Commentary: Sexual and reproductive health services in Tamil Nadu: Progress and way forward

The state of Tamil Nadu in India, increasingly recognised for sustained political and bureaucratic commitment to poverty reduction and human development (Muraleedharan, Dash, & Gilson, 2011) began providing some elements of sexual and reproductive health (SRH) services well before the 1994 International Conference on Population and Development (ICPD). After 1994, the state gradually added to these services while also working to improve health equity. Tamil Nadu is unique within India in sustaining a public health cadre at the district level and an effective network of primary health centres (PHCs), which have together provided a strong platform for integrated SRH services (Das Gupta, Desikachari, Somanathan, & Padmanaban, 2009; Muraleedharan et al., 2011). Higher female literacy, social reform movements leading to greater female autonomy and rising social aspirations have also been identified as key contributors to the success analysed below (Muraleedharan et al., 2011; Visaria, 2000). Investments in reproductive health services began with the introduction of family planning in the mid-1970s. Services were gradually expanded to include maternal health, particularly safe delivery services, and, to a lesser extent, induced abortion (Padmanabhan, Sankararaman, & Mavalankar, 2009; WHO, Regional Office for South-East Asia, 2009). The introduction of the national Reproductive and Child Health (RCH) programme in the years following ICPD increased funding and training of personnel for providing these services (WHO, Regional Office for South-East Asia, 2009). The state also responded in innovative ways to the challenges of HIV/AIDS in the early 1990s by partnering with NGOs to increase awareness and provide specific interventions for populations at risk (Ramasundaram et al., 2001). Treatments of sexually transmitted infections (STIs) and reproductive tract infections (RTIs), as well as school-based adolescent health education, were also included and continue to be a central part of the strategy for HIV prevention (Health and Family Welfare Department, 2012). Major health indicators suggest the effects of these interventions. The total fertility rate (TFR) of the state fell dramatically from 3.8 in 1981 to 2.2 by 1991, reaching 1.7 by 2005 (Health and Family Welfare Department, 2012; State Health Society, 2012). A strong public health infrastructure coupled with demand-side financing (a maternity