Health policy processes in India: The case of abortion policy

India's one billion population faces an estimated 6.400.000 abortions per year. The 1971 Medical Termination of Pregnancy (MTP) act made abortion up to 20 weeks a legal right; the 2002 amended MTP act decentralised the certification of abortion providers and approved modern techniques. In India today, one out of four abortions still occur in illegal conditions, and 9% of maternal deaths are attributable to abortion. The processes leading to the MTP and the amended MTP act differed in a variety of aspects, displaying increasing complexity. The evidence underlying the MTP act consisted of national estimates of abortion deaths, provided by a government committee and with little participation from outside the medical community. By contrast, the amended MTP act was supported by an assortment of national and international evidence, ranging from persistent abortion deaths and declining sex ratio to implementation failure and the need for new techniques, documented and provided mainly by non-governmental actors from the medical sector and beyond. The resulting participatory process revealed competing rationales based on health concerns, population control, family planning and human rights issues. Implementation of both the MTP and the amended MTP act has been state-specific and based on differing interpretations, with limited central planning and monitoring. Six years after the publication of the amended MTP act, renewed agenda setting for policy improvement is ongoing, with discussions on various levels (technical, legal and rights-based). The increasing prominence of media and professional organisations, as well as a tug of war between abortion and anti-sex selection activists, add up to the complexity of the actual policy development process.