Published Sep 21, 2026 | 8:00 AM ⚊ Updated Sep 21, 2026 | 8:00 AM
Male sterilisation remains extremely low across the southern states, while female sterilisation accounts for the overwhelming majority.
Synopsis: South India’s fertility has remained below replacement levels for over two decades, yet family-planning budgets in Keralam, Tamil Nadu and Karnataka continue to heavily favour sterilisation. In the 2025-26 family-planning allocations examined by the EAC-PM, terminal methods, comprising male and female sterilisation, accounted for 88.2 percent of Keralam’s allocation, 84.5 percent of Telangana’s, 83.7 percent of Tamil Nadu’s, 82.2 percent of Andhra Pradesh’s and 77.6 percent of Karnataka’s.
South India has spent decades moving away from the demographic problem that once dominated India’s family-planning policy. Fertility has fallen below replacement levels across Andhra Pradesh, Telangana, Karnataka, Keralam and Tamil Nadu.
Yet a new Economic Advisory Council to the Prime Minister (EAC-PM) working paper finds that the region’s family-planning budgets continue to devote a large share of funds to permanent sterilisation.
The contradiction is particularly visible in Tamil Nadu.
In August 2026, the state expanded maternity leave for women government employees having a third child to one year, replacing the earlier 12-week provision. The stated purpose, according to the EAC-PM paper, was to promote greater births. At the same time, Tamil Nadu budgeted direct-benefit transfers (DBTs) to incentivise 1.6 lakh female sterilisations in 2026-27.
The authors of The Ghost of Population Past: How Population Control Persists in India, Sanjeev Sanyal, Aakanksha Arora and Virat Singh, describe the situation as “an explicit policy contradiction.”
The contradiction becomes clearer when the demographic numbers are placed alongside the budgets.
Tamil Nadu’s total fertility rate was 1.3 in 2024, Keralam’s 1.3, Andhra Pradesh’s 1.4, Karnataka’s 1.5 and Telangana’s 1.5. All five are below the conventional replacement level of 2.1. Andhra Pradesh, Keralam and Tamil Nadu had already reached or fallen below their own calculated replacement fertility by 2001, Karnataka by 2005, while Telangana has remained below replacement fertility since its formation, according to the paper.
The paper puts the demographic shift in stark terms. India’s annual births peaked at roughly 29.3 million in 2001 and fell to about 23.2 million in 2023, even as the country’s population continued to grow because of population momentum and longer life expectancy.
The southern states now have a median age of almost 35 years, placing their demographic profile closer to ageing economies than to India’s national median age of about 30.
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The mismatch becomes clearest when the money is followed.
In the 2025-26 family-planning allocations examined by the EAC-PM, terminal methods, comprising male and female sterilisation, accounted for 88.2 percent of Keralam’s allocation, 84.5 percent of Telangana’s, 83.7 percent of Tamil Nadu’s, 82.2 percent of Andhra Pradesh’s and 77.6 percent of Karnataka’s.
The national share was 79.3 percent.
These allocations include DBTs and other expenses associated with sterilisation. The paper notes that DBTs generally constitute the majority of the headline allocation.
The newer 2026-27 allocations show that the southern states are beginning to diverge.
Keralam continues to devote 90.3 percent of its family-planning allocation to terminal methods. Tamil Nadu allocates 74.5 percent, while Karnataka allocates 75 percent.
Telangana, however, has sharply reduced the share to 26.1 percent, while Andhra Pradesh has allocated zero towards terminal methods. Across India, terminal methods still account for 84.3 percent of the 2026-27 allocation.
The EAC-PM paper says a single sterilisation can trigger three payments: compensation to the person undergoing the procedure, a motivation incentive to the ASHA or other person who mobilised the beneficiary, and a payment to the service provider.
The authors argue that the financial structure continues to favour permanent methods over reversible contraception such as IUCDs and injectables.
The paper puts the concern plainly: “Even if it is true that people themselves are increasingly choosing to opt for sterilisations, it makes no sense for the state to keep giving incentives for the same.”
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The contrast was particularly striking in the 2025-26 data.
Tamil Nadu had budgeted DBTs for 1,55,000 female sterilisations, equivalent to 1,999 incentivised procedures per million population.
Andhra Pradesh had budgeted for 1,25,000, or 2,327 per million.
Karnataka had budgeted for 85,000, or 1,233 per million, while Telangana had budgeted for 70,000, or 1,812 per million.
Uttar Pradesh, despite having a TFR of 2.6 and only 17 percent of married women already sterilised, had budgeted for 350,003 female sterilisations, or 1,441 per million.
In Tamil Nadu, 56.6 percent of married women were already sterilised. The corresponding figure was 69.5 percent in Andhra Pradesh, 56.9 percent in Karnataka and 62.5 percent in Telangana.
The paper notes that Andhra Pradesh and Tamil Nadu, where nearly six in 10 married women were already sterilised, were budgeting for more female sterilisations per capita than Uttar Pradesh.
Andhra Pradesh is now moving in the opposite direction.
The state entered the 2026-27 cycle with no fiscal allocation for DBTs to incentivise male or female sterilisation, after having allocated money for the procedures in the previous cycle.
It has also repealed the two-child restriction that had barred people with more than two children from contesting local-body elections. The restriction was repealed in November 2024. Telangana followed with the abolition of its corresponding restriction in January 2026.
Andhra Pradesh’s new population policy proposes replacing sterilisation incentives with incentives for additional births and spacing methods.
The EAC-PM paper quotes the policy directly: “All incentives for sterilisation shall be eliminated and replaced by incentives for adoption of spacing techniques.”
The proposed Andhra Pradesh Population Management Programme includes a ₹25,000 one-time incentive for a second child, a ₹1,000 monthly stipend for a third child for the first five years, educational support and lifetime health insurance for households with three or more children.
But the financial scale of the reversal is striking.
Until 2024-26, Andhra Pradesh was allocating around ₹12 crore annually in DBTs related to 1.25 lakh female sterilisations. The proposed incentives for a similar number of second and third births are estimated to cost close to ₹1,000 crore annually.
That is more than 80 times the earlier allocation.
The paper also notes that Andhra Pradesh’s own population policy expects the transition to take time. Even under the new pro-natalist approach, it estimates that it could take five to 10 years for the share of sterilised married women to fall to 50 percent.
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Telangana’s position is different from both Andhra Pradesh and the three southern states continuing to devote the majority of their family-planning allocations to terminal methods.
In 2025-26, terminal methods accounted for 84.5 percent of Telangana’s family-planning allocation. In 2026-27, that share dropped to 26.1 percent.
The state also abolished the two-child norm in January 2026.
The demographic pressure is nevertheless already visible. Telangana’s TFR was 1.5 in 2024, while 62.5 percent of married women were already sterilised, according to the figures cited in the EAC-PM paper.
This leaves South India with three distinct policy responses: Andhra Pradesh has moved to eliminate sterilisation incentives, Telangana has sharply reduced their budget share, while Keralam, Tamil Nadu and Karnataka continue to devote most of their contraception-linked allocations to terminal methods.
The other striking feature is who bears the burden of sterilisation.
Male sterilisation remains extremely low across the southern states, while female sterilisation accounts for the overwhelming majority of permanent contraception.
NFHS-6 data cited in the paper puts the share of married women who have undergone sterilisation at 69.5 percent in Andhra Pradesh, 62.5 percent in Telangana, 56.9 percent in Karnataka and 56.6 percent in Tamil Nadu.
The male figures are far lower.
The EAC-PM paper says the financial incentive structure can influence the behaviour of ASHAs because the payment for promoting different methods is not the same.
It cites research showing that financial incentives are a strong motivator for ASHAs providing family-planning services and that there is a tendency to promote methods carrying higher financial incentives.
The paper also cites a UNFPA study that found 14 percent of Indian respondents limited their family size because of advice or pressure from health workers and medical specialists, nearly three times the global average of 5 percent.
An ASHA can also receive a higher incentive when she motivates a couple to adopt a terminal method after having two children. The EAC-PM authors say an ASHA can make four times as much by counselling a couple towards a terminal method and limiting births compared with reversible methods.
The issue, therefore, is not simply whether women voluntarily choose sterilisation. It is whether a public system that financially rewards one contraceptive outcome more heavily than others can genuinely be described as neutral between methods.
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The financial incentives are only one part of the system.
The EAC-PM paper also examines what it calls the institutional persistence of population-control messaging, including World Population Day programmes, population-stabilisation campaigns and Vasectomy Fortnights.
The paper says health departments continue to conduct outreach through schools, universities and rural programmes, while using mobile vans and other communication mechanisms to promote family planning.
It argues that the issue is not family planning itself, but the language of “population stabilisation” that continues to accompany some of these programmes.
The authors write that: “What turns a practice into a ritual is recognition – rituals like ‘World Population Day’ and ‘Vasectomy Fortnights’.”
They describe how frontline workers identify eligible couples before 11 July and how a subsequent population-stabilisation period can include contraception services, including male and female sterilisation.
Poonam Muttreja, executive director of Population Foundation of India, welcomed the EAC-PM paper’s broader argument but cautioned against replacing population-control pressure with pressure to have more children.
“India’s modern contraceptive prevalence rate has risen to 56.5 percent,” she said in a statement responding to the paper, “but the method mix remains overwhelmingly dominated by permanent methods. Female sterilisation alone accounts for about two-thirds of the modern contraceptive method mix, while male sterilisation remains negligible, contributing less than 1 percent.”
She called this pattern a reflection of programme design rather than choice.
“This reflects not genuine choice, but a programme structure that has historically placed the burden of contraception disproportionately on women.”
Muttreja said India should avoid two opposite approaches.
“India’s policy response must avoid two mistakes,” she said, “continuing with old population-control thinking on the one hand, and moving towards fertility panic or pronatalist pressure on the other. The role of the state is not to push families to have fewer or more children. It is to ensure that every person, especially women and young people, has the information, services and freedom to make informed decisions about their lives.”
She argued that family-planning budgets should instead widen access to condoms, pills, injectables and IUCDs, alongside counselling and follow-up care.
“We cannot move from population control to informed choice while continuing to depend on underpaid frontline workers carrying the burden of programme delivery.”
