Spatial perspective on woman’s primary health care services accessibility using Lefebvre's approach

Author Name:NehaVermaMadanAssistant Professor-College of Engineering PunePune, MaharashtraIndiaEmail: nmv.civil@coep.ac.inMob. Number: +91 9049977878

Biography:NehaVermaMadan is working as an Assistant Professor in Planning Section-Civil Engineering Department at College of Engineering Pune (COEP) since last 6 years. She is teaching core Planning subjects to the students in COEP. She has done her B. Planning from School of Architecture, New Delhi and Masters in Regional Planning from Cornell University, New York-USA. 

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Spatial perspective on woman’s primary health care services accessibility using Lefebvre's approach

Abstract

This paper critically examines the social production of space for primary healthcare activities. While many scholars have embraced the idea of considering only socio-economic and cultural factors for non-accessibility of primary health services to women, what these scholars have often left unexplored is how accessibility can also be measured by social production of space in urban areas. The first half of this paper focuses on the idea of Lefebvre’s conceptualization of social production of space and the linkage with the primary health care activities in slum in urban areas. The second section focuses specifically on how social production of space plays an important role in the accessibility of primary health care services to women in slums. I argue that components of social production of space-Perceived, Conceived and Lived- space should be consideredtogether to address solutions in better primary health care accessibility.

Key words: Slum, Health, Space, Lefebvre, Accessibility

Introduction

Nearly one-third of India’s urban population lives in a crowded informal settlements or slum communities. UNHABITAT has estimated that by the year 2020, India’s total slum population will cross 200 million people [1]. Urban slums are characterized by poor access to clean water and inadequate sanitation facilities; the basic requirements for maintaining good hygiene and health. With respect to health care, the urban poor are worse off than their middle- and high-income counterparts in urban area; they also appear to be worse off than their rural counterparts [2]. Every year, Indian slums bear witness to how preventable illnesses cause thousands of deaths and millions of hours of forfeited productivity. The government is aware of the country’s urban health care challenges, but has thus far found it difficult to adequately serve the space [2]. Thousands of women and children in urban slums are living in substandard health conditions with no or little access to medical care. Maternal and early childhood care is scant and sporadic at best with the closest hospital a fair distance away. Access to vaccinations, vitamins, de-worming and other basic health services are not readily available. The results are tragic: preventable illness along with death among mothers, infants and children [3].

The current study seeks to understand issues relating to Primary health care1 accessibility to women in slums by establishing relationship between all the three components of Space -Perceived, Conceived and Lived- of Spatial triad concept devised by Henri Lefebvre in one of his book 'La Production de l'espace' in 1974 (The Production of Space). Lefebvre's argument in 'The Production of Space' is that space is a social product, or a complex social construction (based on values, and the social production of meanings) which affects spatial practices and perceptions [4]. He conceptualized space in three forms: Conceived Space, Perceived Space, and Lived Space. The conceived spaceis the conceptualized space of planners, scientists, urbanists etc. that tends towards a system of verbal signs. Representations of Space take on a physical form. Maps, plans, models and designs are such forms. This space provides a concrete guidelines for how ‘thought’ can become ‘action’.The Perceived space is the physical and experimental deciphering of space. It embodies a close relation between daily reality and urban reality. He defines daily reality as daily routine and urban reality by the routes and networks that link up the places set aside for work, ‘private’ life and leisure.TheLivedspaceis the space of inhabitants and users. It is the passively experienced space, which the imagination seeks to change and appropriate. Lived space overlays physical space, making symbolic use of its objects [5].

The situation of Primary health care accessibility in India can be better understood by establishing the relationship between these three components of Spatial Triad. The research on health care accessibility by women that has been done till now has mainly focused on one of the three aspects (mainly lived space) of Spatial triad but little efforts has been taken to understand 1

Primary healthcare is a vital strategy which remains the backbone of health service delivery. Primary healthcare is the day-to-day care needed to protect, maintain, or restore our health. For most people, it is both their first point of contact with the healthcare system and their most frequently used health service.

the issues with respect to women accessibility to health services taking all the components of Spatial Triad in a collective manner.

Figure 1 Lefebvre Spatial Triad

This paper is therefore using the concept of 'the production of space' as conceptualized by Lefebvre. The current study looks at spatial perspective: space as it is organized by primary health care operators andthus accessible by women. The representation of space (Conceived Space) as propounded by Lefebvre, is the space created by planners. However in India since informality in health service providers is gaining popularity as the “mode of production” in terms of allocating spaces for health care services, it is logical to conclude that informal ways of spatial production are replacing the traditional role of planners and beaurocrats. Politicians as independent agents facilitate or prevent the way informal operators produce their own space. Therefore representation of space could be created by both planners and inhabitants [6]. It is therefore useful to use the social production of space as a theoretical framework that provides a better analysis of how the appropriation of space by health care services is undertaken, in terms of the generative process that results from the relations of all stakeholders involved in the production of that space. This can further allow us to explore the process of producing space and the role of the various agencies involved. Looking at those agencies, it is interesting to consider what they do and how they do it. The social production of logical spaces for formal and informal operators in health care services entails ways in which the spaces are planned, materially and socially appropriated, designed and regulated by various stakeholders involved in the process. In this process, the relationships between operators and urban spaces are redefined. This not only redefines space in an abstract way, it also puts the space in question into a transitional state by imposing formal and informal zoning principles including design and placements of objects. Another emphasis is placed on the representational space, which is focused on the actual use of space, or in Lefebvre’s terms the lived space. This space is often referred to as the space of

everyday life, which in the context of women entails their use of road reserves, markets, pavements and pedestrian walkways for their accessibility to health care services.

Figure 2: Methodology of Literature Review

Explanation of SPATIAL TRIAD with respect to PRIMARY HEALTH CARE

In this current study it is important to develop relationship between Space and Accessibility. Space and Accessibility are two different aspects for understanding the Primary health care scenario. Space constitutes placement of primary health care facilities and the mode of reaching these facilities constitutes accessibility. The relation between space and accessibility can be established by understanding the concept of spatial perspective as from this concept we will try to understand the Perceived space by translating the guiding principles of urban health care into spatial context. The perceived space embodies a close relation between daily reality and urban reality. Lefebvre defines daily reality as daily routine and urban reality by the routes and networks that link up the

places set aside for work, ‘private’ life and leisure. Under perceived space there is a need to clarify the locational decision making process (spatial policy) for distributing public health resources, and provide an ethical framework that enables us to evaluate the performance of alternative spatial distributions of health resources in terms of their contribution to health needs satisfaction. Perceived Space can further be understood using neoclassical economics and its spatial extension as it would enables us to establish a simplified model for the spatial organization of health care provision. This will lead to furtherdiscussion on spatial welfare theory (for Public Services), which will help in understanding the accessibility measures and accessibility concept that will help us assigning the parameters for conducting surveys in this research study.

Neo-Classical economics

Neoclassical economics is an old school economics that presents a view of working of economic activity (in our study it refers to primary health care services)in a society in capitalist economy. It considers the economic processes of production, consumption and distribution of goods and services. Production concerns the creation of all the services needed by society, consumption concerns their utilization by the members of society. What is produced and in what quantity depends, in theory, on what consumers are prepared to buy which, in turn, depends on the price asked by the producer and on what the consumer can afford. In neo-classical economic theory, it is assumed that markets automatically adjust to changes in demand and supply and tend towards a state of equilibrium at a price that brings supply and demand into balance by virtue of the intrinsic price mechanism [7]. The concept of utility - that which individuals try to maximize - is central to the theory of consumer behavior. Consumers maximize utility on the basis of individual tastes and preferences for goods and services and allocate their expenditure accordingly among alternative goods or services, subject to their income and the prevailing set of prices. Producers seek maximization of profits, consumers aim to minimize their expenditure in meeting their consumption needs. The ‘invisible hand’ of the market guides economic activity towards optimal resource allocation and maximization of social welfare [8]. Such an ideal economic or social state is termed Pareto optimal: it is impossible to make any individual better off without at the same time making someone else worse off. Proponents of neoclassical economics consider Pareto optimality as a situation inwhich a society achieves optimal allocation efficiency as well as distributive equity. In this situation everyone in a society gets equal healthcare facility which is quite utopian. The neo-classical economics does not consider geographical space in allocating goods and services. In the next section we explore how neo-classical analysis behaves if we incorporate geographical space.

Neoclassical location theory: a simplified spatial model

In this section we reconsider the processes of production, consumption and distribution considering geographical perspective by adhering to the assumptions set in neoclassical

economics. At the same time, we need to introduce some additional assumptions. Theseassumptions allow us to develop a simplified spatial model of the real world, whichenables us to focus explicitly on the role of geographic distance in the spatial organization (thus giving better understanding of perceived space) of health care provision.In this simplified spatial model it is assumed that consumers (women) live equidistant from one another on an isotropicplane in which transportation costs are uniform and exactly proportional to distance in all directions. The women are exhibiting uniform utility maximizing behavior, which means that they have identical incomes, demands and tastes. Producers and consumers both act economically as well as spatially rational. As werecall from the theory of consumer behavior, the rate of consumption of a utility maximizing individual depends on the price or exchange value of a good or service.In a world in which geographical space matters, this price will be made up of twoelements. The first element is the market price of the good or service at the point of sale. The second element is the cost of travelling to and from that point. This means that, with a fixed budget of time, money or effort, the amount of a particular good or service or the frequency with which it will be consumed, will decrease with increasing distance from the production facility up to a point where demand for that good or service will become zero (see Figure 3).Thus in this model the production of primary healthservices will depend on two economic mechanisms: the threshold value and the range of a good. The threshold value is defined as the minimum level of consumer demand of primary health care service needed for the profitable production of a heath care service. The range of a health care service describes the effective size of this demand, which is defined by themaximum distance women are willing to travel to obtain a health care facility. If the threshold exceeds the range, profitable provision of a service is notpossible. Range and threshold value bothhavea spatial form as illustrated in Figure 3. The analysis of individual producer behavior in geographical space can subsequentlybe extended to represent the collective spatial arrangement of production within adefined territory. The outcome of a perfect market in a space economy would, in theory, generate a‘spatial Pareto’ situation. In our simplified model of the spaceeconomy, spatial Pareto optimality is seen as a situation in which a society achievesoptimal spatial efficiency as well as equitable spatial distribution of primary health care services.The above discussion has provided us with two analytical constructs offundamental importance: threshold value and range. On the basis of these twomechanisms, the characteristics of service supply in relation to the spatial expression ofconsumer demand can be described. Important also is that we are not only concernedwith the location of individual service supply points, but also how they function inrelation to one another in geographic space. Finally, the notion of hierarchy in servicesupply has been introduced. Each of the above mentioned issues are essentialconsiderations in the structure of any health care system. Apart from the hierarchicalnature of health care systems, concepts such as market area, efficiency of provision andequality of access are fundamentally important considerations.At the same time, the normative nature of the neoclassical approach and its strictassumptions make that the model does not reflect reality sufficiently well. In the nextparagraph, we move away from this firm approach

and re-examine some of therestrictive assumptions in an attempt to bring our model closer to reality through a discussion of spatial welfare theory [10].

Spatial welfare theory: a more realistic spatial model for urban healthcare

The spatial welfare approach defines the state of society by the quantities of services produced and their distribution among consumers who are territorially disaggregated. Unlike neo-classical economics Spatial welfare theory demonstrates that an unregulated free market system does not culminate in welfare maximization but results in social, economic as well as spatial inequality. The theory provides arguments that there is a need for governments to intervene in imperfect markets for welfare maximization [10]. The keywords of the welfare approach are ‘who gets what where and how’ [11]. The who refers to the population of the area under study, in this current study it refers to woman population in slums.Thewhatrefers to the primary health care facilitiesenjoyed. The emphasis on where provides the spatial perspective and concerns the identification and understanding of place-to-place variations in welfare, which includes differential access to health services. The how refers to broader societal processes, such as the functioning of the economic and political system, that influence human welfare [11]. Spatial welfare theory identifies a number of shortcomings of the neo-classical perspective. The fundamental objection to neo-classical thought is its reliance on unrestricted individual consumer preferences as the origin of collective consumption patterns: the individual is seen as the primary atom and his/her preferences as the ultimate data for the welfare of society. The counter position of spatial welfare theory is that consumer preferences and the budget constraint are not autonomous but strongly influenced by the society and economy in which the individual lives. Another obvious shortcoming of neoclassical thought is the assumption that individuals act as ‘homo economicus’. In reality consumers and producers are not perfectly informed and rational beings capable of optimization. They will not fully maximize utility/profit as they have sub-optimal knowledge of the market and imperfect ability to process this knowledge. Instead of optimizing, they exhibit satisficing behavior, that is, they make decisions that allow them to reach a threshold level of satisfaction. Upon achieving the threshold, they feel little incentive to strive for maximum satisfaction. Spatial welfare theory incorporates geographical space as an element of utility or welfare but in a way that differs from neoclassical location theory. The very theoretical constructs of the isotropic plane and uniform consumer behavior are abandoned in favor of the realistic conception that alternative locations in geographic space offer alternative combinations of goods and that consumer will exhibit different spatial behavior as a result of differences in preferences and incomes. The individual will nevertheless tend to locate himself at that place whose characteristics possess a higher level of utility than other places known to him. The concept of place utility - the spatial equivalent of economic utility - is used to describe consumption in space. Place utility refers to the net composite of (dis-) utilities, which an individual derives at some point in geographic space. In their spatial behavior, individuals are not

only constrained by imperfect knowledge but also by economic constraints - embodied by the budget constraint - that impact on them. In the following section, we further elaborate spatial welfare theory but there the production and consumption of collectively provided public services in geographic space is at the centre of thediscussion.

Linking spatial welfare theory to urban health care

The theoretical framework of spatial welfare theory can be liked to provision of primary health care facility. The subject of this section is to link spatial welfare theory to urban health care by briefly addressing to the question ‘who’ gets ‘what’ ‘where’ and ‘how’.

The broader context of urban health care provision

In anutopian society health care systems is capable of meeting all the health needs of aall population. However, this has proven to be unrealistic and planners recognize that the need for care will almost inevitably exceed supply. In India the demand for health care is also growing due to rapidpopulation growth, and urbanization. Issues such as poverty, malnutrition and unhealthy living conditions are the main causes of morbidity and mortality in India. The strength of spatial welfare theory is that it provides a unifying framework that can be used to describe the spatial arrangement of private as well as public health provision.

Health seeking behavior: access and utilization

An important contribution of spatial welfare is its dismissal of the neoclassical assumptions of equal friction of distance in all directions and of absolute rationality in human (spatial) behavior. Obviously, the friction of distance is not equal in all directions but largely determined by existing road patterns and restricted by physicalbarriers to travel (this is perceived space as per Lefebvre). Furthermore, it is not aonly function of physical distance alone but influenced by the available modes of transportation, travel time, costs, congestion level, and so forth. Health care utilization - the outcome of the process through which individuals decide which particular medical facility to use - will not occur under conditions of perfect information and will not necessarily be economically and spatially rational [12]. Commonly recognized co-determinants of health seeking behavior include socio-economic status, demographic characteristics, health care costs, type and severity of illness, perceived quality of care and, friction of distance [13]. As illustrated in Figure 3 health seeking behavior can be viewed upon in two ways. Firstly, as the outcome of a given spatial arrangement of health care provision. Second, it can be used as the input for the planning of health care interventions aimed at increasing health needs satisfaction. The analysis of the factors governing health seeking behavior is the subject of Methodology chapter. The argumentation presented above has shown the strength of spatial welfare theory as a theoretical framework for describing the functioning of urban health care (whether private or public) in

geographic space. In the next section we move away from theoretic abstraction and orient the discussion to in establishing relationship between Perceived space and lived space.

Figure 4: Understanding Perceived Space-Lefebvre Concept using economics

Definition of Spatial Accessibility-

From the discussions above it is evident that spatial accessibility involves parameters of Space and Access. A workable space is produced when the elements of Spatial triad; Physical, Mental and Lived spaces interact with each other in a harmonious manner. Consequently the degree of relationship between Spatial and Aspatial factors is important in maintaining this harmonious relationship. Spatial Accessibility is defined as potential of interactions between various services and population in a smooth manner. It can be an ease with which services can be reached from one location using any transport system. Using the definition; parameters have been evolved to study the Spatial accessibility of health care services in selected slum locations:

Reasons for non-accessibility of Health services-Lived Space

In this section we will try and understand the conceived and lived space taking consideration primary health care facilities. It is important to understand the issues relating to primary health care accessibility taking consideration of everyday experiences of women while accessing these services. MeenakshiThapan [14] examines the relationship between culture, education andwomen's health through an analysis of secondary data. Her paper examines thatalthough education plays a crucial role in providing the possibilities for personal growth andindependence, the importance of cultural norms; values and customs in determining the life choices andphysical and mental well-being of women cannot be denied. This study gives an overview of lived experience (one of the component of Spatial triad). The personal experience in terms of cultural norms plays an important role in assessing women's health as norms and traditions plays a decisive factor in women's lives in accessing the primary health services.

Benarjee et.al. [15] presented their study giving emphasis on Lived experience by taking experiences of slum people by hospital staff in accessing Primary health care services in the case study area. They examined the accessibility to health services among Slum dwellers in an Industrial Township and surrounding rural areas and according to their study more than 50% of respondents were living in poor housing and insanitary conditions. Besides the burden of communicable diseases, risk of lifestyle diseases was found. Private medical practitioners were more accessible than government facilities. More than 60% people in their sample population sought treatment from private medical facilities for their own ailments. People who visited government facilities were more dissatisfied with the services than those who visited private facilities. The main barriers to health care identified were waiting time long, affordability, poor quality of care, distance, and attitude of health workers. It is evident that the experience gained by women slum dwellers by hospital staff, doctors plays an important role in deciding the accessibility of Primary health care facilities.

The Lived experience with respect to Primary Health care is also explained by Deogaonkar [16] in one of his study by presenting the social and economic inequality leading to low accessibility to primary health care services. Especially when the society is diverse, multicultural, overpopulated and undergoing rapid but unequal economic growth. According to him the difficulty in accessibility to primary health services is mainly attributed to three factors, i.e. geographical distance, socio-economic distance and gender distance. The issue of geographic distance relates to those who live in remote areas with poor transportation facilities are often removed from the reach of primary health systems. Incentives for doctors and nurses to move to rural locations are generally insufficient and ineffective. The socio-economic distance relates to lack of good housing, proper sanitation, and proper education. Economically slum dwellers do not have back-up savings, large food stocks that they can draw down over time. Similar to Deogaonkar,Goswami[17] also examined the factors that affect the health of women in the slums of Raipur city. Information about different levels of socioeconomic development and various dimensions of the health conditions of women was collected from the participants of slums in

Raipur city, from 300 families across four slums. This study was based on a micro level survey, and information was collected through a structured interview schedule. He proposed in his paper that social, economic, spatial, and cultural factors together determine the healthcare behavior of women in slum areas.

Akter [18] in his study highlights the relationship between socio economic conditions and theconsumption pattern of slum dwellers, which is indirectly affecting their health. . The field data of his study analyzed the living conditions, physical environment, household’s health behavior particularly dietary practice and health outcomes in Dhaka city. Socioeconomic status of slum dwellers was characterized by inadequate education, poor physical environment with non-existent solid waste disposal system. On the basis of access to food and utilization of food, the situation of food security of urban poor was analyzed. The study observed that living condition of slum dwellers was considerably poor; therefore, there was high prevalence of disease among children’s living in slums. Under such circumstances food security of urban poor is a challenge as socio economic conditions are not good. The study found that majority of slum dwellers can’t afford nutritious food which was beyond their reach; socio economic factors like income, expenditure and education were influencing food security in slums. Socio-economic factors are detrimental factors not only in consumption pattern but also in primary health care facilities.

Kiranmai K [19] in their study talks about three major ideas that are related to comprehensive women's health outcomes; personal factors, the health system factors, and social, economic and cultural factors. Their work is a cross-sectional study designed to examine the perceived and actual health status and health practices of women aged 18 to 64 years in the selected case study area.The results indicate that the perceived health condition by the women is good as a fact that inspiteofmany health effects they were not in medication and doesn't visit a doctor.

Sribas [20] in her study also concluded that social, economic, spatial, and cultural factors together determine the healthcare behavior of women in slum areas. In the case study area, only 31.33% of women breastfed their children one day after delivery, 31% of women respondents purchased medicines from local unrecognized shops, 6.67% of infant mortality cases have been reported, and 32.33% of women used sterilization method to control reproductive health. Low education and ignorance of women lead to continuation of wrong beliefs and unscientific attitudes toward health. The outcome of this attitude is incomplete immunization, insufficient gynecological checkup during pregnancy, unsafe deliveries at home, and improper postnatal care of mothers and children, especially in terms of diet and immunization. Incomplete tuberculosis and malaria treatment leads to recurrences and relapses. The unhealthy and polluted environment, lack of immunization, malnutrition, and absence of educational exposure also affect children in slums. Sadly, their physical, emotional, and intellectual growth is stunted from a very early age. Access to community facilities and health centers in these settlements is limited and not adequate.Sribas in her study also mentioned widespread ignorance, and the low social

status of women result in malnutrition, low immunization rates, low maternal and child care, and neglect of health, thus further contributing to the ill-health of the poor. The problem is further aggravated by the absence of a user friendly healthcare system. Clinics and hospitals are often far from poor settlements and entail a long and expensive trip. The hospitals are also often overcrowded and staffed by unfriendly, unsympathetic doctors. Therefore, despite good number of highly subsidized government hospitals, dispensaries, and maternal/child health centers in urban areas the poor remain unattended and untreated. Most urban poor women, when they fall ill, prefer to consult a private practitioner, and, as these doctors charge a heavy fee, the tendency is to avoid consulting a doctor until the illness becomes very serious.

Geethaet al [21] in a field study in the slum area of Mumbai revealed that absence of basic civic amenities such as safe and adequate water supply, sewerage and sanitation, toilets are the root cause of many diseases leading to under-nutrition in slum areas. The sex wise nutritional status, children aged five and below showed that girls have higher prevalence of under nutrition compared to boys. In this study weight for age and Midarm circumference indicators were used. On the basis of weight for age, 60.9% of boys and 72% of girls were undernourished. The MAC indicator showed that 19.8% of boys and 36.8% of girls were under nourished and another 25.2% of boys and 33.1% of girl’s were moderately undernourished. Both the indicators show that the incidence of under nutrition was significantly higher among girls than boys. Invariably, these studies document that men andwomen have unequal access to health care at various stages of the life cycle. For example, girl children are less immunized than boy children; have less access to hospital treatment [22]. The untreated morbidity rates are higher among women than men, and a strong class gradient by gender is found for in-patient health care as shown the table 1.

Short term morbidity Major Morbidity

2004-05 2011-12 2004-05 2011-12Male 100.21 154.05 49.11 93.91

Female 124.10 194.24 60.80 119.86Table 1: The morbidity rate is the frequency with which a disease appears in a population.Source: Balarajan, 2011 Bilkis[23] mentioned socio-psychological perceptions of most rural and many urban women petrified by centuries of patriarchal supremacy and a family system where the father and subsequently the husband are considered as equivalent to God. “The feeling of inferiority has been embedded in their psyche so much so, that far from condemning acts of violence against them, they are more likely to throttle the voices in favor of them. This is part of the clichéd vicious circle of illiteracy and social backwardness that accounts for all the resultant backwardness of the gender”The solution to this is suggested by Thapan [24]; he suggested imparting education with women can play a significant role in improving poor health status of

women living in slums. With good education women will realize the importance of primary health care and this will improve the delivery as well as accessibility mechanism.

Sufaira [25]studiedthehealth behavior of five social classes, upper class, upper middle, lower middle, upper lower, lower in the utilization of health services in Kannur district. The prevalence rate of illness was high among children below 15 and those exceed 55 both in the slum and urban areas. Those in the age group of 36 to 55 alsoaccounted for high morbidity both in the slum and urban areas. The study revealed that morbidity prevalence was inversely related to education and household size. The linkage of morbidity and occupation reveals that among employed group’s unskilled workers accounts for higher morbidity of infectious illness, whereas chronic disease is dominated among business class and white collar workers.

The concept of Space’ is well defined by Henri Lefebvre and using his understanding of space a lot can be deduced in terms of accessibility of health care services. The reason for choosing this topic is to identify areas of possible interventions in terms of spatial perspective including factors relating to social, economic, cultural aspects that can help in increasing the accessibility of basic health care by woman of urban slums.

In the literature review it was observed that researchers give more emphasis on social, economic and cultural factors in understanding primary health care accessibility as well as delivering mechanism. These factors are the structural determinants and conditions in which people are born, grow, live, work and age; including factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care.

It is also observed that in the previous studies addressing the health care accessibility issues doesn't consider both structural determinants and space together. It is important to understand the problem of non-accessibility of health care services taking perspective of Space; space in which these services are distributed.

The current study seeks to present relations between structural determinants and Space in accessing health care facilities and try to find answers on why despite of many policies and programs on health care delivery and accessibility there is still a huge gap between provisions of health care services to women living in slums.In this study an attempt will be made to understand issues relating to health care accessibility to women in slums located in Pune, Maharashtra. Parameters with respect to accessibility and space will be identified from literature research and using this parameters questionnaire will be developed. Accessibility impacts of land-use and transport strategies will be evaluated using accessibility measures, which researchers and policy makers can easily operationalize and interpret; such as travelling speed, inclusion of individual's spatial–temporal constraints and feedback mechanisms between accessibility, land-use and travel behavior which generally do not satisfy theoretical criteria. Lefebvre’s development of a spatial triad suggests an approach to organizational analysis that facilitates the contemplation of social,

physical and mental spaces to provide an integrated view of organizational space, an approach that is in contrast to many current discussions of organizational space in which the focus is often on only a singular aspect of space. At the end of this study recommendations and spatial framework for better spatial accessibility to health services will be provided to policy makers for make health care services and policies better accessible of woman in slums.

About the current study

The study aims address the primary health care issues by establishing relationship between various parameters of SPATIAL ACCESSIBILITY and finally proposing a framework for better health care service accessibility using urban planning interventions for woman in slums of Pune.

And the objectives of current study

1. To understand health concerns of people living in slums of Pune 2. To assess delivery mechanism of health care services and its accessibility to women3. To understand the concept of Space and establish relationship between parameters (land

use, spatial, social, economic, cultural) of Spatial accessibility approach in provision of health care services in slums

4. To suggest policy or spatial framework suitable for the needs of woman for better health service accessibility in slums

ConclusionsThe reviews covered in the many research papersmentioned low accessibility of primary health care services and reasons for this is mainly due to social, economic and cultural aspects of women living in slum areas. Although the main idea was to review each and every aspect of space; ie, perceived, conceived and lived space but in the literature authors mainly talked about lived experience of women which in most of the literature is responsible for low accessibility of primary health care services. Not many authors mentioned conceived spaced and perceived space in assessing low accessibility to primary health care services. It is important that all the aspects of space should be taken together to understand the reasons for low accessibility and then devising the framework for solutions. Primary health care service is essential for everyone; males, females or children. But in India as compared to males, females have less accessibility to Primary health care services. There are many factors leading to low accessibility and in this paper an attempt is made to identify the factors using Lefebvre concept of space.

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