Family planning is often presented as a shared responsibility between partners. In practice, South Asia's family planning programme continues to place most of that responsibility on women. Evidence from India, viewed alongside lessons from Pakistan and Nepal, suggests this imbalance is not simply a matter of personal choice, but of how family planning systems engage men.
As governments prepare for the next generation of male contraceptive methods, redesigning those systems will become just as important as expanding the range of available technologies.
A Burden Written into the Data
Contraception is not merely a pill or a procedure. It involves labour: remembering, obtaining, paying for and managing side effects, year after year. When that labour falls almost entirely on one sex, the challenge becomes one of equity rather than technical limitation, given that contraceptive options exist for both men and women. This unequal distribution of responsibility is increasingly recognised as the contraceptive burden, raising questions of ethics as much as efficiency.
South Asian programmes did not set out to create this imbalance, but its architecture sustains it. Services continue to be organised primarily around women's reproductive journeys. Men are treated largely as partners to be engaged, gatekeepers to be persuaded, or obstacles to be managed, but only rarely as contraceptive users with contraceptive needs of their own. A global review asked the question bluntly: Are men well served by family planning programmes? The answer remains largely no, and little has changed since.
Programme design extends well beyond the availability of contraceptive methods. It also determines who services are organised around, who receives counselling, which outcomes are measured and whose contraceptive needs are treated as central to family planning.
Programme Design Shapes Participation
A common assumption is that South Asian men's limited participation reflects indifference. The available evidence suggests otherwise. Men's use of contraceptive methods rises sharply with education and, crucially, with exposure to family planning information. Indian men fully exposed to family planning messages across media are more than twice as likely to use a male contraceptive method than unexposed men, a pattern that is also observed in Nepal. When programmes engage men directly, participation tends to increase. Yet India's family planning programme rarely engages men consistently.
Evidence from Pakistan illustrates why programme design matters. Men who had recently discussed family planning with a health worker were less likely to be using a male method. Rather than suggesting that counselling discourages male participation, the finding most plausibly reflects consultations that remained centred on contraceptive options for wives rather than men themselves. A limited range of methods, combined with service delivery that rarely addresses men directly, constrains participation even where interest exists.
The broader international evidence nevertheless points in a different direction. Majorities of men express interest in new male contraceptives, with interest highest among current condom users. Women, too, generally report that they would trust their partners to use such methods.
Lessons from Success and Failure
Nepal records a male sterilisation rate of 3.6 percent – roughly twelve times India's level. One reason appears to be programme design: vasectomy carries less stigma and mobile clinics have long delivered services within communities. Where services engage men respectfully, participation tends to increase.
India also illustrates why this must be done carefully. The coercive vasectomy drives during the Emergency in the 1970s did not merely violate rights; they disrupted public trust so thoroughly that male sterilisation collapsed and has never recovered, five decades on. That history is the strongest argument for pursuing male responsibility through rights and choice, never through targets. Repeating a camp-and-quota approach for new male methods would recreate the same mistake – and likely the same public distrust.
Preparing for the Next Generation of Contraception
If today's imbalance stems primarily from programme design, the arrival of new male contraceptive technologies makes reform of family planning systems more urgent. A hormonal gel that men apply daily, combining segesterone acetate and testosterone, has reached late-stage international trials, marking the most advanced reversible male contraceptive in decades. When such methods become available, the countries that benefit most will be those whose programmes already treat men as contraceptive users in their own right. India's family planning programme is not yet designed for that transition.
Governments need not wait for these methods to arrive. Many of the necessary reforms concern programme delivery rather than new technology, making them achievable within existing family planning systems. India's Ministry of Health and Family Welfare has already identified greater male participation as a priority, including under Mission Parivar Vikas. The challenge now is to translate that commitment into programme design.
The first priority is to strengthen counselling so that men are addressed directly, with content that tackles persistent misconceptions surrounding vasectomy and the perception that contraception signals mistrust within marriage. Provider training should equip frontline health workers to offer men contraceptive options for themselves rather than treating them primarily as conduits to their wives' contraceptive choices. Programme monitoring systems should routinely report contraceptive uptake by the sex of the user, allowing male participation to be measured as an outcome in its own right rather than merely as attendance at counselling sessions. Finally, procurement and regulatory systems should begin preparing for the arrival of long-acting male contraceptive methods so that regulatory approval elsewhere does not leave India a decade behind.
A Fair Share
For sixty years, South Asia's family planning programme has advanced by asking more of women. That approach has reached its limits, both ethically and practically. The quiet handover evident in the data, with responsibility progressively shifting to wives as marriages mature, is not a private arrangement between spouses. It is the predictable output of programmes that never seriously invited men in.
The next step is to redesign family planning systems so that responsibility is shared more equitably. Recognising men as contraceptive users in their own right would strengthen reproductive choice while distributing responsibility more evenly between partners. What remains is for governments to recognise contraception as what it has always been: a shared responsibility that requires programmes to engage both partners as users, decision-makers and stakeholders.