Maternity or catastrophe: A study of household expenditure on maternal health care in India
TL;DR: It was found that maternal health care expenditure in urban households was almost twice that of rural households, and increasing education level, higher consumption expenditure quintile and higher caste of women was associated with increasing odds of impoverishment due to maternalhealth care expenditure.
Abstract: Using data from 60th round of the National Sample Survey, this study attempts to measure the incidence and intensity of ‘catastrophic’ maternal health care expenditure and examines its socio-economic correlates in urban and rural areas separately. Additionally, it measures the effect of maternal health care expenditure on poverty incidence and examines the factors associated with such impoverishment due to maternal health care payments. We found that maternal health care expenditure in urban households was almost twice that of rural households. A little more than one third households suffered catastrophic payments in both urban and rural areas. Rural women from scheduled tribes (ST) had more catastrophic head counts than ST women from urban areas. On the other hand, the catastrophic head count was greater among illiterate women living in urban areas compared to those living in rural areas. After adjusting for out-of-pocket maternal health care expenditure, the poverty in urban and rural areas increased by almost equal percentage points (20% in urban areas versus 19% in rural areas). Increasing education level, higher consumption expenditure quintile and higher caste of women was associated with increasing odds of impoverishment due to maternal health care expenditure. To reduce maternal health care expenditure induced poverty, the demand-side maternal health care financing programs and policies in future should take into consideration all the costs incurred during prenatal, delivery and postnatal periods and focus not only on those women who suffered catastrophic expenditure and plunged into poverty but also those who forgo maternal health care due to their inability to pay.
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TL;DR: There has been more than twofold increase in hospitalisation rates in India during the last two decades, and significantly higher rates were observed among infants and older adults.
Abstract: Objectives The prime objective of this study is to examine the trends of disease and age pattern of hospitalisation and associated costs in India during 1995–2014. Design Present study used nationally representative data on morbidity and healthcare from the 52nd (1995) and 71st (2014) rounds of the National Sample Survey. Settings A total of 120 942 and 65 932 households were surveyed in 1995 and 2014, respectively. Measures Descriptive statistics, logistic regression analyses and decomposition analyses were used in examining the changes in patterns of hospitalisation and associated costs. Hospitalisation rates and costs per hospitalisation (out-of-pocket expenditure) were estimated for selected diseases and in four broad categories: communicable diseases, non-communicable diseases (NCDs), injuries and others. All the costs are presented at 2014 prices in US$. Results Hospitalisation rate in India has increased from 1661 in 1995 to 3699 in 2014 (per 100 000 population). It has more than doubled across all age groups. Hospitalisation among children was primarily because of communicable diseases, while NCDs were the leading cause of hospitalisation for the 40+ population. Costs per hospitalisation have increased from US$177 in 1995 to US$316 in 2014 (an increase of 79%). Costs per hospitalisation for NCDs in 2014 were US$471 compared with US$175 for communicable diseases. It was highest for cancer inpatients (US$942) followed by heart diseases (US$674). Age is the significant predictor of hospitalisation for all the selected diseases. Decomposition results showed that about three-fifth of the increase in unconditional costs per hospitalisation was due to increase in mean hospital costs, and the other two-fifth was due to increase in hospitalisation rates. Conclusion There has been more than twofold increase in hospitalisation rates in India during the last two decades, and significantly higher rates were observed among infants and older adults. Increasing hospitalisation rates and costs per hospitalisation are contributing substantially to the rising healthcare costs in India.
26 citations
TL;DR: Caesarean births were significantly higher among mothers belonging to higher socioeconomic status, first order births, mothers with high BMI, pregnancy complications, repeat caesareans and in private health centres confirming that both maternal demand and institutional factors are leading to the increasing in caesAREan rates in India.
24 citations
TL;DR: OOP payments for all ANC and delivery care services are a challenge to women, as one of fifteen women become impoverished and a further one-fifth incur catastrophic expenditures after visiting facilities that offer these services.
Abstract: Objectives (1) To assess the levels of impoverishment and catastrophic expenditure due to out-of-pocket (OOP) payments for antenatal care (ANC) and delivery care in Yangon Region, Myanmar; and (2) to explore the determinants of impoverishment and catastrophic expenditure. Design, setting and participants A community-based cross-sectional survey among women giving birth within the past 12 months in Yangon, Myanmar, was conducted during October to November 2016 using three-stage cluster sampling procedure. Outcome measures Poverty headcount ratio, normalised poverty gap and catastrophic expenditure incidence due to OOP payments in the utilisation of ANC and delivery care as well as the determinants of impoverishment and catastrophic expenditure. Results Of 759 women, OOP payments were made by 75% of the women for ANC and 99.6% for delivery care. The poverty headcount ratios after payments increased to 4.3% among women using the ANC services, to 1.3% among those using delivery care and to 6.1% among those using both ANC and delivery care. The incidences of catastrophic expenditure after payments were found to be 12% for ANC, 9.1% for delivery care and 20.9% for both ANC and delivery care. The determinants of impoverishment and catastrophic expenditure were women’s occupation, number of household members, number of ANC visits and utilisation of skilled health personnel and health facilities. The associations of the outcomes with these variables bear both negative and positive signs. Conclusions OOP payments for all ANC and delivery care services are a challenge to women, as one of fifteen women become impoverished and a further one-fifth incur catastrophic expenditures after visiting facilities that offer these services.
17 citations
Cites background or result from "Maternity or catastrophe: A study o..."
...20 Two studies from India using data from 2004 and 2015 found that the poverty headcount ratio for maternal healthcare expenditures declined after introducing free services for delivery care in 2015.(32) 33 Likewise, variations in the incidence of catastrophic expenditure due to maternal healthcare expenditures depend on the different maternal services measured, whether household income or capacity to pay is considered, and the catastrophic expenditure threshold used....
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...Higher incidences of catastrophic expenditure due to OOP payments were reported in India and Ethiopia because poorer women were included and all ANC, delivery and postnatal care services were considered.(32) 34 Prior studies from Africa and Bangladesh concluded that more than one-third of women faced catastrophic expenditure due to OOP payments for emergency obstetric care because they were poor and were required to pay for drugs....
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...In contrast, a study in India used the local poverty line and found higher impoverishment due to maternal healthcare expenditure than the findings of our study.(32) Although Yangon Region is the most developed region in Myanmar, a lot of non-poor households face impoverishment and deep poverty which could be explained by high maternal healthcare payments without a compensation scheme....
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TL;DR: Household health spending is growing faster than the consumption expenditure (economic well being) of household and changing age structure is significantly affecting health spending in India.
Abstract: This paper examines the pattern, growth and determinants of household health spending in India and compares the growth of per capita household health spending and per capita consumption expenditure over the last two decades. The unit data of various rounds of the National Sample Survey (consumption expenditure surveys 1993–1994, 2004–2005 and 2011–2012 and morbidity and health care surveys 1995–1996 and 2004) along with data from other secondary sources are used in the analyses. The patterns and growth of health spending are analyzed by demographic, social and economic attributes and economic well-being is measured using per capita consumption expenditure. Household health spending is subdivided into age structure, population growth, real cost of medical care and increased hospitalization. Descriptive statistics, fixed effect models and simple decomposition methods are used in the analyses. Results suggest that during 1993–2012, the annual growth rate of real per capita household health spending was twice (6.14 %) the real per capita consumption expenditure (2.60 %). On average, per capita household health spending among the richest consumption quintile was at least eight times higher than that of the poorest consumption quintile, linking household health spending to ability to pay. Household health spending was income inelastic. Though medicine accounts for a larger share of household health spending, household spending on medical tests is growing fast. We found a strong and positive gradient of age on per capita household health spending after controlling for income and other confounders. During 1995–2004, the age structure, hospitalization and real cost of hospitalization accounted for a 14, 42 and 26 % increase in the cost of hospitalization respectively. Household health spending is growing faster than the consumption expenditure (economic well being) of household and changing age structure is significantly affecting health spending in India. Increased public spending on health, upgrading the public health system and increasing access to health insurance can reduce the household health spending in India.
16 citations
TL;DR: While mechanisms such as JSSK, JSY, and Mamata had benefitted the vast majority, around half of those who did incur OOPE experienced CE, and additional insurance facility for cesarean section delivery might reduce the excessive financial burden on households.
Abstract: Background: Out-of-pocket expenditure (OOPE) is an obstacle in the path of getting universal health coverage in India. Objective: This study aimed to explore the OOPE, sources of funding, and experience of catastrophic expenditure (CE) for healthcare related to delivery, postpartum, and neonatal morbidity. Methods: A community-based, cross-sectional survey was conducted among a sample of 240 recently delivered women from the slums of Bhubaneswar, Odisha. Information on background, details of delivery, expenditure on delivery and on morbidities, and sources of funding was collected using a structured interview schedule. Results: Only 29.6% of the households incurred OOPE, and the others incurred either nil OOPE or had a net income because of benefits received from Janani Shishu Suraksha Karyakram (JSSK), Janani Suraksha Yojana (JSY), and “Mamata” schemes of the government. The median total OOPE was found to be 2100 INR (100–38,620). Multivariate analysis found parity, place of delivery, type of delivery, and presence of morbidity to be significantly associated with incurring any OOPE. Nearly 15% of the households incurred OOPE exceeding 40% of the reported monthly household income including 9%, whose OOPE was 100% or more of the reported household monthly income. Conclusion: While mechanisms such as JSSK, JSY, and Mamata had benefitted the vast majority, around half of those who did incur OOPE experienced CE. Additional insurance facility for cesarean section delivery might reduce the excessive financial burden on households.
15 citations
Cites result from "Maternity or catastrophe: A study o..."
...The prevalence of CE is similar to studies from other states and has reduced after JSY.[24] For sources of funding, it is the JSY, 77% of the households got benefited by an amount of 1000 INR in contrast to 40%[25] households in the year 2010 while for “Mamata” which is a state government run scheme 70% of the households got benefited by 5000 INR, respectively....
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...The prevalence of CE is similar to studies from other states and has reduced after JSY....
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References
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TL;DR: Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress and substantial, albeit varied, progress has been made towards MDG 5.
2,163 citations
Additional excerpts
...Health Care; Poverty; NSSO; Catastrophic Expenditure...
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Posted Content•
TL;DR: In this paper, the authors provide a step-by-step practical guide to the measurement of a variety of aspects of health equity, including gaps in health outcomes between the poor and the better-off in specific countries or in the developing world as a whole.
Abstract: This book shows how to implement a variety of analytic tools that allow health equity - along different dimensions and in different spheres - to be quantified. Questions that the techniques can help provide answers for include the following: Have gaps in health outcomes between the poor and the better-off grown in specific countries or in the developing world as a whole? Are they larger in one country than in another? Are health sector subsidies more equally distributed in some countries than in others? Is health care utilization equitably distributed in the sense that people in equal need receive similar amounts of health care irrespective of their income? Are health care payments more progressive in one health care financing system than in another? What are catastrophic payments? How can they be measured? How far do health care payments impoverish households? This volume has a simple aim: to provide researchers and analysts with a step-by-step practical guide to the measurement of a variety of aspects of health equity. Each chapter includes worked examples and computer code. The authors hope that these guides, and the easy-to-implement computer routines contained in them, will stimulate yet more analysis in the field of health equity, especially in developing countries. They hope this, in turn, will lead to more comprehensive monitoring of trends in health equity, a better understanding of the causes of these inequities, more extensive evaluation of the impacts of development programs on health equity, and more effective policies and programs to reduce inequities in the health sector.
1,301 citations
Book•
02 Nov 2007
TL;DR: This book shows how to implement a variety of analytic tools that allow health equity - along different dimensions and in different spheres - to be quantified to lead to more comprehensive monitoring of trends in health equity, a better understanding of the causes of these inequities, and more extensive evaluation of the impacts of development programs on health equity.
Abstract: This book shows how to implement a variety of analytic tools that allow health equity - along different dimensions and in different spheres - to be quantified. Questions that the techniques can help provide answers for include the following: Have gaps in health outcomes between the poor and the better-off grown in specific countries or in the developing world as a whole? Are they larger in one country than in another? Are health sector subsidies more equally distributed in some countries than in others? Is health care utilization equitably distributed in the sense that people in equal need receive similar amounts of health care irrespective of their income? Are health care payments more progressive in one health care financing system than in another? What are catastrophic payments? How can they be measured? How far do health care payments impoverish households? This volume has a simple aim: to provide researchers and analysts with a step-by-step practical guide to the measurement of a variety of aspects of health equity. Each chapter includes worked examples and computer code. The authors hope that these guides, and the easy-to-implement computer routines contained in them, will stimulate yet more analysis in the field of health equity, especially in developing countries. They hope this, in turn, will lead to more comprehensive monitoring of trends in health equity, a better understanding of the causes of these inequities, more extensive evaluation of the impacts of development programs on health equity, and more effective policies and programs to reduce inequities in the health sector.
993 citations
"Maternity or catastrophe: A study o..." refers background in this paper
...Following O’ Donnell et al. (2008), pre and post maternal health care poverty head count ratios can be written in the following manner....
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...OPEN ACCESS S. Mukherjee et al. / Health 5 (2013) 109-118 111 phic expenditure, only if total maternal health care expenditure is more than 40% of “capacity to pay”....
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Book•
01 Jan 2005
TL;DR: The World Health Report 2005 – Make Every Mother and Child Count, says that this year almost 11 million children under five years of age will die from causes that are largely preventable.
Abstract: The World Health Report 2005 – Make Every Mother and Child Count, says that this year almost 11 million children under five years of age will die from causes that are largely preventable. Among them are 4 million babies who will not survive the first month of life. At the same time, more than half a million women will die in pregnancy, childbirth or soon after. The report says that reducing this toll in line with the Millennium Development Goals depends largely on every mother and every child having the right to access to health care from pregnancy through childbirth, the neonatal period and childhood.
986 citations
TL;DR: Two threshold approaches to measuring the fairness of health care payments are presented, one requiring that payments do not exceed a pre-specified proportion of pre-payment income, the other that they do not drive households into poverty, and the incidence and intensity of 'catastrophe' payments were reduced and became less concentrated among the poor.
Abstract: This paper presents and compares two threshold approaches to measuring the fairness of health care payments, one requiring that payments do not exceed a pre-specified proportion of pre-payment income, the other that they do not drive households into poverty. We develop indices for 'catastrophe' that capture the intensity of catastrophe as well as its incidence and also allow the analyst to capture the degree to which catastrophic payments occur disproportionately among poor households. Measures of poverty impact capturing both intensity and incidence are also developed. The arguments and methods are empirically illustrated with data on out-of-pocket payments from Vietnam in 1993 and 1998. This is not an uninteresting application given that 80% of health spending in that country was paid out-of-pocket in 1998. We find that the incidence and intensity of 'catastrophic' payments - both in terms of pre-payment income as well as ability to pay - were reduced between 1993 and 1998, and that both incidence and intensity of 'catastrophe' became less concentrated among the poor. We also find that the incidence and intensity of the poverty impact of out-of-pocket payments diminished over the period in question. Finally, we find that the poverty impact of out-of-pocket payments is primarily due to poor people becoming even poorer rather than the non-poor being made poor, and that it was not expenses associated with inpatient care that increased poverty but rather non-hospital expenditures.
979 citations
Additional excerpts
...Health Care; Poverty; NSSO; Catastrophic Expenditure...
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