Out-of-pocket expenditure on institutional delivery in India
TL;DR: The objective of this paper is to understand the regional pattern and socio-economic differentials in out-of-pocket (OOP) expenditure on institutional delivery by source of provider in India and recommend that facilities in public health centres of poorly performing states are improved and public-private partnership models are developed to reduce the economic burden for households of maternal care.
Abstract: Context Though promotion of institutional delivery is used as a strategy to reduce maternal and neonatal mortality, about half of the deliveries in India are conducted at home without any medical care. Among women who deliver at home, one in four cites cost as barrier to facility-based care. The relative share of deliveries in private health centres has increased over time and the associated costs are often catastrophic for poor households. Though research has identified socio-economic, demographic and geographic barriers to the utilization of maternal care, little is known on the cost differentials in delivery care in India. Objective The objective of this paper is to understand the regional pattern and socio-economic differentials in out-of-pocket (OOP) expenditure on institutional delivery by source of provider in India. Methods The study utilizes unit data from the District Level Household and Facility Survey (DLHS-3), conducted in India during 2007-08. Descriptive statistics, principal component analyses and a two-part model are used in the analyses. Findings During 2004-08, the mean OOP expenditure for a delivery in a public health centre in India was US$39 compared with US$139 in a private health centre. The predicted expenditure for a caesarean delivery was six times higher than for a normal delivery. With an increase in the economic status and educational attainment of mothers, the propensity and rate of OOP expenditure increases, linking higher OOP expenditure to quality of care. The OOP expenditure in public health centres, adjusting for inflation, has declined over time, possibly due to increased spending under the National Rural Health Mission. Based on these findings, we recommend that facilities in public health centres of poorly performing states are improved and that public-private partnership models are developed to reduce the economic burden for households of maternal care in India.
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TL;DR: Half the global population is at risk of financial catastrophe from surgery, with the burden of catastrophic expenditure highest in countries of low and middle income; within any country, it falls on the poor.
208 citations
TL;DR: Strengthening national health systems to improve maternal and newborn health will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.
Abstract: Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth. The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care. Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships. Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.
115 citations
Cites background from "Out-of-pocket expenditure on instit..."
...A recent study in India showed that the mean out-of-pocket expenditure on a normal delivery in a public facility was US$28 compared with US$84 in a private facility, and caesarean delivery costs three times more than a normal delivery [22]....
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TL;DR: It is concluded that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children.
Abstract: In a webinar in 2015 on health financing and gender, the question was raised why we need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage (UHC) will automatically be equitable and gender balanced. This article provides a reflection on this question from a panel of health financing and gender experts.We trace the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. We find that unless explicit attention is paid to gender and its intersectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations (e.g. poor women, unemployed men, female-headed households), movement towards UHC can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to UHC and the needs of less powerful groups, which can include women and children, are not necessarily given priority.We identify the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of UHC decisions, political economy as well as technical research should be prioritized.We conclude that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children. This constitutes the 'progressive universalism' advocated for by the 2013 Lancet Commission on Investing in Health.
88 citations
Cites methods from "Out-of-pocket expenditure on instit..."
...A study using national survey data for 2007–08 reported the mean expenditure incurred for a normal delivery in a private health facility to be 84 USD, and for a caesarean delivery as high as 256 USD (Mohanty and Srivastava 2013)....
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TL;DR: Evidence based on intersectional framework reveals that, despite similar socioeconomic background, males are more likely to use borrowings for health care financing than females, and the need for social protection policies and improved health care coverage is emphasized to curtail the incidence of distressed health care finance in India.
Abstract: Out-of-pocket (OOP) health care payments financed through borrowings or sale of household assets are referred to as distressed health care financing. This article expands this concept (to include contributions from friends or relatives) and examines the incidence and correlates of distressed health care financing in India. The analysis finds a decisive influence of distressed financing in India as over 60 and 40% of hospitalization cases from rural and urban areas, respectively, report use of such coping strategies. Altogether, sources such as borrowings, sale of household assets and contributions from friends and relatives account for 58 and 42% share in total OOP payments for inpatient care in rural and urban India, respectively. Further, the results show significant socioeconomic gradient in the distribution of distressed financing with huge disadvantages for marginalized sections, particularly females, elderly and backward social groups. Multivariate logistic regression informs that households are at an elevated risk of indebtedness while seeking treatment for non-communicable diseases, particularly cancer. Evidence based on intersectional framework reveals that, despite similar socioeconomic background, males are more likely to use borrowings for health care financing than females. In conclusion, the need for social protection policies and improved health care coverage is emphasized to curtail the incidence of distressed health care financing in India.
80 citations
TL;DR: The Lancet Commission on Global Surgery has proposed the elimination of impoverishment due to surgery by 2030, but no country‐level estimates exist of the financial burden of surgical access.
Abstract: Background
Approximately 30 per cent of the global burden of disease is surgical, and nearly one-quarter of individuals who undergo surgery each year face financial hardship because of its cost. The Lancet Commission on Global Surgery has proposed the elimination of impoverishment due to surgery by 2030, but no country-level estimates exist of the financial burden of surgical access.
Methods
Using publicly available data, the incidence and risk of financial hardship owing to surgery was estimated for each country. Four measures of financial catastrophe were examined: catastrophic expenditure, and impoverishment at the national poverty line, at 2 international dollars (I$) per day and at I$1·25 per day. Stochastic models of income and surgical costs were built for each country. Results were validated against available primary data.
Results
Direct medical costs of surgery put 43·9 (95 per cent posterior credible interval 2·2 to 87·1) per cent of the examined population at risk of catastrophic expenditure, and 57·0 (21·8 to 85·1) per cent at risk of being pushed below I$2 per day. The risk of financial hardship from surgery was highest in sub-Saharan Africa. Correlations were found between the risk of financial catastrophe and external financing of healthcare (positive correlation), national measures of well-being (negative correlation) and the percentage of a country's gross domestic product spent on healthcare (negative correlation). The model performed well against primary data on the costs of surgery.
Conclusion
Country-specific estimates of financial catastrophe owing to surgical care are presented. The economic benefits projected to occur with the scale-up of surgery are placed at risk if the financial burden of accessing surgery is not addressed in national policies.
64 citations
References
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TL;DR: New estimates for 2008 of the major causes of death in children younger than 5 years in 193 countries are reported to help to focus national programmes and donor assistance.
2,898 citations
TL;DR: JSY had a significant effect on increasing antenatal care and in-facility births and emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities.
720 citations
"Out-of-pocket expenditure on instit..." refers background in this paper
...therefore a need to target maternal care utilization among the poorest women (Lim et al. 2010)....
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TL;DR: Results show that utilization of maternal health care services is highest in Kerala followed by Tamil Nadu, Andhra Pradesh and Karnataka, and there was no significant rural-urban gap in the case of antenatal care.
476 citations
"Out-of-pocket expenditure on instit..." refers background in this paper
...…include the availability of and accessibility to a health facility, presence of a lady medical doctor and availability of drugs (Rama Rao 2001; Navaneetham and Dharamalingam 2002; IIPS 2010); the demand-side factors are maternal education, economic status of household, caste and religion…...
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...The supply-side factors mainly include the availability of and accessibility to a health facility, presence of a lady medical doctor and availability of drugs (Rama Rao 2001; Navaneetham and Dharamalingam 2002; IIPS 2010); the demand-side factors are maternal education, economic status of household, caste and religion (Bhatia and Cleland 1995; Singh and Singh 2007; Mohanty and Pathak 2009; Kesterton et al....
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Book•
28 Feb 2002
TL;DR: This report focuses on four areas of the health system in which reforms, and innovations would make the most difference to the future of the Indian health system: oversight, public health service delivery, ambulatory curative care, and inpatient care (together with health insurance).
Abstract: This report focuses on four areas of the health system in which reforms, and innovations would make the most difference to the future of the Indian health system: oversight, public health service delivery, ambulatory curative care, and inpatient care (together with health insurance). Part 1 of the report contains four chapters that discuss current conditions, and policy options. Part 2 presents the theory, and evidence to support the policy choices. The general reader may be most interested in the overview chapter, and in the highlights found at the beginning of each of the chapters in part 2. These highlights outline the empirical findings, and the main policy challenges discussed in the chapter. The report does not set out to prescribe detailed answers for India's future health system. It does however, have a goal: to support informed debate, and consensus building, and to help shape a health system that continually strives to be more effective, equitable, efficient, and accountable to the Indian people, and particularly to the poor.
400 citations
TL;DR: It is concluded that the poorest members of the community incurred catastrophic health expenses, and this has important policy implications and can be used to ensure better access to health services and a higher degree of financial protection for low-income groups against the economic impact of illness.
Abstract: OBJECTIVE: To quantify the extent of catastrophic household health care expenditure and determine the factors responsible for it in Nouna District, Burkina Faso. METHODS: We used the Nouna Health District Household Survey to collect data on 800 households during 2000-01 for our analysis. The determinants of household catastrophic expenditure were identified by multivariate logistic regression method. FINDINGS: Even at very low levels of health care utilization and modest amount of health expenditure, 6-15% of total households in Nouna District incurred catastrophic health expenditure. The key determinants of catastrophic health expenditure were economic status, household health care utilization especially for modern medical care, illness episodes in an adult household member and presence of a member with chronic illness. CONCLUSION: We conclude that the poorest members of the community incurred catastrophic health expenses. Setting only one threshold/cut-off value to determine catastrophic health expenses may result in inaccurate estimation leading to misinterpretation of important factors. Our findings have important policy implications and can be used to ensure better access to health services and a higher degree of financial protection for low-income groups against the economic impact of illness.
341 citations
"Out-of-pocket expenditure on instit..." refers background in this paper
...Research studies agree that cost is a major barrier for poor households to access maternal care (Frenk 2006; Su et al. 2006; Bonu et al. 2009; Skordis-Worrall et al. 2011)....
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