In India, most states continue to collect user fees, despite the on-paper consensus that phasing out user fees is an urgent pre-requisite in achieving health equity goals. Despite the influx of funds through the National Rural Health Mission to improve the health care infrastructure, officials acknowledge that rogi kalyan samitis, that could potentially play a role in improving equity, are perceived by the public as a mere vehicle of user fee collection.

This paper will explore the ethical case against user fees in health. User fees were introduced purportedly to achieve the objectives of reducing frivolous demand, increasing revenue, improving quality and coverage, and rationalising patterns of care. Equity considerations were to be protected primarily through exemptions systems. In Maharashtra, user fees were introduced in 1988, and the scope and scale have been steadily increasing, with no visible effort at any rollback. Through a primary survey in a municipal hospital of Mumbai, the exemption systems in place and the efficiency of their implementation will be examined using qualitative interviews, while the flow of user fees collected will be mapped vis-à-vis the stated objectives, using secondary data sources. The status and relevance of these objectives will also be explored. About 50% of the primary data has been collected by conducting semi-structured in-depth interviews with the clinical and administrative staff of the facility. Data collection will be complete in October and at the conference, we will present our analysis and observations.