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: Findings indicate that there is considerable amount of variation in use of maternity care by educational attainment, household wealth, religion, parity and region of residence.
Abstract: Background. Low use of maternal healthcare services is one of the reasons why maternal mortality is still considerably high among adolescents mothers in India. To increase the utilization of these services, it is necessary to identify factors that affect service utilization. To our knowledge, no national level study in India has yet examined the issue in the context urban adolescent mothers. The present study is an attempt to fill this gap. Data and Methods. Using information from the third wave of District Level Household Survey (2007-08), we have examined factors associated with the utilization of maternal healthcare services among urban Indian married adolescent women (aged 13-19 years) who have given live/still births during last three years preceding the survey. The three outcome variables included in the analyses are 'full antenatal care (ANC)', 'safe delivery' and 'postnatal care within 42 days of delivery'. We have used Chi-square test to determine the difference in proportion and the binary logistic regression to understand the net effect of predictor variables on the utilization of maternity care. Results. About 22.9% of mothers have received full ANC, 65.1% of mothers have had at least one postnatal check-up within 42 days of pregnancy. The proportion of mother having a safe delivery, i.e., assisted by skilled personnel, is about 70.5%. Findings indicate that there is considerable amount of variation in use of maternity care by educational attainment, household wealth, religion, parity and region of residence. Receiving full antenatal care is significantly associated with mother's education, religion, caste, household wealth, parity, exposure to healthcare messages and region of residence. Mother's education, full antenatal care, parity, household wealth, religion and region of residence are also statistically significant in case of safe delivery. The use of postnatal care is associated with household wealth, woman's education, full antenatal care, safe delivery care and region of residence. Conclusion. Several socioeconomic and demographic factors affect the utilization of maternal healthcare services among urban adolescent women in India. Promoting the use of family planning, female education and higher age at marriage, targeting vulnerable groups such as poor, illiterate, high parity women, involving media and grass root level workers and collaboration between community leaders and health care system could be some important policy level interventions to address the unmet need of maternity services among urban adolescents.
58 citations
TL;DR: NHM has been successful in increasing maternal care and reducing the catastrophic health spending in public health centers and Regulating private health centres and continuing cash incentive under NHM is recommended.
Abstract: The National Health Mission (NHM), one of the largest publicly funded maternal health programs worldwide was initiated in 2005 to reduce maternal, neo-natal and infant mortality and out-of-pocket expenditure (OOPE) on maternal care in India. Though evidence suggests improvement in maternal and child health, little is known on the change in OOPE and catastrophic health spending (CHS) since the launch of NHM. The aim of this paper is to provide a comprehensive estimate of OOPE and CHS on maternal care by public and private health providers in pre and post NHM periods. The unit data from the 60th and 71st rounds of National Sample Survey (NSS) is used in the analyses. Descriptive statistics is used to understand the differentials in OOPE and CHS. The CHS is estimated based on capacity to pay, derived from household consumption expenditure, the subsistence expenditure (based on state specific poverty line) and household OOPE on maternal care. Data of both rounds are pooled to understand the impact of NHM on OOPE and CHS. The log-linear regression model and the logit regression models adjusted for state fixed effect, clustering and socio-economic and demographic correlates are used in the analyses. Women availing themselves of ante natal, natal and post natal care (all three maternal care services) from public health centres have increased from 11% in 2004 to 31% by 2014 while that from private health centres had increased from 12% to 20% during the same period. The mean OOPE on all three maternal care services from public health centres was US$60 in pre-NHM and US$86 in post-NHM periods while that from private health center was US$170 and US$300 during the same period. Controlling for socioeconomic and demographic correlates, the OOPE on delivery care from public health center had not shown any significant increase in post NHM period. The OOPE on delivery care in private health center had increased by 5.6 times compared to that from public health centers in pre NHM period. Economic well-being of the households and educational attainment of women is positively and significantly associated with OOPE, linking OOPE and ability to pay. The extent of CHS on all three maternal care from public health centers had declined from 56% in pre NHM period to 29% in post NHM period while that from private health centres had declined from 56% to 47% during the same period. The odds of incurring CHS on institutional delivery in public health centers (OR .03, 95% CI 0.02, 06) and maternal care (OR 0.06, 95% CI 0.04, 0.07) suggest decline in CHS in the post NHM period. Women delivering in private health centres, residing in rural areas and poor households are more likely to face CHS on maternal care. NHM has been successful in increasing maternal care and reducing the catastrophic health spending in public health centers. Regulating private health centres and continuing cash incentive under NHM is recommended.
56 citations
20 Jul 2020
TL;DR: Evidence, moving from descriptive towards explanatory studies which provide insights into the “hows” and “whys” of processes and pathways are essential for guiding policy and programme actions.
Abstract: If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-a-vis universal cove...
33 citations
TL;DR: Even though services at the public health facilities in India are supposed to be provided free of cost, it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain delivery care.
Abstract: To expand access to safe deliveries, some developing countries have initiated demand-side financing schemes promoting institutional delivery. In the context of conditional cash incentive scheme and free maternity care in public health facilities in India, studies have highlighted high out of pocket expenditure (OOPE) of Indian families for delivery and maternity care. In this context the study assesses the components of OOPE that women incurred while accessing maternity care in public health facilities in Uttar Pradesh, India. It also assesses the determinants of OOPE and the level of maternal satisfaction while accessing care from these facilities. It is a cross-sectional analysis of 558 recently delivered women who have delivered at four public health facilities in Uttar Pradesh, India. All OOPE related information was collected through interviews using structured pre-tested questionnaires. Frequencies, Mann-Whitney test and categorical regression were used for data reduction. The analysis showed that the median OOPE was INR 700 (US$ 11.48) which varied between INR 680 (US$ 11.15) for normal delivery and INR 970 (US$ 15.9) for complicated cases. Tips for getting services (consisting of gifts and tips for services) with a median value of INR 320 (US$ 5.25) contributed to the major share in OOPE. Women from households with income more than INR 4000 (US$ 65.57) per month, general castes, primi-gravida, complicated delivery and those not accompanied by community health workers incurred higher OOPE. The significant predictors for high OOPE were caste (General Vs. OBC, SC/ST), type of delivery (Complicated Vs. Normal), and presence of ASHA (No Vs. Yes). OOPE while accessing care for delivery was one among the least satisfactory items and 76 % women expressed their dissatisfaction. Even though services at the public health facilities in India are supposed to be provided free of cost, it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain delivery care.
28 citations
TL;DR: Results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery and Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened.
Abstract: Though Janani Suraksha Yojana (JSY) under National Rural Health Mission (NRHM) is successful in increasing antenatal and natal care services, little is known on the cost coverage of out-of-pocket expenditure (OOPE) on maternal care services post-NRHM period. Using data from a community-based study of 424 recently delivered women in Rajasthan, this paper examined the variation in OOPE in accessing maternal health services and the extent to which JSY incentives covered the burden of cost incurred. Descriptive statistics and logistic regression analyses are used to understand the differential and determinants of OOPE. The mean OOPE for antenatal care was US$26 at public health centres and US$64 at private health centres. The OOPE (antenatal and natal) per delivery was US$32 if delivery was conducted at home, US$78 at public facility and US$154 at private facility. The OOPE varied by the type of delivery, delivery with complications and place of ANC. The OOPE in public health centre was US$44 and US$145 for normal and complicated delivery, respectively. The share of JSY was 44 % of the total cost per delivery, 77 % in case of normal delivery and 23 % for complicated delivery. Results from the log linear model suggest that economic status, educational level and pregnancy complications are significant predictors of OOPE. Our results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery. Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened.
26 citations
References
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Journal Article•
TL;DR: The number of vacancies in Tamil Nadu has decreased dramatically over the past decade and more and more young graduates are joining service, which could be attributed to the opportunity provided to medical officers to choose a job site near home and the creation of more medical colleges in the state.
Abstract: While one would expect the percentage of vacancies to increase when new posts are created, surprisingly, in Tamil Nadu, the number of vacancies has decreased dramatically over the past decade and more and more young graduates are joining service. This unexpected trend could be attributed to the opportunity provided to medical officers to choose a job site near home and the creation of more medical colleges in the state. CONCLUSION In isolation, the factors mentioned above seem insignificant and trivial, but they have led to a substantial improvement in the health sector in Tamil Nadu. The problem of lack of availability of doctors for primary care in the government sector has been a perennial one for many health administrators. Other health administrators can study the government orders and rules mentioned above, most of which are available online, to modify them to suit the local needs and implement them to provide better care to patients through rural health set-ups.
28 citations
"Maternity or catastrophe: A study o..." refers background in this paper
...The state of government health services in India is marked by unavailability and absenteeism of health professions, poor health facility infrastructure, shortage of drugs and equipment, physical inaccessibility and callous behavior of health care professionals [6-8]....
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TL;DR: The findings show that the impact of health expenditures on household economic wellbeing and poverty is most severe in Albania and Kosovo, while Montenegro is striking for the financial protection that the health system seems to provide.
Abstract: This paper investigates the extent to which the health systems of the Western Balkans (Albania, Bosnia and Herzegovina, Montenegro, Serbia, and Kosovo) have succeeded in providing financial protection against adverse health events. The authors examine disparities in health status, healthcare utilization, and out-of-pocket payments for healthcare (including informal payments), and explore the impact of healthcare expenditures on household economic status and poverty. Methodologies include (i) generating a descriptive assessment of health and healthcare disparities across socioeconomic groups, (ii) measuring the incidence and intensity of catastrophic healthcare payments, (iii) examining the effect of out-of-pocket payments on poverty headcount and poverty gap measures, and (iv) running sets of country-specific probit regressions to model the relationship between health status, healthcare utilization, and poverty. On balance, the findings show that the impact of health expenditures on household economic wellbeing and poverty is most severe in Albania and Kosovo, while Montenegro is striking for the financial protection that the health system seems to provide. Data are drawn from Living Standards and Measurement Surveys.
24 citations
"Maternity or catastrophe: A study o..." refers background in this paper
...This catastrophic expenditure has been shown to have effects on poverty levels in many other countries [19-22]....
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TL;DR: Using government reported data, this brief reports on NRHM expenditures along the following parameters: overall trends in fund allocation and expenditures, physical coverage of Primary Health Centres (PHCs), human resource availability, and performance of Janani Suraksha Yojana.
Abstract: Launched in 2005, the National Rural Health Mission (NRHM) is the Government of India's (GOI) largest public health program.Using government reported data, this brief reports on NRHM expenditures along the following parameters: a) Overall trends in fund allocation and expenditures b) Physical coverage of Primary Health Centres (PHCs) c) Human Resource availability d) Performance of Janani Suraksha Yojana (JSY), and e) Progress in health outcomes.
11 citations
01 Jan 2005
TL;DR: Survey actual costs to consumers for reproductive health care services and assess the degree to which residual costs to Consumers (after accounting for fee exemptions) may constitute a barrier to these services.
Abstract: Although user fees are increasingly being used in government health programs to alleviate the pressure on constrained budgets as demand for services increases results in developing countries thus far have been mixed and concerns that fees reduce access to services among the poor have led to the promotion of fee exemption mechanisms. These exemptions however may not be an effective response because (1) informal fees and other costs associated with seeking and receiving services are not alleviated by most exemption mechanisms and (2) exemption mechanisms are often poorly implemented. The low proportion of formal fees to total costs to the consumer and the unpredictable nature of informal fees may actually work against formal fee exemption mechanisms. Thus it is important to assess whether these mechanisms alone hold promise for protecting access among the poor or whether they need to be supplemented with other strategies. The objectives of this study were to: (1) survey actual costs to consumers for reproductive health (RH) care services including antenatal care (ANC) delivery care family planning (FP) postabortion care (PAC) child healthcare and reproductive tract infection (RTI) treatment; (2) review fee and waiver mechanisms; (3) assess the degree to which these mechanisms function as intended; (4) assess the degree to which residual costs to consumers (after accounting for fee exemptions) may constitute a barrier to these services; and (5) review current policies and practices on setting charges and collecting retaining and using fee revenue. (excerpt)
10 citations
"Maternity or catastrophe: A study o..." refers background in this paper
...Many studies have explored the issue of the cost of maternal health care in the past [10-14]....
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