Health policy processes in India: the case of abortion policy

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• Health policy processes in India the case of
  abortion policy

HEPVIC team IIM Ahmedabad ITM Antwerp
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India HEPVIC team
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India selected indicators

• Population 1,000,000,000
• Below-poverty-line population 35
• Maternal mortality ratio 301/100,000 childbirths
• Female life expectancy at birth 63 years
• Median age of marriage, girls 18 years
• Total national health expenditure 4.8 of GDP
• Government health expenditure 0.9 of GDP
• Out-of-pocket payment 70 of total expenditure

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Policy issue abortion

• Three case studies for HEPVIC
• Skilled birth attendance
• Adolescent reproductive and sexual health
• Abortion
• 6,400,000 abortions/year
• 1/2 in unregistered facilities
• 1/4 by informal providers
• up to 9 of maternal deaths

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Timeline

• 1971 Medical Termination of Pregnancy act legal
  right, India-wide
• 1972 on certification, different
  interpretations, state-specific implementation
• 2000-2002 civil society-driven agenda setting,
  Agra meeting Abortion Assessment project
• 2002 amended MTP act decentralised
  certification, introduction of manual vacuum
  aspiration medical abortion
• 2003 on gradual implementation, unachieved
  agendas, ongoing process

1971
2002
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Staging

• Two main periods, centred around 1971 2002 acts
• MTP act
• Agenda-setting 1964 (deaths x unsafe abortions)
  culminating in 1966 Shah committee, 5 years of
  formal development, uneven implementation
• Amended MTP act
• Agenda-setting 1991 (sex ratio) importance of
  1994 Pre-Natal Diagnostic Techniques act and
  2000 Agra meeting, consultative development,
  uneven implementation
• Today, start of a new period discussions and
  moves on various levels technical, rights-based,
  legal,

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Context

• Political context
• Paradigm shift, from government-appointed
  committees to civil society-driven consultative
  process
• Socio-cultural context differences between
  national / international actors, policy-makers /
  service providers / target population regarding
• Perception and appreciation
• Use and type of evidence
• Agenda and rationale deaths, health, population
  control, family planning, womens health rights,
  hospital functionality

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Evidence

• MTP period
• Concern over abortion deaths, estimates from
  Shah committee, closed, no international evidence
  used
• Amended MTP period
• Documented persistent abortion deaths and
  declining sex ratio, concern over poor services,
  new procedures, wide divulgation of national and
  international evidence
• Today
• Renewed agenda setting, evolving technical
  criteria, a media case and tug of war between
  abortion and anti-sex selection activists

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Actors

• MTP period
• Government and invited actors, with majority
  from medical community
• Amended MTP period
• Civil society claiming space and producing
  evidence, government coming in with pressure from
  civil society after conference organised by
  international actor, government alone decisive
• Today
• Media and professional organisations
  increasingly claiming space, adding to continuing
  pressure from still divided civil society,
  pressure in different directions

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Lessons learnt

• Strong relation between evidence and actors
• Actors rationale indicative of type of evidence
  used
• Actors power indicative of perceived importance
  and impact of evidence in the policy process
• Not one power more important than others
• Continuing power game between an increasing
  number of actors with different rationales and
  objectives
• Most important actor largely missing women in
  need of safe abortion

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Question marks

• Are we moving towards
• Less avoidable suffering?
• Better health?
• Improved entitlement?
• What is the contribution of
• Changing policy processes?
• Increased consultation and voice?
• The invisible actor?

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