Critiquing India’s Reproductive and Child Health Policy: Gaps and Challenges

When a country shifts its public health strategy from population control to individual rights, you would expect the results to speak for themselves. But the story of the Reproductive and Child Health (RCH) policy is far more complicated. Launched in 1997, the RCH programme was supposed to mark a clean break from decades of target-driven family planning. It promised women autonomy over their bodies, access to quality healthcare, and a rights-based approach to reproduction. On paper, the transformation was significant. In practice, deep-rooted institutional habits, cultural barriers, and structural gaps have prevented this promise from being fully realised.

From population control to reproductive health: a brief history 🔗

India was the first country in the world to launch a state-sponsored family planning programme, way back in 1952. For decades, the focus remained narrowly fixed on reducing birth rates. The most extreme expression of this approach came during the Emergency period of 1975-77, when mass sterilisation drives were carried out under deeply coercive conditions. That traumatic chapter left lasting scars on public trust in family planning efforts.

By the early 1990s, growing criticism from women’s organisations, health activists, and feminist scholars pushed for a fundamental rethinking of how the state approached reproduction. The turning point came in 1994 at the International Conference on Population and Development (ICPD) in Cairo, where 179 governments agreed that population policies must centre on individual rights and empowerment rather than demographic targets. India was a signatory. The ICPD Programme of Action called for universal access to voluntary family planning, safe pregnancy services, and the prevention of sexually transmitted infections. It also affirmed that reproductive health is inseparable from broader human rights, including the right to dignity and freedom from discrimination.

Following these commitments, the RCH Programme was launched in 1997 under the Ministry of Health and Family Welfare. It integrated earlier maternal and child health initiatives into a single framework. The National Population Policy (NPP) of 2000 further articulated a target-free, rights-based approach. RCH Phase II rolled out in 2005 and was later folded into the broader National Health Mission. The programme’s objectives were ambitious: reduce maternal and infant mortality, improve access to antenatal and postnatal care, promote institutional deliveries, expand family planning choices, and address adolescent health.

The rights-based framework: promise versus reality 🔗

The shift from demographic targets to a rights-based framework was not merely a bureaucratic relabelling. It was supposed to fundamentally change how health workers interacted with communities, how women accessed care, and how the state understood its role in reproductive health. Instead of treating women as instruments of population policy, the new approach was meant to recognise their bodily autonomy and informed decision-making.

However, the transition has been deeply uneven. Research from fieldwork conducted in Rajasthan reveals that the policy discourse around reproductive governance remains caught between two conflicting impulses: a demographic rationale that pushes for strict fertility regulation and a rights-based framework that promotes individual choice. This tension does not simply exist at the policy level. It plays out daily in the interactions between health workers and the communities they serve. Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists (ASHAs), the backbone of rural healthcare delivery, find themselves caught between official directives that espouse rights and ground-level expectations that still revolve around meeting numbers.

The abolition of formal sterilisation targets was supposed to relieve this pressure. But in practice, state-level programmes continued to set what are euphemistically called Expected Levels of Achievement (ELAs), which function remarkably like the old targets. Health workers who fail to meet these benchmarks face consequences ranging from withheld salaries to unfavourable transfers. This creates a system where the language of rights sits uneasily alongside the mechanics of coercion.

The persistence of sterilisation as the default method 🔗

One of the most telling indicators of the gap between policy intent and ground reality is the continued dominance of female sterilisation as the primary method of family planning. According to national survey data, nearly 38 percent of contraceptive users in India rely on female sterilisation. This is not a pattern that emerges from genuine informed choice across the board. It reflects a system that has historically prioritised permanent, irreversible methods over spacing methods like pills, condoms, or IUDs.

The Human Rights Watch has documented how state authorities aggressively pursued sterilisation numbers, sometimes threatening health workers with salary cuts or dismissals if they did not meet quotas. In some states, incentive schemes offered prizes like cars, motorcycles, and even gun licences to those who agreed to be sterilised. These practices overwhelmingly affected women from economically and socially marginalised backgrounds, including Dalit and Adivasi communities, who were often not fully informed about the permanent nature of the procedure.

The 2014 tragedy in Bilaspur, Chhattisgarh, where fifteen women died after undergoing sterilisation surgeries in appalling conditions, brought global attention to the continuing horrors of the camp-based approach. The Supreme Court eventually ruled to shut down sterilisation camps in the Devika Biswas v. Union of India case, noting that incentive-driven policies could undermine the reproductive freedoms of vulnerable groups. Yet the structural incentives that drive this behaviour have not been fully dismantled.

Socio-cultural barriers that the policy overlooks 🔗

The RCH policy’s rights-based framework assumes a certain level of awareness and agency among its intended beneficiaries. But for millions of women, particularly in rural and semi-urban areas, the very concept of reproductive rights remains unfamiliar. Deep-rooted gender inequality, early marriage, low literacy, and social stigma around discussions of sexual health all contribute to a situation where women are unable to exercise the choices the policy theoretically offers them.

In many communities, decisions about family size, contraception, and even whether a woman visits a health centre are made by husbands, mothers-in-law, or other family elders. A woman who wants to use a spacing method of contraception may face resistance from her family, and the health system rarely provides the kind of counselling or support that could help her navigate these pressures. The policy acknowledges male participation as a goal, but in practice, the burden of family planning continues to fall almost entirely on women.

Cultural attitudes around fertility and motherhood also create friction with the rights-based approach. Societal norms that view a woman’s identity as being primarily defined by her reproductive role make it difficult to advance the idea that women have a right to decide whether to have children, not just how many. This is particularly relevant for women who do not fit the conventional mould of married motherhood, a group the policy has consistently struggled to include.

The exclusion of single women and non-traditional beneficiaries 🔗

One of the most significant blind spots of the RCH policy is its implicit assumption that reproductive health services are needed primarily by married women in the context of pregnancy and childbearing. This framing effectively excludes several groups whose reproductive health needs are just as real but far less visible in policy discussions.

Single women – whether unmarried, divorced, separated, or widowed – often find themselves outside the scope of RCH services. The programme’s infrastructure, from registration systems to incentive structures, is built around the married couple as the default unit. A single woman seeking contraceptive advice, treatment for a reproductive tract infection, or even basic gynaecological care may find that the system is not designed to accommodate her. In a society where sexual activity outside marriage remains stigmatised, seeking such services can expose women to judgement from both health providers and their communities.

Adolescents represent another underserved group. While RCH Phase II recognised adolescent health as a priority, implementation has been patchy. Comprehensive sexuality education remains controversial, and many young people lack access to accurate information about their bodies, consent, contraception, and sexually transmitted infections. The policy’s emphasis on delaying marriage and preventing teenage pregnancy is important, but it often stops short of providing the practical tools and services that adolescents need.

Women with disabilities face a particularly harsh reality. As documented by researchers at the London School of Economics, disabled women in India are frequently subjected to sterilisation without their informed consent, with family members or institutional guardians making decisions on their behalf. The assumption that disabled women are incapable of understanding their own sexuality or making reproductive choices reflects deeply entrenched ableist attitudes that the RCH framework has not adequately challenged.

Infrastructure and implementation gaps 🔗

Even where the policy’s intent aligns with genuine need, infrastructure failures often prevent delivery. The Comptroller and Auditor General (CAG) has flagged several persistent problems, including unsatisfactory financial management at both central and state levels, with substantial unspent balances sitting with State Health Societies year after year. The Janani Suraksha Yojana, which incentivises institutional deliveries among poor women, has faced issues of delayed or non-payment of benefits to eligible women.

Regional disparities remain stark. States like Uttar Pradesh, Bihar, and Madhya Pradesh continue to report significantly higher maternal and infant mortality rates compared to southern and western states. Within states, inter-district variation can be enormous. Data from the Annual Health Survey showed that in Madhya Pradesh alone, the under-five mortality rate varied by nearly 90 points between the best and worst performing districts. This means that a child’s chances of survival can depend heavily on which district they happen to be born in.

The shortage of skilled healthcare professionals in rural areas compounds the problem. Primary Health Centres that are supposed to offer round-the-clock delivery services often lack the staff, equipment, or medicines to do so reliably. When the senior gynaecologist at a district hospital is absent several days a week because she is conducting sterilisation camps elsewhere, the quality of routine maternal healthcare inevitably suffers.

The demographic shadow over a rights-based policy 🔗

Perhaps the most fundamental critique of the RCH policy is that it has never fully escaped the shadow of demographic thinking. The Lancet noted that reproductive health should be a matter of rights, informed choice, and wellbeing rather than population control, and that the focus should shift to addressing unmet needs for contraception and ensuring access to comprehensive care. Yet in practice, the language of population stabilisation continues to appear alongside the language of rights in policy documents, creating a confusing and sometimes contradictory mandate for implementers.

This dual framing is not accidental. It reflects a genuine tension within the state between its responsibilities towards individual citizens and its anxieties about aggregate population growth. When politicians make public statements about population control or when state assemblies introduce bills penalising larger families, they undermine the very foundation of the rights-based approach. Health workers on the ground receive mixed signals: they are told to respect choice while being evaluated on how many sterilisations they facilitate.

The result is a policy environment where the stated goals of empowerment and autonomy coexist uneasily with operational realities that incentivise control. This is not just a theoretical problem. It has tangible consequences for the women and families who interact with the health system, particularly those who are poor, marginalised, or lack the social capital to assert their preferences.

What has improved and what remains 🔗

It would be unfair to suggest that the RCH programme has achieved nothing. The numbers tell a story of real, if incomplete, progress. The Maternal Mortality Ratio has declined from 398 per 100,000 live births in the late 1990s to 97 by 2018-20. The Infant Mortality Rate has dropped from 72 per 1,000 live births in 1998 to 27 in recent years. Institutional deliveries have risen from around 39 percent in 2005 to over 89 percent. Immunisation coverage has expanded significantly. These are meaningful gains that have saved lakhs of lives.

But progress on the numbers does not automatically translate into progress on rights. A woman who delivers in a hospital because she was financially incentivised to do so has not necessarily exercised reproductive autonomy. A community that has achieved replacement-level fertility through aggressive sterilisation drives has not necessarily embraced a culture of informed choice. The challenge now is to move beyond output metrics and towards outcomes that reflect genuine empowerment: women who understand their options, can access a full range of contraceptive methods without coercion, receive respectful and quality care regardless of their marital status or social position, and are supported in making decisions that are truly their own.

The way forward 🔗

Strengthening the RCH framework requires action on several fronts simultaneously. The programme needs to genuinely decouple reproductive health services from population stabilisation goals at every level of implementation, not just in policy language. Health worker evaluation must shift from counting procedures to measuring the quality of counselling, the range of contraceptive options actually offered, and patient satisfaction.

The scope of services needs to expand to include single women, adolescents, and other groups currently marginalised by a framework that equates reproductive health with married motherhood. Community-level engagement must go beyond awareness campaigns and address the gender norms and power dynamics that prevent women from exercising their choices. Investment in rural healthcare infrastructure, human resources, and supply chains must be sustained and equitable across states and districts.

Most critically, there needs to be a genuine cultural shift within the health bureaucracy – from viewing women as targets to be met, to recognising them as rights-bearing individuals whose health decisions deserve respect and support.

What do you think? 🔗

What do you think? Can a policy framework that still operates within the shadow of demographic goals ever truly deliver reproductive autonomy to women? And how should the healthcare system be redesigned to serve not just married mothers, but every person who needs reproductive health services, regardless of their social circumstances?

References

1. https://www.ncbi.nlm.nih.gov/books/NBK584062/
2. https://www.unfpa.org/icpd
3. https://www.gktoday.in/rch-scheme/
4. https://onlinelibrary.wiley.com/doi/10.1111/sifp.12274
5. https://www.hrw.org/news/2012/07/12/india-target-driven-sterilization-harming-women
6. https://pmc.ncbi.nlm.nih.gov/articles/PMC12615512/
7. https://blogs.lse.ac.uk/humanrights/2023/03/20/forced-sterilization-of-disabled-women-in-india-a-tale-of-lost-autonomy/
8. https://prsindia.org/policy/report-summaries/reproductive-and-child-health-under-national-rural-health-mission
9. https://pmc.ncbi.nlm.nih.gov/articles/PMC3341742/