurate information, and adolescents represent a key demographic targeted by Indian government health and well-being policies. Specifically supporting adolescents, the NHM houses the Rashtriya Kishor Swasthva Karyakram (RKSK) adolescent health program. The RKSK includes a monitoring dashboard intended to support states to adapt their strategies and implementation to fit their youth populations. One-fifth of the world’s adolescents live in India, and this dedicated health program demonstrates how other countries with large youth bulges could tailor interventions by age and stage of life. Non-governmental stakeholders are also invested in improving youth access to family planning and reproductive health services. According to interviewees Koki Agarwal and Anne Pfitzer, Jhpiego, for example—an international NGO operational in India, at which both women are senior leaders—supports domestic, youth-led civil society organizations (CSOs) to advocate for targeted services and information, and partners with private-sector companies to host websites with accurate, context-specific information on family planning aimed at adolescents. Similarly, UNFPA has launched an AI chatbot with the support of Amazon Web Services, co-funded by Bayer, aimed at providing young people with safe, private information about sexual and reproductive health.

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Looking ahead: Pursuing untapped opportunities and key priorities

India has made significant strides in its work on reproductive health and family planning, particularly since shifting toward a rights-based approach to care. Government prioritization of the issue has contributed to India’s success in achieving previous family planning goals—such as significant reduction of the maternal mortality rate, and the expansion of contraceptives available—and as such will be essential to continued progress in the next five years leading up to the SDG and FP2030 deadlines. Interviewees noted that, as a middle-income country with a growing economy, India receives less financial support from bilateral and multilateral donors, and as a result will need to identify the areas of unmet need and the most impactful interventions to inform investment and prioritize its limited resources. Technical assistance, and mutual partnerships such as that between India and Japan focused on expanding health care infrastructure into remote regions, will be critical to supporting these efforts.

Public-private partnerships and collaboration represent another avenue for investment and innovation. Working closely with India’s thriving pharmaceutical development and manufacturing industry could be a pathway to increasing access to contraceptives and developing effective new methods, while philanthropic foundations and other international actors can support the import of necessary contraceptives and treatments to supplement domestic supply chains. This will also be critical to securing supply and access in times of upheaval such as natural disasters, which India experiences frequently (the country is especially susceptible to climate change), as will improving health infrastructure.

Additionally, continuing to hire, train, and upskill health workers will be key. ASHAs, midwives, and other community health workers are crucial to debunking myths and misinformation regarding different contraceptives, medications, and screening methods. They can also help to disrupt cultural and religious taboos and stigmas that remain attached to reproductive health, menstruation, and abortion access, particularly regarding the provision of family planning care to unmarried women and girls. They could additionally play a critical role in shifting contraceptive choices away from sterilization toward reversible methods, if this were to become a priority of the Indian government. Given the prevalence of sterilization among marginalized groups, a cultural shift toward reversible contraceptives could support greater equity, choice, and rights for all women. India’s reliance on personal outreach and primary care in slums, villages, and remote or underserved areas could be replicated in other resource-scarce countries, particularly those with low internet penetration and high levels of skepticism of modern medicine. However, addressing potential pressures on this health care workforce—which is “underpaid, maldistributed, and overworked,” as noted by Anne Pfitzer of the MOMENTUM project at Jhpiego—will be key to their continued impact and success in achieving family planning and reproductive health goals. Partnerships with universities and the private sector could facilitate access to necessary training while avoiding a prohibitive cost burden, similar to those rolled out across the European Union, for example, which are co-funded by pharmaceutical companies.