1. Analysis of Budget Allocations and Spending
Cost of Inaction in Family Planning in India: An Analysis of Health and Economic Implications
&
Analysis of Budget Allocations and Spending
for Family Planning
We are presenting findings from two studies conducted by Population Foundation of India (PFI). One study is an analysis of the potential health and economic gains if family planning policies and programs are prioritized. The second study examines the current level of allocation and spending on family planning under the National Health Mission to understand the barriers for underspending.

2. all 17 SUSTAINABLE DEVELOPMENT GOALS
Need for greater focus on family planning policies
To begin with let me highlight the need for greater investment in family planning. As per global assessments for every dollar spent on family planning and sexual and reproductive health, the return on investment is $120.
Family Planning directly and indirectly impacts all 17 of the sustainable development goals. Advancing and investing in family planning will be one of the primary drivers for translating the development goals of the nation and impacting SDGs. Universal access to contraception is a priority target for the achievement of the SDGs. .
Investment in family planning
Directly or indirectly impacts
a ‘best buy’
all 17 SUSTAINABLE DEVELOPMENT GOALS

3. Progress so far Coercive policies – neither required nor effective
A slow down in population growth and decline in fertility rate witnessed in India.
Decadal population growth rate was 17.7 in 2011 as against 23.9 in 1991
Total Fertility Rate (TFR) of India is 2.2 whereas the desired fertility (as reported by women) is 1.8
Unmet need for family planning is 13% - a clear disconnect between the fertility rates and desired fertility
The Ministry of Health and Family Welfare has made sustained efforts to reach the last mile through its programs. So there is good news on the average number of children per woman, i.e. the total fertility rate (TFR) came down from 3.4 in to 2.2 in states in India have already achieved replacement level fertility of 2.1.
However, while the TFR is 2.2, most women across urban and rural areas have reported that they want only 2 children or less and there is an unmet need of 13% for family planning. This clearly shows that there is a need to address this gap through better access to family planning services.
This also clearly points to the fact that coercive policies such as the 2 child norm are not required. Further, there is no evidence on the effectiveness of two-child norm. Similar policies in states like Uttar Pradesh and Bihar have failed to bring down the fertility rates to the desired level. China had a coercive policy for 35 years and they are now in a population crisis. We would like to emphasize here that the need is really to change social norms around early marriage and early child birth and ensure universal access to family planning services, especially among the youth.
Coercive policies – neither required nor effective
China lifted the one child policy in 2015, as the country is undergoing a population crisis: skewed sex ratio and reduced working age population.
Need to change social norms, ensure universal access to family planning services and gender inclusive policies for a stable and balanced population.

4. 30 year window of opportunity
Need for greater focus on family planning policies
India’s Population Pyramid: 2011
India’s Population Pyramid: 2051
The next important reason for a greater focus on family planning is that India is a young nation today with close to two-thirds of its population below 35 years of age and over 50% under 25 years of age.
As we can see, the projected population age structure shows a much larger proportion of younger population, which implies that there will be a rise in the share of working age population, implying a reduction in the proportion of dependents. Therefore we have a window of 30 years to capitalize on this opportunity, making now the best time to push for greater investments in family planning.
65% under 35 years
30 year window of opportunity
Source: Demographic transition in India, Kulkarni P.M., 2014

5. Loss of potential benefits
The Study
COST OF INACTION IN FAMILY PLANNING IN INDIA: AN ANALYSIS OF HEALTH AND ECONOMIC IMPLICATIONS
WHAT?
Loss of potential benefits
to individuals, households, economy & society if family planning is not treated as a priority
Recognizing this opportunity, Population Foundation of India conceptualized and commissioned a study called “Cost of Inaction in Family Planning in India: An Analysis of Health and Economic Implications”.
Cost of inaction in Family Planning can be defined as the loss of potential benefits to individuals, households, the economy and the government if family planning is not treated as a priority

6. The Study Methodology
COST OF INACTION IN FAMILY PLANNING IN INDIA: AN ANALYSIS OF HEALTH AND ECONOMIC IMPLICATIONS
HOW?
Current Scenario
Existing strategies for family planning continue as they are
Policy Scenario
Family planning programmes implemented to full extent as per population policies
The study estimates the potential costs and benefits to the nation over the course 15 years, from , under two scenarios:
1. Current Scenario, defined as the ‘business-as-usual’ scenario whereby the Union and the State governments continue the existing strategies and approach towards family planning.
2. Policy Scenario attempts to describe a scenario where the Union and the State governments undertake greater investments and efforts in implementing the respective National and State Population Policies to full extent.
The difference between the two scenarios provide an insight into the cost of inaction as well as potential benefits of timely action.

7. The Study Findings
DEMOGRAPHIC & HEALTH GAINS UNDER POLICY SCENARIO COMPARED TO CURRENT SCENARIO (2016 – 2031)
Avert 206 million unsafe abortions
Avert 2.9 million infant deaths
The projected demographic and health gains of the policy scenario include prevention of 2.9 million infant deaths, 1.2 million maternal deaths, 206 million unsafe abortions and 69 million additional births at the national level. (These figures are cumulative for the period of )
Prevent 1.2 million maternal deaths
Avoid 69 million additional births

8. Increase in per capita GDP by 13% by 2031
The Study Findings
ECONOMIC GAINS UNDER POLICY SCENARIO COMPARED TO CURRENT SCENARIO (2016 – 2031)
Estimated savings of Rs 270 billion on National Health Mission (NHM) budget ( )
Savings of at least Rs. 776 billion or 20% of households’ OOP Expenditure on child birth and child hospitalisation
The Potential benefits of investing in family planning include savings of up to 270 billion Rupees to the National Health Mission budget. Households could potentially save 776 billion rupees or 20% of their out of pocket health expenditure. The policy scenario could lead to an additional 13% increase in per capita GDP.
Increase in per capita GDP by 13% by 2031

9. Status of planning, budgeting and expenditure for family planning in India
At the FP2020 Summit, India committed to invest upto $3 billion by While good policies are in place in India, we could greatly gain from implementation of these policies to their full potential.
The CoI study highlights the need to invest more in FP; therefore, it is equally important to analyse the current status of investments by government for family planning activities.
PFI commissioned a study to understand the trends in proposed and approved budgets for FP activities. It covered three Financial Years – , and and spanned 18 High Focus Large States including the North East states which account for almost 60% of the total National Health Mission (NHM) allocations. In two high focus states (Bihar and UP) we did a deeper analysis to understand the reasons for low allocations and expenditure.

10. Budget allocations for family planning
Key findings: Allocations
Budget allocations for family planning
Allocations for family planning has remained at 4% of the National Health Mission budget during the study period. The study reveals that budgetary allocations are skewed towards limiting methods and therefore does not align with our demographic needs.
In the High Focus Large States, close to 70% of the FP budgets allocated for limiting methods and 10% for incentives to frontline health workers
Barely 3-4% allocated for spacing methods. India’s large youth population require spacing methods
Less allocations for IEC/BCC activities (3%) and training (2%)
Only 4% of the total NHM budget allocated to family planning activities

11. Utilisation of budgets for family planning
Key findings: Utilisation
Utilisation of budgets for family planning
Aligned with allocation, the spending for FP activities is also skewed towards limiting methods and incentives to frontline health workers.
Spending on spacing methods is only 35 to 44% of the allocated budgets in U.P. and Bihar, respectively.
Similarly, with allocations for IEC/BCC activities being merely 2-3 per cent of the family planning budgets, only 10 per cent was spent in Bihar; in U.P. the funds for this activity remained unutilised in Utilisation of budgets for training also remains low, especially in U.P. where only 7 per cent of the allocated budget was spent.
Of allocated budgets, 45 % in Bihar and 66% in Uttar Pradesh remain unutilised

12. Key Findings: Constraints
Absence of decentralized planning and inadequate capacity at the village, block and district level
Delays in PIP approvals and release of funds resulting in lesser spending and compromise on the quality of services
Poor data availability and management to track or monitor progress in fund utilisation
The study noted several constraints that hinder the prioritisation of FP in the allocation of budgets, and contribute to delays in resource flows as well as inefficiencies in spending in Bihar and U.P.
The constraints shared by officials included inadequate capacities for decentralised planning; delayed approvals and release of funds; lack of integration of accounting systems resulting in poor tracking of expenditure.
Lack of integration due to different accounting systems between the treasury and the Public Financial Management System (PFMS)

13. Recommendations SPENDING AVAILABLE FUNDS MORE EFFICIENTLY
INCREASED FUNDING
To align family planning programmes with national priorities and commitments
SPENDING AVAILABLE FUNDS MORE EFFICIENTLY
By identifying local needs
Re-prioritising existing family planning budgets
Overall, our recommendations would be to:
Increase budgetary allocations for family planning to ensure alignment with national priorities and commitments.
Spend available funds more efficiently by identifying resource needs for family planning at a decentralized level and reprioritizing existing budgets.

14. Recommendations STRENGTHENING IMPLEMENTATION
By using behaviour change communication
Increasing access to family planning information and services
Adopting a multi-sectoral approach
Increasing community engagement
Strengthening implementation by using effective tools, like behavior change communication, increase access to family planning information and services.
Adopting a multisectoral approach which increasing community engagement. A multisectoral approach would include convergence of different stakeholders across different sectors (private sector, CSOs, different ministries (eg. Women and Child Development, Panchayati Raj etc) to leverage their expertise, skills, knowledge and resource for improving FP outcomes.

15. Conclusion
“While we have quantified the demographic and economic impacts of inaction in family planning, it is equally important to understand the hardships of families, particularly the quality of life of mothers and children. Clearly, in one way or the other, inaction affects our daily lives and this can be a momentous occasion to realise that all is not lost.”
I would like to summarise with a quote from the Lead Researcher of the study, Dr. William Joe.
Dr. William Joe, Lead Researcher, COI study Institute of Economic Growth

16. Thank you!