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Journal ArticleDOI

Out of pocket expenditure to deliver at public health facilities in India: a cross sectional analysis

24 Aug 2016-Reproductive Health (BioMed Central)-Vol. 13, Iss: 1, pp 99-99
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.

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RES E A R C H Open Access
Out of pocket expenditure to deliver at
public health facilities in India: a cross
sectional analysis
Anns Issac, Susmita Chatterjee, Aradhana Srivastava and Sanghita Bhattacharyya
*
Abstract
Background: 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.
Method: 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.
Results: 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.
Conclusion: Even though services at the public health facilities in India are supp osed 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.
Keywor ds: Out of pocket expenditure, Tips for getting services, Delivery care, Public health facilities, India
Abbreviations: ASHA, Accredited social health activist; JSSK, Janani Shishu Suraksha Karyakram; JSY, Janani Suraksha
Yojana; OBC, Other backward caste; OOPE, Out of pocket expenditure; SC/ST, Scheduled caste/scheduled tribe
* Correspondence: sanghita@phfi.org
Public Health Foundation of India, Plot no. 47, Sector 44 Institutional Area,
Gurgaon 122002, Haryana, India
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Issac et al. Reproductive Health (2016) 13:99
DOI 10.1186/s12978-016-0221-1

Plain English summary
Some developing countries have introdu ced p romo-
tional schemes for institutional delivery so that they
could improve womens access t o safe delivery care. In
India , there is a scheme, titled Janani Shishu Suraksha
Karyakram, which entitles women to free delivery care
at public health facilities. Howe ver, a few studies sug-
gested that the women ha d to pay for obtaining ser vices
even at the public health facilities. To understand the
different components of c ost of care, the present study
conducted a sur vey of 558 women who had delivered at
public health facilities in two districts of Uttar Pradesh.
The majority (97 %) of the women paid from their
pocket for services, and the median cost was INR 700
(US$ 11.48); this was half the cash incentive provided by
the government scheme. This amount varied between
INR 680 (US$ 11.15) for normal delivery and INR 970
(US$ 15.9) for complicated cases. The major component
was tips for getting services (consisting of gifts and tips
for services) with a median value of INR 320 (US$ 5.25).
Women from higher income households (more than INR
4000 (US$ 65.57)/ month), general castes, those who were
the first-time mothers, complicated delivery and those not
accompanied by community health workers paid more.
The study concludes that the care from the public
health facility is in fact not free, and this can discourage
women opting for institutional delivery.
Background
Developing countries suffer from unacceptably high
rates of maternal and infant mortality, accounting for
99% of glo bal maternal deaths [1]. One of the primary
reasons for this is the lack of access to safe deliveries,
especially among the poor, where healthcare access often
imposes a considerable financial burden on families [2].
To expand access to safe deliveries and reduce the risk
of maternal and newborn emergencies, some developing
countries have initiated demand-side financing schemes
to promote institutional delivery. Among the South
Asian countries, Nepal has the cash incentive scheme
and Bangladesh and Pakistan have voucher schemes [3].
Several studies from low and middle-income countries
have shown that the cost of care is a major determinant
of maternal care utilization and satisfaction with institu-
tional delivery care [4, 5]. Significant associations of cost
or affordability of care with maternal satisfaction and the
utilization of care in institutional births were found in
studies in Nigeria, Zambia, Kenya, Egypt, India, Gambia
and Ghana [613].
With a high maternal mortality ratio of 178, saving
maternal and newborn lives is a key concern in India [14].
The Government of India launched the conditional cash
transfer scheme of Janani Suraksha Yojana (JSY) in 2005
to promote institutional deliveries, offering a monetary in-
centive of INR 1400 (US$ 22.95)
1
to women delivering in
public or ac credited private facilities. The program is
supported by the Accredited Social Health Activist
(ASH A), a community health worker who motivates
women to deliver at public facilities and also accom-
panies them to the facilities [15]. The delivery services,
including medicines, tests and food are provided free of
cost to encourage women to opt for institutional deliv-
ery and offset their related expenditure burden [16].
Later, JSY wa s modified to Janani Shishu Suraksha
Karyakram (JSSK), which included additional services
such as support for travel to and from the facility and
medical treatment for sick newborn [17, 18].
As a consequence of JSY and JSSK , institutional de-
liveries in India have inc reas ed from 40.7% in 2005-06
to 72.9% in 2009-10 [19, 20]. Howe ver, se veral studies
show a persistent and unaccounted high le vel of out-
of-pocket expenditure (OOPE) on mate rnal care (ante-
natal, delivery a nd postnatal), similar to expenditure
on othe r public hospita l based services [2123 ]. The
high OOPE is especially catastrophic for poor house-
holds, who are of ten pushed into further poverty and
indebtedness on account of this [2428]. Though some
studies have highlighted OOPE for delivery care, there
is less attention to explore the components o f OOPE
during delivery care at public health facilities.
Our objective was to assess the OOPE incurred by
rural Indian women while accessing institutional delivery
services at public health facilities and to examine com-
ponents of OOPE. We also assessed the determinants of
OOPE and the level of maternal satisfaction with the
OOPE on delive ry care. For this study, OOPE refers to
all the direct expenditure for delivery care including
transportation and services availed from private pharma-
cies and laboratories due to lack of provision at the pub-
lic health facility.
Methods
The present analysis is part of a larger s tudy on
womens experience of care and their levels of satisfac-
tion with maternal services from secondary health care
facilities in India. The study followed a mixed-method
design with a literature review and qualitative pha se
preceding the quantitative phase. The literature review
aided in exploring the determinants and themes of care
from de veloping countries [4]. This i nformed t he quali-
tative phase in which perspectives from both the
women and healthcare providers were sought. The
quantitative phase consisted of a community sur vey
and focused entirely on women s perspective of delivery
care at health facilities. The data presented in this pa per
is part of the cross-se ctional sur vey.
Issac et al. Reproductive Health (2016) 13:99 Page 2 of 9

Study area
The community survey was co nducted durin g J uly -
August 2014 in two p oor performing districts in Uttar
Pradesh, one of the high-focus states in India with poor
health indicators. The state ha s high infant mortality
rate (50 per 1000 live births) [29], maternal mortality
ratio (292 per 100000 live births) and a low percentage
of institutional deliveries (45.6 %) [30]. The sele cted
districts had a maternal mortality ratio of 330. The
infantmortalityratewas80and82forthetwodistricts
whereas the percent of institutional delivery wa s 3 5.2
and 42.4 respectively [30]. The sur vey wa s aimed at
capturing the experience of women with maternal care
from secondary level health facilities. Secondary level
health facilities are designated to manage complications
with childbirth and have provisions for surgical care,
blood transfusion and newborn care. These facilities
function a s the first referral unit for primary level facil-
ities. There were four functional secondary le vel h ealth
facilities in the two study districts.
Study instrument
The survey instrument comprised of two parts: the first
part was a structured interview schedule capturing
womens experience of accessing care from the fa cility
including OOPE on reaching the facility till discharge,
and the second part comprised of a scale to assess their
satisfaction with care. Based on the literature review and
the qualitative study that preceded the survey, items in
the instrument were derived from the determinants of
structure, process and outcome of care. Among structural
determinants, physical environment, cleanliness, availabil-
ity of human resources, medicines and supplies were
included. Determinants of the process of care included
interpersonal behavior, privacy, promptness, cognitive
care, perceived provider competency and emotional
support. Outcome related determinants were the health
status of the mother and newborn.
A set of queries focused exclusively on the expend-
iture across nine categories viz. tr ansportat ion (hiring
vehicle to and from the facility), medicines and supplies
(prescribed from the facility), laboratory and diagnostic
ser vices, blood transfusion (expenditure for arranging
blood), newborn care (in case of neonatal complication,
while the mother was still admitted in the facility),
expenses on food during her stay in the facility, tips for
getting services (in cash or kind: gifts and sweets to
facility staff, tips to ambulance driver and facility staff
for their services), and other category includes all the
expenditure that the women cou ld not cla ssify under
the spe cific categories.
The instrument also included information on socio-
economic status and reproductive history of women. In
terms of social profile in India, general ca ste means the
non-vulnerable groups and the vulnerable category in-
cludes the backward, scheduled and caste and tribe. The
maternal satisfaction scale is a 5- point Likert scale with
ratings ranging from fully satisfied, somewhat satisfied,
neither satisfied nor dissatisfied, somewhat dissatisfied
and fully dissatisfied. The scale used had 14 items for
understanding satisfaction and included items pertaining
to structural, technical and interpersonal a spects of care.
The study instrument, prepared originally in English, was
translated into the local language (Hindi) of the study
area. Translation and back translation was carried out to
ensure the exactness of meaning of items in the survey
instrument and it was pretested among 20 women in a
setting similar to that of the study area.
Sampling and data collection
The study included women who had delivered at the
secondary level health facilities and discharged seven to
42 days prior to the interview. Only women with live
births were included in the study. A list of the women
with their home address who fulfilled the inclusion cri-
teria was collected from the delivery records of the four
secondary facilities in the two study districts. The list
contained 2130 women, who had given birth between
20
th
June and 20
th
July, 2014. The sample size calculated
for the study was 550 with 80% power and 95% confi-
dence interval. The participants wer e chosen randomly
and the randomization sequence was generated using
Excel. A sample of 600 women wa s selected for survey;
oversampling was to address dropouts. There were 10
refusals and 32 women could not be traced due to incor-
rect address. The dropout rate was seven percent. Total
558 women participated in the study. This included both
normal and complicated delivery, and there was no
stratification on type of delivery during the sampling.
The survey was conducted at womens residences by
female researchers who had knowledge of the research
topic and local dialect.
Data analysis
The study refers to OOPE as all the dire ct expenditure
incurred by the women in av ailing d elivery care at the
health facility including t ransportation, all of which are
provisioned to be free. This excludes mandatory pay-
ments , but inc ludes payment for services from private
providers (for transportation, laboratories and pharmacies,
etc.) due to shortage or non-functioning of respective
services at the public health facility. The costs incurred by
relatives or those who accompanied the women were
not considered during analysis. Since the women were
not aware of all the OOPE related to their deliveries,
inter viewers sought the help of family members present
duringthesurveytocompletetheinformation.Data
were collected to calculate dire ct expenditure only. The
Issac et al. Reproductive Health (2016) 13:99 Page 3 of 9

total expenditure wa s calculated by adding all the
category-wise expenditure mentioned by the respon-
dents. In order to verify the information, cross ques -
tions such as did you pay from your own pocket for
medicine etc. were included in the instrument. Any
discrepancy in the data was noted at the site and clari-
fied from the respondent s. Since the respondents were
unable to distinguish between mandatory fee and
others, information on stipulated fees for ser vices was
collected from the respective health facilities.
Survey data were analyzed using IBM SPSS version 19.
Data analysis included frequencies, Mann-Whitney test
(for comparing the difference between the median ex-
penditure of two groups) and categorical regr ession (to
identify the predictors of OOPE whe re the dependent
variable is on numeric scale while indepe ndent variables
are on nominal & numeric scales). As the average
monthly income and OOPE data were highly skewed,
log transformation was done to make the distribution
normal.
Results
All the women paid a registration cost of one rupee at
the health facility and this was not included for analysis
as it was a mandatory payment specified by the govern-
ment. Among the 558 women surveyed for the study,
total 540 women paid for one or the other type of ser-
vices from the public health facilities. Hence the present
analysis is confined to the sample size of 540.
Profile of the respondents
The characteristics of the respondents are given in Table 1.
The mean age of the women was 25 years. Majority of the
women were housewives (98.1 %) and belonged to lower
socio-economic strata. For the majority, their husbands
were daily wage laborers (43.9 %). Majority women in the
sample had a normal vaginal delivery (93.0 %) and were
multi-gravida (64.8 %). A significant proportion of them
had to travel more than five kilometers to access the
health facility (79.8 %). On an average, the women stayed
at the facility for two days after delivery.
Out of pocket expenditure (OOPE)
The median OOPE incurred for delivery at the public
health facility was INR 700 (US$ 11.48) (Table 2). There
was wide variation in the amount paid and it ranged
from INR 15 (US$ 0.25) to INR 14400 (US$ 236.07).
The women were entitled to receive free transportation
to and from the facility; however, in majority of the
cases, they had to arrange own transport due to non-
responsiveness of government ambulance service. Even
among those who availed the ser vice, it wa s restricted
toonesidetravel.Hencethetotalexpenditurefor
transportation varied from INR 20 (US$ 0.33) to INR
1634 ( US$ 26.79) with a median expenditure of INR
142.5 (US$ 2.34). Expenditure for newborn care, if he/
she was referred to a private facility, ranged f rom INR
100 2000 (US$ 1.64 32.7 9) depending on the nature
of complication. More than half of the women spent on
medicines, cotton pads , syringes and saline, which they
bought from private pharmacies. The laboratory facility
was not functional round the clock, leading to users
relying on private laboratories in the vicinity of the hos-
pital. Tips for getting services , which 86% of women
had to incur, included tips to avail government ambu-
lance,andbribeseitherincashorkind(forexample,
distributing sweet s) to facility staff for their s ervices.
Overcrowding in the facility led t o women paying the
Table 1 Socio-demographic and reproductive profile of
respondents (N = 540)
Characteristics Respondents,
n (%)
Age (years) Mean (SD) 24.9 (4.01)
Education of woman Illiterate 259 (48.0)
Literate 281 (52.0)
Mean years of schooling (SD) 8.4 (3.44)
Religion Hindu 479 (88.7)
Muslim 59 (10.9)
Sikh 2 (0.4)
Caste General 109 (20.2)
Other backward caste 232 (43.0)
Scheduled caste/scheduled
tribe
199 (36.9)
Type of household Nuclear 220 (40.7)
Joint 320 (59.3)
Occupation of woman Homemaker 530 (98.1)
Other work 10 (1.9)
Occupation of husband Cultivator 149 (27.6)
Casual labourer 237 (43.9)
Salaried workers 59 (10.9)
Self-employed in petty trade/
small scale industry
91 (16.9)
Unemployed 4 (0.7)
Average monthly
household income (INR)
a
4000 299 (55.4)
>4000 241 (44.6)
Gravidity 1 190 (35.2)
2 or more 350 (64.8)
Delivery Normal vaginal 502 (93.0)
C-section & breech 38 (7.0)
Duration of stay (days) Mean (SD) 2.1 (1.7)
Distance to health facility Upto 5 km 109 (20.2)
More than 5 km 431 (79.8)
a
Median income is INR 4000
Issac et al. Reproductive Health (2016) 13:99 Page 4 of 9

staff for obtaining a be d in the antenatal and postnatal
care wards.
The classification of normal refers to normal vaginal
delivery, and complicated indicates all the caesarian and
breech deliveries along with maternal complic ations
post-delivery. There was a noticeable difference in the
expenditure incurred for normal and complicated cases.
Complicated cases had higher OOPE for most of the
items compared to normal cases. The difference was
striking for laboratory investigations with median INR
450 (US$ 7.38) for complicated cases and only INR 20
(US$ 0.33) for normal cases.
Determinants of OOPE
Table 3 present s the total OOPE against selec ted socio-
economic and reproductive variables. The significant
variables were caste, income , gravidity, type of delivery ,
and pre sence of Accredited Social Health Activist
(ASH A). The OOPE for other castes was higher than
the vulnerable groups of other backward caste, sched-
uled caste/tribe taken together. Similarly, those in the
higher income group ( above INR 4000 per month) paid
more compared to lower income group. The OOPE for
multi-gravida was less compared to primi-gravida. The
complications associated with delivery (such as C-section
and breech cases as well as health complications of
mother soon after delivery) incurred higher OOPE than
normal delivery. Presence of ASHA during delivery led to
less OOPE as the median expenditure was INR 680
compared to INR 980 for the women when ASHA was
not present.
Regression analysis for OOPE provided three signifi-
cant predictors for OOPE viz. caste, type of delivery and
presence of ASH A during delivery (Table 4).
Level of maternal satisfaction with OOPE
Level of satisfaction with delivery care at the secondary
level public hea lth facilities was assessed using the
Maternal Satisfaction Scale (Table 5). Out of pocket
expenditure wa s one of the least satisfied items marked
by the women. Only three percent women were fully
satisfied with it. Similarly, the dissatisfaction score was
strikingly high with 18.7% which wa s the se cond high-
est among the enquired items.
Discussion
The study estimated the OOPE incurred by rural Indian
women while accessing institutional delivery services at
secondary le vel public health facilities and also examined
Table 2 Item-wise expenditure for delivery care (N = 540)
Items (n) Median expenditure in INR (min-max)
Normal (n = 461) Complicated (n = 79) Total (N = 540)
Transportation (n = 458) 130 (20-1500) 150 (20- 1634) 142.5 (20 1634)
Medicines and supplies (n = 298) 100 (15-1200) 110 (35-8000) 100 (15 8000)
Laboratory investigations (n = 13) 20 (10-200) 450 (100 1700) 100 (10 1700)
Blood transfusion (n = 2) - 500 (500 500) 500 (500 500)
Newborn care in private facility (n =3)
aa
200 (100 2000)
Tips for getting services (n = 466) 300 (10-2000) 400 (20-7000) 320 (10 7000)
Food (from the facility) (n = 15) 200 (20-500) 225 (30-500) 200 (20 500)
Any other (n = 265) 300 (20-3000) 400 (20-6000) 300 (20 6000)
Total expenditure (n = 540) 680 (15-5200) 970 (20-14400) 700 (15 14400)
a
Number of cases are not enough to calculate median as they are divided between normal (1) and complicated (2) categories
US$ 1 = 61 INR
Table 3 Total expenditure for care across selected variables
(N =540)
Variable Median expenditure in INR (IQR)
Age (Years) <25 680 (520)
25 740 (665)
Education of woman Illiterate 670 (510)
Literate 730 (600)
Religion Hindu 700 (550)
Non-Hindu 600 (540)
Caste*** General 850 (780)
OBC, SC/ST 670 (535)
Income (INR)** 4000 620 (520)
>4000 750 (550)
Gravida** Primi 785 (678)
Multi 660 (495)
Sex of baby Female 655 (493)
Male 720 (569)
Type of delivery*** Normal 680 (510)
Complicated 970 (1050)
Presence of ASHA*** Yes 680 (510)
No 980 (1675)
**p < 0.01, ***p <0.001
Significance level is determined using Mann- Whitney test
US$ 1 = 61 INR
Issac et al. Reproductive Health (2016) 13:99 Page 5 of 9

Citations
More filters
Journal ArticleDOI
27 Sep 2018-PLOS ONE
TL;DR: The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.
Abstract: Background Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality. Methods Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care. Results Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments. Conclusions The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.

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Abstract: To promote skilled attendance at births and reduce maternal deaths, the government of Ghana introduced the free maternal care policy under the National Health Insurance Scheme (NHIS) in 2008. The objective is to eliminate financial barriers associated with the use of services. But studies elsewhere showed that out of pocket (OOP) payments still exist in the midst of fee exemptions. The aim of this study was to estimate OOP payments and the financial impact on women during childbirth in one rural and poor area of Northern Ghana; the Kassena-Nankana municipality. Costs were taken from the perspective of women. Quantitative and qualitative data collection techniques were used in a convergent parallel mixed methods study. The study used structured questionnaire (n = 353) and focus group discussions (FGDs =7) to collect data from women who gave birth in health facilities. Quantitative data from the questionnaire were analysed, using descriptive statistics. Qualitative data from the FGDs were recorded, transcribed and analysed to determine common themes. The overall mean OOP payments during childbirth was GH¢33.50 (US$17), constituting 5.6% of the average monthly household income. Over one-third (36%, n = 145) of women incurred OOP payments which exceeded 10% of average monthly household income (potentially catastrophic). Sixty-nine percent (n = 245) of the women perceived that the NHIS did not cover all expenses incurred during childbirth; which was confirmed in the FGDs. Both survey and FGDs demonstrated that women made OOP payments for drugs and other supplies. The FGDs showed women bought disinfectants, soaps, rubber pads and clothing for newborns as well. Seventy-five percent (n = 264) of the women used savings, but 19% had to sell assets to finance the payments; this was supported in the FGDs. The NHIS policy has not eliminated financial barriers associated with childbirth which impacts the welfare of some women. Women continued to make OOP payments, largely as a result of a delay in reimbursement by the NHIS. There is need to re-examine the reimbursement system in order to prevent shortage of funding to health facilities and thus encourage skilled attendance for the reduction of maternal deaths as well as the achievement of universal health coverage.

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Journal ArticleDOI
TL;DR: Interacting logistical, cultural and structural barriers affect all aspects of immediate neonatal care and resuscitation in Bihar and must be addressed in any intervention focused on improving providers’ clinical skills.
Abstract: In India, the neonatal mortality rate is nearly double the Sustainable Development Goal target with more than half of neonatal deaths occurring in only four states, one of which is Bihar. Evaluations of immediate neonatal care and neonatal resuscitation skills in Bihar have demonstrated a need for significant improvement. However, barriers to evidence based practices in clinical care remain incompletely characterized. To better understand such barriers, semi-structured interviews were conducted with 18 nurses who participated as mentors in the AMANAT maternal and child health quality improvement project, implemented by CARE India and the Government of Bihar. Nurse-mentors worked in primary health centers throughout Bihar facilitating PRONTO International emergency obstetric and neonatal simulations for nurse-mentees in addition to providing direct supervision of clinical care. Interviews focused on mentors’ perceptions of barriers to evidence based practices in immediate neonatal care and neonatal resuscitation faced by mentees employed at Bihar’s rural primary health centers. Data was analyzed using the thematic content approach. Mentors identified numerous interacting logistical, cultural, and structural barriers to care. Logistical barriers included poor facility layout, supply issues, human resource shortages, and problems with the local referral system. Cultural barriers included norms such as male infant preference, traditional clinical practices, hierarchy in the labor room, and interpersonal relations amongst staff as well as with patients’ relatives. Poverty was described as an overarching structural barrier. Interacting logistical, cultural and structural barriers affect all aspects of immediate neonatal care and resuscitation in Bihar. These barriers must be addressed in any intervention focused on improving providers’ clinical skills. Strategic local partnerships are vital to addressing such barriers and to contextualizing skills-based trainings developed in Western contexts to achieve the desired impact of reducing neonatal mortality.

12 citations


Cites background from "Out of pocket expenditure to delive..."

  • ...These financial burdens continue to exist despite the Janani Shishu Sukaksha Karyakaram program launched by the Government of India in 2011 to eliminate out-of-pocket costs for maternal and neonatal care at public facilities [37]....

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Journal ArticleDOI
TL;DR: Affordable and accessible health care will substantially reduce the OOPE for sick newborn care in hospitals in Nepal, which varied by neonatal morbidity and duration of stay.
Abstract: Almost all preventable neonatal deaths take place in low- and middle-income countries and affect the poorest who have the least access to high quality health services. Cost of health care is one of the factors preventing access to quality health services and universal health coverage. In Nepal, the majority of expenses related to newborn care are borne by the caregiver, regardless of socioeconomic status. We conducted a study to assess the out of pocket expenditure (OOPE) for sick newborn care in hospitals in Nepal. This cross-sectional study of hospital care for newborns was conducted in 11 hospitals in Nepal and explored OOPE incurred by caregivers for sick newborn care. Data were collected from the caregivers of the sick newborn on the topics of cost of travel, accommodation, treatment (drugs, diagnosis) and documented on a sick newborn case record form. Data were collected from 814 caregivers. Cost of caregivers’ stay accounted for more than 40% of the OOPE for sick newborn care, followed by cost of travel, and the baby’s stay and treatment. The overall OOPE ranged from 13.6 to 226.1 US dollars (USD). The median OOPE was highest for preterm complications ($33.2 USD; CI 14.0–226.1), followed by hyperbilirubinemia ($31.9 USD; CI 14.0–60.7), respiratory distress syndrome ($26.9 USD; 15.3–121.5), neonatal sepsis ($ 25.8 USD; CI 13.6–139.8) and hypoxic ischemic encephalopathy ($23.4 USD; CI 13.6–97.7). In Nepal, OOPE for sick newborn care in hospitals varied by neonatal morbidity and duration of stay. The largest proportion of OOPE were for accommodation and travel. Affordable and accessible health care will substantially reduce the OOPE for sick newborn care in hospitals.

10 citations

References
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01 Jan 2012
TL;DR: The MDG 5 Target 5A calls for the reduction of maternal mortality ratio by three quarters between 1990 and 2015 as mentioned in this paper, which has been a challenge to assess the extent of progress due to the lack of reliable and accurate maternal mortality data.
Abstract: Millennium Development Goal (MDG) 5 Target 5A calls for the reduction of maternal mortality ratio by three quarters between 1990 and 2015. It has been a challenge to assess the extent of progress due to the lack of reliable and accurate maternal mortality data -- particularly in developing-country settings where maternal mortality is high. As part of ongoing efforts the WHO UNICEF UNFPA and The World Bank updated estimates of maternal mortality for the years 1990 1995 2000 2005 and 2010.

663 citations

Book
13 Feb 2019
TL;DR: The National Policy on Open Standards for e- Governance provides a set of guidelines for the uniform and reliable implementation of e-Governance solutions to ensure seamless interoperability of various solutions developed by multiple agencies.
Abstract: The Government of India (GoI) has taken major initiatives to accelerate the development and implementation of e-Governance and to create right environments for introducing G2G, G2B, G2E and G2C services within the country. The National Policy on Open Standards for e-Governance provides a set of guidelines for the uniform and reliable implementation of e-Governance solutions. It has been designed to ensure seamless interoperability of various solutions developed by multiple agencies. It also aims to improve the technology choices available and avoid vendor lock-in.

650 citations


"Out of pocket expenditure to delive..." refers background in this paper

  • ...The state has high infant mortality rate (50 per 1000 live births) [29], maternal mortality ratio (292 per 100000 live births) and a low percentage of institutional deliveries (45....

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Journal ArticleDOI
TL;DR: The paper argues for better methods of capturing drugs expenditure in household surveys and recommends that special attention be paid to expenditures on drugs, in particular for the poor.
Abstract: Based on Consumer Expenditure Survey (CES) data from the National Sample Survey (NSS), conducted in 1999–2000, the share of households’ expenditure on health services and drugs was calculated. The number of individuals below the state-specific rural and urban poverty line in 17 major states, with and without netting out OOP expenditure, was determined. This also enabled the calculation of the poverty gap or poverty deepening in each region. Estimates show that OOP expenditure is about 5% of total household expenditure (ranging from about 2% in Assam to almost 7% in Kerala) with a higher proportion being recorded in rural areas and affluent states. Purchase of drugs constitutes 70% of the total OOP expenditure. Approximately 32.5 million persons fell below the poverty line in 1999–2000 through OOP payments, implying that the overall poverty increase after accounting for OOP expenditure is 3.2% (as against a rise of 2.2% shown in earlier literature). Also, the poverty headcount increase and poverty deepening is much higher in poorer states and rural areas compared with affluent states and urban areas, except in the case of Maharashtra. High OOP payment share in total health expenditures did not always imply a high poverty headcount; state-specific economic and social factors played a role. The paper argues for better methods of capturing drugs expenditure in household surveys and recommends that special attention be paid to expenditures on drugs, in particular for the poor. Targeted policies in just five poor states to reduce OOP expenditure could help to prevent almost 60% of the poverty headcount increase through OOP payments.

333 citations

Journal ArticleDOI
TL;DR: Quality improvement efforts in developing countries could focus on strengthening the process of care, as evidence from the review points to the importance women attach to being treated respectfully, irrespective of socio-cultural or economic context.
Abstract: Developing countries account for 99 percent of maternal deaths annually. While increasing service availability and maintaining acceptable quality standards, it is important to assess maternal satisfaction with care in order to make it more responsive and culturally acceptable, ultimately leading to enhanced utilization and improved outcomes. At a time when global efforts to reduce maternal mortality have been stepped up, maternal satisfaction and its determinants also need to be addressed by developing country governments. This review seeks to identify determinants of women’s satisfaction with maternity care in developing countries. The review followed the methodology of systematic reviews. Public health and social science databases were searched. English articles covering antenatal, intrapartum or postpartum care, for either home or institutional deliveries, reporting maternal satisfaction from developing countries (World Bank list) were included, with no year limit. Out of 154 shortlisted abstracts, 54 were included and 100 excluded. Studies were extracted onto structured formats and analyzed using the narrative synthesis approach. Determinants of maternal satisfaction covered all dimensions of care across structure, process and outcome. Structural elements included good physical environment, cleanliness, and availability of adequate human resources, medicines and supplies. Process determinants included interpersonal behavior, privacy, promptness, cognitive care, perceived provider competency and emotional support. Outcome related determinants were health status of the mother and newborn. Access, cost, socio-economic status and reproductive history also influenced perceived maternal satisfaction. Process of care dominated the determinants of maternal satisfaction in developing countries. Interpersonal behavior was the most widely reported determinant, with the largest body of evidence generated around provider behavior in terms of courtesy and non-abuse. Other aspects of interpersonal behavior included therapeutic communication, staff confidence and competence and encouragement to laboring women. Quality improvement efforts in developing countries could focus on strengthening the process of care. Special attention is needed to improve interpersonal behavior, as evidence from the review points to the importance women attach to being treated respectfully, irrespective of socio-cultural or economic context. Further research on maternal satisfaction is required on home deliveries and relative strength of various determinants in influencing maternal satisfaction.

288 citations


"Out of pocket expenditure to delive..." refers background in this paper

  • ...Several studies from low and middle-income countries have shown that the cost of care is a major determinant of maternal care utilization and satisfaction with institutional delivery care [4, 5]....

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  • ...The literature review aided in exploring the determinants and themes of care from developing countries [4]....

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Journal ArticleDOI
TL;DR: In this paper, the authors investigated women's accounts of interactions with health care providers during labour and delivery and assessed the implications for acceptability and utilisation of maternity services in Ghana.
Abstract: Background This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana.

285 citations