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Given that health is a state subject, an independent working group of experts was set up in Maharashtra to evolve a framework for Universal Access to Health Care (UAHC) and it has developed a framework document for restructuring the public healthcare system and its financing that will help facilitate the implementation of a UAHC model. This chapter reviews how, over the years, the health financing strategy failed to develop a robust public health financed system through underinvestment in health and further discusses the financing strategy of the proposed Maharashtra UAHC model to establish universal access to healthcare.

The way in which healthcare is financed is critical for equity in access to healthcare. At present the proportion of public resources committed to healthcare in India is one of the lowest in the world, with less than one-fifth of health expenditure being publicly financed. India has large-scale poverty and yet the main source of financing healthcare is out-of-pocket expenditure. This is a cause of the huge inequities we see in access to healthcare. The article argues for strengthening public investment and expenditure in the health sector and suggests possible options for doing this. It also calls for a reform of the existing healthcare system by restructuring it to create a universal access mechanism which also factors in the private health sector. The article concludes that it is important to over-emphasize the fact that health is a public or social good and so cannot be left to the vagaries of the market.

In the present paper an analysis of utilization patterns of public health-care services at Mumbai is undertaken from the perspective of inadequate availability of such services in the city. Mumbai the commercial capital of India is the largest city in the country carrying a population of 11.9 million (DCO 2001). The high density of population (21190 persons per square kilometre) has put tremendous pressure on its infrastructure and amenities. About 49 per cent of the population are residing in slums characterized by shortage of living space water supply and sanitation facilities. Slums in Mumbai are unique in the sense that only 4 per cent are Kacha hutments while 45 per cent and 51 per cent of houses in slums are Semipucca and Pucca respectively. (excerpt)

This debate piece focuses on the concerns of the human papilloma virus (HPV) vaccine specifically in India. It discusses the efficacy of the vaccine side effects cost effectiveness and marketing techniques. It provides strong recommendations and demands to the Indian Government as to how the HPV vaccine should be handled in terms of other reproductive health services the trials and studies that are currently under way and financing and prioritization.

Countries with universal or near universal access to healthcare have health financing mechanisms which are single-payer systems in which either a single autonomous public agency or a few coordinated agencies pool resources to finance healthcare. This contributes to both equity in healthcare as well as to low levels of poverty in these countries. It is only in countries like India and a number of developing countries, which still rely mostly on out-of-pocket payments, where universal access to healthcare is elusive. In such countries those who have the capacity to buy healthcare from the market most often get healthcare without having to pay for it directly because they are either covered by social insurance or buy private insurance. In contrast, a large majority of the population, who suffers a hand-to-mouth existence, is forced to make direct payments, often with a heavy burden of debt, to access healthcare from the market because public provision is grossly inadequate or non existent. Thus, the absence of adequate public health investment not only results in poor health outcomes but it also leads to escalation of poverty. This article critically reviews the linkages of poverty with healthcare financing using evidence from national surveys and concludes that public financing is critical to good access to healthcare for the poor and its inadequacy is closely associated with poverty levels in the country.

The Abortion Assessment Project–India, begun in August 2000, is one of the largest studies on abortion ever undertaken in India. This article synthesises the findings of the six facility surveys, two community-based surveys, eight qualitative studies, policy review and commissioned working papers that were produced as part of the project by researchers from across India. Public investment in abortion services nationally was found to be grossly inadequate. 75% of facilities were found in the private sector in the six states and were overwhelmingly perceived to give better services. Although some important changes were made in the 1971 Medical Termination of Pregnancy Act related to clinic certification and medical abortion, further changes during the second phase of the government's Reproductive and Child Health Programme are recommended, based on this research and state and national-level consultations organised by the project. These include integrating abortion services into primary and community health centres, increased investment in public facilities, promoting use of vacuum aspiration and medical abortion, convincing providers to stop using curettage, broadening the base of abortion providers by training paramedics to do first trimester abortions, and reskilling traditional providers to play alternative roles that support women's access to safe abortion services.

Access to abortion services is not difficult in India, even in remote areas. Providers of abortion range from traditional birth attendants to auxiliary nurse midwives and pharmacists, unqualified and qualified private doctors, to gynaecologists. Despite a well-defined law, there is a lack of regulation of abortion services or providers, and the cost to women is determined by supply side economics. The state is not a leading provider of abortions; services remain predominantly in the private sector. Abortions in the public sector are free only if the woman accepts some form of contraception; other fees may also be charged. The cost of abortion varies considerably, depending on the number of weeks of pregnancy, the woman's marital status, the method used, type of anaesthesia, whether it is a sex-selective abortion, whether diagnostic tests are carried out, whether the provider is registered and whether hospitalisation is required. A review of existing studies indicates that abortions cost a substantial amount--first trimester abortion averages Rs.500- 1000 and second trimester abortion Rs.2000-3000. Given the number of unqualified providers and with 15-20% of maternal deaths due to unsafe abortions, the costs of unsafe abortions must also be counted. It is imperative for the state to regulate the abortion economy in India, both to rationalise costs and assure safe abortions for women.

International audience