Out-of-pocket expenditure and correlates of caesarean births in public and private health centres in India

Preventing the preventable: Assessing the burden of incessant caesarean deliveries in select Indian states using NFHS-5

The World Health Organization (WHO) recommends that life-saving Caesarean sections (CS) should account for 10-15% of deliveries. Southern states of India have good obstetric facilities and better public health systems than other parts of India. However, CS rates in select states are considerably higher. This study examines the prevalence and determinants of preventable CS among mothers in select Indian states, specifically the states that have high institutional deliveries (>95%) viz. Andhra Pradesh, Kerala, Karnataka, and Tamil Nadu. It further compares the complications faced by CS and vaginal delivery cases. Data has been derived from a cross-sectional survey, the National Family Health Survey-5. Bivariate and Logistic regression analyses were used. The main outcome measured is Preventable C-sections, defined as per conditions in Robson's criteria of 10-group classification based on obstetric characteristics for a woman. Results show that the preventable CS rates in these selected states were much higher than at the national level. Key correlates were higher education and middle socioeconomic status. The study highlights the need for policy reforms, maternal education, and healthcare system improvements to reduce unnecessary CS in select states of India, where the health system is exceptionally good but , have another health burden in form of demand for unnecessary caesarean deliveries.

Out of pocket expenditure and distress financing on cesarean delivery in India: evidence from NFHS-5

BACKGROUND

Though over three-fourths of all births receive medical attention in India, the rate of cesarean delivery (22%) is twice higher than the WHO recommended level. Cesarean deliveries entail high costs and may lead to financial catastrophe for households. This paper examines the out-of-pocket expenditure (OOPE) and distress financing of cesarean deliveries in India.

METHODS

We used data from the latest round of the National Family Health Survey conducted during 2019-21. The survey covered 636,699 households, and 724,115 women in the age group 15-49 years. We have used 159,643 births those delivered three years preceding the survey for whom the question on cost was canvassed. Descriptive analysis, bivariate analysis, concentration index (CI), and concentration curve (CC) were used in the analysis.

RESULT

Cesarean deliveries in India was estimated at 14.08%, in private health centres and 9.96%  in public health centres. The prevalence of cesarean delivery increases with age, educational attainment, wealth quintile, BMI and high for those who had pregnancy complications, and previous birth as cesarean. The OOPE on cesarean births was US$133. It was US$498 in private health centres and US$99 in public health centres. The extent of distress financing of any cesarean delivery was 15.37%; 27% for those who delivered in private health centres compared to 16.61% for those who delivered in public health centres. The odds of financial distress arising due to OOPE on cesarean delivery increased with the increase of OOPE [AOR:10.00, 95% CI, 9.35-10.70]. Distress financing increased with birth order and was higher among those with low education and those who belonged to lower socioeconomic strata.

CONCLUSION

High OOPE on a cesarean delivery leads to distress financing in India. Timely monitoring of pregnancy and providing comprehensive pregnancy care, improving the quality of primary health centres to conduct cesarean deliveries, and regulating private health centres may reduce the high OOPE and financial distress due to cesarean deliveries in India.

Out-of-pocket expenditure and its correlates for institutional deliveries in private and public healthcare sectors in India: findings from NFHS 5

BACKGROUND

Increased coverage for institutional delivery (ID) is one of the essential factors for improved maternal and child health (MCH). Though, ID increased over time, out-of-pocket expenditure (OOPE) for the care-seeking families had been found to be growing, parallelly. Hence, we estimated OOPE in public and private health centres for ID, along with their sources and attributing factors and compared state and union territory-wise, so that financial risk protection can be improved for MCH related services.

METHODS

We used women's data from the National Family Health Survey, 2019-2021 (NFHS-5). Reproductive aged women (15-49 years) delivering one live child in last 5 years (n = 145,386) in any public or private institutions, were included. Descriptive statistics were presented as frequency and proportions. OOPE, was summarized as median and interquartile range (IQR). To estimate the extent for each covariate's effect, linear regression model was conducted.

RESULTS

Overall median OOPE for ID was Rs. 4066 (median OOPE: private hospitals: Rs.25600, public hospitals: Rs.2067). Health insurance was not sufficient to slash OOPE down at private facilities. Factors associated significantly to high OOPE were mothers' education, elderly pregnancy, complicated delivery, birth order of the latest child etc. CONCLUSION: A standard norm for ID should be implemented as a component of overseeing and controlling inequality. Aiding the needy is probably just one side of the solution, while the focus is required to be shifted towards reducing disparity among the health facilities, so that the beneficiaries do not need to spend on essential services or during emergencies.

Prevalence and correlates of low birth weight in India: findings from national family health survey 5

BACKGROUND

Childhood mortality and morbidity has become a major public health issue in low-middle-income countries. However, evidence suggested that Low birth weight(LBW) is one of the most important risk factors for childhood deaths and disability.This study is designed to estimate the prevalence of low birth weight (LBW) in India and to identify maternal correlates associated with LBW.

METHODS

Data has been taken from National Family Health Survey 5 (2019-2021) for analysis. 149,279 women belonging to reproductive age group (15-49) year who had last recent most delivery preceding the NFHS-5 survey.

RESULTS

Mother's age, female child, birth interval of less than 24 months, their low educational level, low wealth index, rural residence, lack of insurance coverage, women with low BMI, anaemia, and no ANC visits during pregnancy are predictors that contribute to LBW in India. After adjusting for covariates, smoking and alcohol consupmtion is strongly correlated with LBW.

CONCLUSION

Mother's age, educational attainment and socioeconomic status of living has a highly significant with LBW in India. However, consumption of tobacco and cigarrettes are also associated with LBW.

Early arrivals: association of maternal obstetric factors with preterm births and their survival in India

OBJECTIVES

Preterm birth (PTB) increases the risk of various acute and chronic morbidities and premature mortality in children under 5 years of age. The present study examines the association between different maternal obstetric factors and PTB. In addition, this study estimates the risk of neonatal mortality among children born preterm.

STUDY DESIGN

Retrospective two-stage stratified sample design.

METHODS

The weighted prevalence of PTB was estimated using data on 148,746 most recent institutional births from the National Family Health Survey (NFHS)-4, 2015-16. The Poisson regression model was used to investigate the association between maternal obstetric factors and PTB. Using Cox's proportional hazard model, the risk of neonatal mortality among PTBs was estimated.

RESULTS

Maternal obstetric factors, such as minimal antenatal care, delivery complications, history of previous caesarean delivery and delivery at private health facilities, were significantly associated with an increased risk of PTB. The survival probability of preterm babies sharply declined in the first week of life and thereafter was found to stabilise. The risk of mortality in the first 28 days of life increased 2.5-fold if the baby was born preterm. Optimising antenatal care was found to lower the likelihood of PTB and improve their chances of survival.

CONCLUSION

Antenatal care services and delivery care practices in private facilities were strongly associated with the incidence and survival of PTB. Evaluating associations of history of caesarean births on future pregnancies can help understand their deleterious effects on PTB. Affordable, accessible and available antenatal care services, in both public and private facilities, can increase the survival rates of PTBs.

Sterilization incentives and associated regret among ever married women in India, NFHS, 2015–16

Objective

Sterilization is the only family planning method that involves relatively large amount compensation. So, the study attempts to examine the role of incentives received against the sterilization procedures on the reporting of sterilization regret in India.

Methods

The study used data from the fourth round of National Family Health Survey, 2015–16, which gathered the information on sterilization regret from 1,94,207 ever-married women. Multivariate logistic analysis and predicted probabilities approach was used to study the effect of compensation received on the sterilization regret in India.

Results

Results show that women who have received compensation were 33% less likely to report sterilization regret. It was found that 70% of women who undergone sterilization in public facility didn’t incur any expenditure, rather received incentives. It is observed that women who had undergone operation in private facility spent a large amount than women who had done their operation in public facility. The regret in the private facility mainly results from high out of pocket expenditure on sterilization procedures. Around eight percent of women regretted getting sterilized in a private hospital and received some compensation amount, vis a vis the six percent who regretted undergoing sterilization in public facility and received compensation.

Conclusion

The study calls for a need to standardize the cost of sterilization procedure in India's health facilities. A good alternative for reducing the cost could be Public–Private Partnership.

Are cesarean deliveries equitable in India: assessment using benefit incidence analysis

BACKGROUND

In the last two decades, cesarean section (CS) deliveries in India have increased by six-fold and created economic hardship for families and households. Although several schemes and policies under the National Health Mission (NHM) have reduced the inequality in the use of maternal care services in India, the distributive effect of public health subsidies on CS deliveries remains unclear. In this context, this paper examines the usage patterns of CS delivery and estimates the share of public health subsidies on CS deliveries among mothers by different background characteristics in India.

DATA

Data from the fourth round of the National Family Health Survey (NFHS-4) was used for the study. Out-of-pocket (OOP) payment for CS delivery was used as a dependent variable and was analyzed by level of care that is, primary (PHC, UHC, other) and secondary (government/municipal, rural hospital). Descriptive statistics, binary logistic regression, benefit incidence analysis, concentration curve and concentration index were used for the analysis.

RESULTS

A strong economic gradient was observed in the utilization of CS delivery from public health facilities. Among mothers using any public health facility, 23% from the richest quintile did not pay for CS delivery compared to 13% from the poorest quintile. The use of the public subsidy among mothers using any type of public health facility for CS delivery was pro-rich in nature; 9% in the poorest quintile, 16.1% in the poorer, 24.5% in the middle, 27.5% among richer and 23% in the richest quintile. The pattern of utilization and distribution of public subsidy was similar across the primary and secondary health facilities but the magnitude varied. The findings from the benefit-incidence analysis are supported by those obtained from the inequality analysis. The concentration index of CS was 0.124 for public health centers and 0.291 for private health centers. The extent of inequality in the use of CS delivery in public health centers was highest in the state of Mizoram (0.436), followed by Assam (0.336), and the lowest in Tamil Nadu (0.060), followed by Kerala (0.066).

CONCLUSION

The utilization of CS services from public health centers in India is pro-rich. Periodically monitoring and evaluating of the cash incentive schemes for CS delivery and generating awareness among the poor would increase the use of CS delivery services in public health centers and reduce the inequality in CS delivery in India.

Accessing Maternal Health Care in the Midst of the COVID-19 Pandemic: A Study in Two Districts of Assam, India

Background

COVID-19 pandemic and the subsequent national lockdown in India compelled the health system to focus on COVID-19 management. Information from the field indicated the impact of COVID- 19 on the provision of maternal health services. This research presents users' and providers' perspectives about the effect of the pandemic on maternal health services in select districts of Assam.

Methods

The study was undertaken to understand the status of maternal health service provision and challenges faced by 110 pregnant and recently delivered women, 38 health care providers and 18 Village Health Sanitation and Nutrition Committee members during COVID-19 pandemic. Telephonic interviews were conducted with the users identified through simple random sampling. Healthcare providers and the community members were identified purposively.

Results

Most of the interviewed women reported that they could access the health services, but had to spend out-of-pocket (for certain services) despite accessing the services from government health facilities. Healthcare providers highlighted the lack of transportation facilities and medicine unavailability as challenges in providing routine services. The study revealed high proportion of Caesarian section deliveries (42.6%, n = 32) and stillbirths (10.6%, n = 8).

Discussion

This research hypothesizes the supply-side (health system) factors and demand-side (community-level) factors converged to affect the access to maternal health services. Health system preparedness by ensuring availability of all services at the last mile and strengthening existing community-reliant health services is recommended for uninterrupted good quality and affordable maternal health service provision.

Geographical variability and factors associated with caesarean section delivery in India: a comparative assessment of Bihar and Tamil Nadu

Background

Caesarean section delivery is a major life-saving obstetric surgical intervention for mothers and babies from pregnancy and childbirth related complications. This paper attempts to investigate the geographical variations and correlating factors of caesarean section delivery in India, particularly focusing on the states of Bihar and Tamil Nadu, accounting for one of the lowest and highest prevalence states of caesarean section delivery respectively.

Methods

This study is based on secondary data, collected from the fourth round of the National Family Health Survey (NFHS-4), 2015–16. We utilized 190,898 women aged 15–49 years who had a living child during the past 5 years preceding the survey. In this study, caesarean section delivery was the outcome variable. A variety of demographic, socio-economic, and pregnancy- and delivery-related variables were considered as explanatory variables. Descriptive statistics, bivariate percentage distribution, Pearson’s Chi-square test, and multivariate binary logistic regression models were employed to draw the inferences from data.

Results

Of participants, about 19% of women had undergone caesarean section delivery in the country. The state-wise distribution shows that Telangana (60%) followed by Andhra Pradesh (42%) and Tamil Nadu (36%) represented the topmost states in caesarean delivery, while Bihar (7%), Madhya Pradesh (10%), and Jharkhand (11%) placed at the bottom end. Multivariate logistic models show that the likelihood of caesarean delivery was higher among older women (35–49 years), women with higher levels of education, Muslims, women belonging to the upper quintiles of the household wealth, and those who received antenatal care (ANC), experienced pregnancy loss and delivery complications. Moreover, the odds of caesarean section delivery were remarkably greater for the private health sector than the public health sector in both focused states: Bihar (odds ratio [OR] = 12.84; 95% confidence interval [CI]: 10.90, 15.13) and Tamil Nadu (OR = 2.90; 95% CI: 2.54, 3.31).

Conclusion

Findings of this study suggest that improvement in female education, providing economic incentives, and spreading awareness through mass media could raise the caesarean section delivery among women whose vaginal delivery could be unsafe for them as well as for their babies. Moreover, providing adequate ANC and well-equipped public healthcare services would facilitate caesarean delivery among needy women.

Addressing data and methodological limitations in estimating catastrophic health spending and impoverishment in India, 2004-18

Background

Estimates of catastrophic health expenditure (CHE) are counterintuitive to researchers, policy makers, and developmental partners due to data and methodological limitation. While inferences drawn from use of capacity-to-pay (CTP) and budget share (BS) approaches are inconsistent, the non-availability of data on food expenditure in the health survey in India is an added limitation.

Methods

Using data from the health and consumption surveys of National Sample Surveys over 14 years, we have overcome these limitations and estimated the incidence and intensity of CHE and impoverishment using the CTP approach.

Results

The incidence of CHE for health services in India was 12.5% in 2004, 13.4% in 2014 and 9.1% by 2018. Among those households incurring CHE, they spent 1.25 times of their capacity to pay in 2004 (intensity of CHE), 1.71 times in 2014 and 1.31 times by 2018. The impoverishment due to health spending was 4.8% in 2004, 5.1% in 2014 and 3.3% in 2018. The state variations in incidence and intensity of CHE and incidence of impoverishment is large. The concentration index (CI) of CHE was − 0.16 in 2004, − 0.18 in 2014 and − 0.22 in 2018 suggesting increasing inequality over time. The concentration curves based on CTP approach suggests that the CHE was concentrated among poor. The odds of incurring CHE were lowest among the richest households [OR 0.22; 95% CI: 0.21, 0.24], households with elderly members [OR 1.20; 95% CI:1.12, 1.18] and households using both inpatient and outpatient services [OR 2.80, 95% CI 2.66, 2.95]. Access to health insurance reduced the chance of CHE and impoverishment among the richest households. The pattern of impoverishment was similar to that of CHE.

Conclusion

In the last 14 years, the CHE and impoverishment in India has declined while inequality in CHE has increased.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01421-6.

Association between the type of provider and Cesarean section delivery in India: A socioeconomic analysis of the National Family Health Surveys 1999, 2006, 2016

BACKGROUND

Prevalence of Cesarean section (C-section) is unequally distributed. Since both extremely low and high levels of C-section can not only cause adverse birth outcomes but also impose a double burden of inefficiency within maternal health care, it is important to monitor the dynamics of key factors associated with the use of C-section.

OBJECTIVES

To examine the association between type of provider and C-section in India in three-time points: 1999, 2006, and 2016, and also to assess whether this association differed across maternal education and wealth level.

METHODS

Data were from three waves of cross-sectional and nationally representative Indian National Health Family Survey: Wave II (1999), III (2006), and IV (2016). Target population is women aged 15 and 49 who had an institutional delivery for the most recent live birth during the three or five years preceding the survey (depending on the survey round). Multivariate logistic regression models adjusting for state cluster effect were performed to determine the association between the type of providers and C-section. Differential association between the type of providers and C-section by maternal education and wealth level was examined by stratified analyses.

RESULTS

The prevalence of C-section among institutional delivery increased from 20.5% in 1999 to 24.8% in 2006 while it declined to 19.4% in 2016. The positive association between private providers and C-section became stronger over the study period (Odds Ratio (OR) = 1.39, 95% Confidence Interval (CI) 1.18-1.64 in 1999, OR = 3.71 95% CI 2.93-4.70 in 2016). The association was consistently significant across all states in 2016. The gap in C-section between public and private providers was greater among less-educated and poorer women. The ORs gradually increased from the poorest to the richest quintiles, and also from the least educated group (no formal education) to the most educated group (college graduate or above).

CONCLUSIONS

Our results suggest that disparity in C-section between private and public providers has increased over the last 15 years and was higher in lower SES women. The behavior of providers needs to be closely monitored to ensure that C-section is performed only when medically justified.

Increasing trend of C-section deliveries in India: A comparative analysis between southern states and rest of India

OBJECTIVE

To examine the socio-demographic variations in overwhelming existence of C-section deliveries in south India, with a comparison to rest of India.

METHODS

This study analyses data collected from 51,136 mothers under National Family Health Survey (NFHS)-3 (2005-06) and 2,52,183 mothers under NFHS-4 (2015-16), those who have given births during last five years preceding the survey.

MAIN OUTCOME MEASURES

Descriptive statistics, bivariate analysis with Chi-squared tests and binary logistic regression models with 95% confidence intervals are used.

RESULTS

In south India at least one out of four women deliver through C-section and there was a notable rise in caesarean deliveries in public facilities as well as among tribal population. In aggregate, number of states exceeding 15% prevalence rate of C-section deliveries doubled to sixteen, while nineteen states registered more than 100% rise. Rural-urban difference is slim in south India, while likelihood for C-section deliveries for richest women as compared to poorest has gone down from 2.76 to 1.88 in south India and 7.75 to 4.58 in other regions during 2005-06 to 2015-16. The odds ratio for C-section is higher in private hospitals (3.26) of southern states with reference to public institutions, while the odds are 3.90 times higher for private facilities in other states. In south India, percentage of C-section deliveries were actually lower among those who reported about pregnancy complications.

CONCLUSIONS

Despite, several maternal and child health related programs being launched in India, their impact on improving the C-section scenario has remained microscopic, or they have continued to contribute towards a rising prevalence of C-section, especially in south India.

Understanding equity of institutional delivery in public health centre by level of care in India: an assessment using benefit incidence analysis

BACKGROUND

The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India.

METHODS

Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015-16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis.

RESULTS

Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015-16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was - 0.161 [95% CI, - 0.158, - 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres.

CONCLUSION

Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India.

An epidemic of avoidable caesarean deliveries in the private sector in India: Is physician-induced demand at play?

PURPOSE AND SETTING OF RESEARCH

Caesarean section (C-section) rates of over 15% suggest overuse of the surgery which may be difficult to justify on medical grounds. One important contributor to the rise in Csection rates is the rapid expansion of unregulated private-sector providers in number of settings. This study analyses the contribution of private sector in the rapid rise in Csection deliveries in India and the extent to which these can be justified on medical grounds.

METHODS

This is a cross sectional study design using National Family Health Surveys. Logistic regression and propensity score matching (PSM) analyses are performed. The main outcome measured is avoidable C-sections in the private sector.

PRINCIPAL FINDINGS

Our findings suggest that the rising trend in C-section rates in the private sector cannot be explained by medical reasons alone. The odds of C-section among women who chose to deliver in private was over 4 times higher than women who chose to delivery in public facilities. Despite, controlling for medical complications, women's characteristics and preferences, our PSM analysis suggest that the public-private gap has doubled over the years and that the difference cannot be explained by known determinants of C-section. Over supply of avoidable C-section to the extent of 21%, as a result of physician induced demand and perverse financial incentives was observed in the private sector.

CONCLUSIONS

This paper attempts to understand the reason for the high C-section rates in the private sector in India and the extent to which these are avoidable. Our analysis supports the assumption that physician induced demand as a result of perverse financial incentives in the private sector is at play.

Does delivery in private hospitals contribute largely to Caesarean Section births? A path analysis using generalised structural equation modelling

BACKGROUND

The rate of Caesarean Section (CS) deliveries has shown an alarming rise in recent years. CS is a surgical procedure used when there is apprehension of risk to the life of mother or baby in case of vaginal delivery, but its rates higher than 10-15 per cent are not justifiable. It is well recognised that a CS delivery could have a large number of adverse impacts on women and infants. Several studies, especially in developing countries, have revealed that delivery in private hospitals is one of the most contributing factors in CS deliveries. The present study conceptualises a causal pathway in which the possible risk factors, socio-economic, maternal and pregnancy-related, as well as institutional, influence the chances of CS delivery. It is hypothesised that certain factors would contribute to CS deliveries largely indirectly through the place of delivery, that is, either a public or private institution.

METHODS AND FINDINGS

To test the hypotheses, this study analysed 146,280 most recent live births delivered in hospitals during the five years preceding the fourth round of India's National Family Health Survey (NFHS-4), carried out during 2015-2016. The analysis, using generalised structural equation modelling (GSEM), revealed that many exogenous variables considered in the path models influence CS deliveries significantly, directly and/or indirectly through the place of delivery factor. Prominent among these are wealth index and receiving ANC services at only private hospitals; the total effects of these variables are even higher than the direct/total effect of place of delivery.

CONCLUSION

From this finding, it could be said that the place of delivery is a proximate determinant of a CS delivery or a mediator of other co-factors. Interventions to curb higher CS deliveries should be focused on improving the quality of public health sectors and on developing protocols for CS deliveries.

Pattern and correlates of out-of-pocket payment (OOP) on female sterilization in India, 1990-2014

Background

Large scale public investment in family welfare programme has made female sterilization a free service in public health centers in India. Besides, it also provides financial compensation to acceptors. Despite these interventions, the use of contraception from private health centers has increased over time, across states and socio-economic groups in India. Though many studies have examined trends, patterns, and determinants of female sterilization services, studies on out-of-pocket payment (OOP) and compensations on sterilisation are limited in India. This paper examines the trends and variations in out-of-pocket payment (OOP) and compensations associated with female sterilization in India.

Methods

Data from the National Family Health Survey - 4, 2015–16 was used for the analyses. A composite variable based on compensation received and amount paid by users was computed and categorized into four distinct groups. Multivariate analyses were used to understand the significant predictors of OOP of female sterilization.

Results

Public health centers continued to be the major providers of female sterilization services; nearly 77.8% had availed themselves of free sterilization and 61.6% had received compensation for female sterilization. About two-fifths of the women in the economically well-off state like Kerala and one-third of the women in a poor state like Bihar had paid but did not receive any compensation for female sterilization. The OOP on female sterilization varies from 70 to 79% across India. The OOP on female sterilization was significantly higher among the educated and women belonging to the higher wealth quintile linking OOP to ability to pay for better quality of care.

Conclusion

Public sector investment in family planning is required to provide free or subsidized provision of family welfare services, especially to women from a poor household. Improving the quality of female sterilization services in public health centers and rationalizing the compensation may extend the reach of family planning services in India.

Determinant of inequality in cesarean delivery in India: A decomposition analysis

In India, Cesarean Section (CS) rate had got doubled in the last decade, with widespread diversity across the population subgroup. Hence, this study examined the pattern, inequality and driving correlates of CS in India. The attributes that shape the inequality in CS were private health facility, followed by the richest economic status, southern region, highest education level. A substantial rise in CS in private sectors and richer section raises the apprehension as to whether commercial motive of private providers contributes to the undue rise in CS that need not necessarily be genuine.

Do poor people in the poorer states pay more for healthcare in India?

BACKGROUND

Rising health spending is associated with high out-of-pocket expenditure (OOPE), catastrophic health spending (CHS), increasing poverty, and impoverishment. Though studies have examined poverty and impoverishment effect of health spending in India, there is limited research on the regional patterns of health spending by type of health centers. This paper tests the hypothesis that the poor people from the poorer states of India pay significantly more for hospitalization in public health centers than those in the richer states of India.

METHODS

Data from the Social Consumption of Health Survey (71st round, 2014), carried out by the National Sample Survey (NSS) is used in the analyses. Descriptive statistics, log-linear regression model and tobit model were used to examine the determinants and variations in health spending.

RESULTS

Inter-state variations in the utilization of public health services and the OOPE on hospitalization are high in India. States with high levels of poverty make higher use of the public health centers and yet incur high OOPE. In 2014, the mean OOPE per episode of hospitalization in public health centers in India was ₹5688 and ₹4264 for the economically poor households. It was lowest in the economically developed state of Tamil Nadu and highest in the economically poorer state of Bihar. The OOPE per episode of hospitalization in public health centers among the poor in the poorer states was at least twice that in Tamil Nadu. Among the poor using public health centers, the share of direct cost account 24% in Tamil Nadu compared to over 80% in Bihar, Odisha and other poorer states. Adjusting for socio-economic correlates, the cost of hospitalization per episode (CHPE) among the poor using public health centers was 51% lower than for the non-poor using private health centers in India.

CONCLUSION

The poor people in the poorer states in India pay significantly more to avail hospitalization in public health centers than those in the developed states. Provision of free medicines, surgery and free diagnostic tests in public health centers may reduce the high OOPE and medical poverty in India.

Out-of-pocket expenditure and distress financing on institutional delivery in India

BACKGROUND

Despite large investment in central and state sponsored schemes for maternal care, out-of-pocket expenditure (OOPE) and catastrophic health spending (CHS) on institutional delivery remain high over time, across states and across socio-economic groups. Though many studies have examined the OOPE and CHS, few studies have examined the nature and extent of distress financing on institutional delivery in India.

DATA

Data from the fourth round of National Family Health Survey (NFHS 4), 2015-16 was used for the analysis. Distress financing was defined as borrowing money or selling assets to meet the OOPE on delivery care. Composite variables, descriptive analyses, concentration index (CI), concentration curve (CC) and predicted probability were used to estimate the extent of distress financing for institutional delivery in India.

RESULTS

The OOPE on institutional delivery has strong economic and educational gradient. One in four mothers resorted to borrowing or selling to meet the OOPE on institutional delivery. The extent of distress financing on institutional delivery was high in poorer state of Bihar and Odisha and in the state of Telangana that had highest prevalence of caesarean delivery. Savings was more prevalent among mothers compared to those who met the OOPE by borrowing/selling of assets. Finding are robust across the states of India. The predicted probability of incurring distress financing was 0.31 among mothers belonging to the poorest wealth quintile compared to 0.09 in the richest quintile, and 0.40 for those who incurred OOPE of more than INR 20,000. The probability of incurring distress financing was higher for mothers who had caesarean birth, delivered in private health centers and incurred high OOPE on institutional delivery.

CONCLUSION

Distress financing on institutional delivery was higher among the less educated, poor and in private health centers. Increasing use of public health centers, reducing caesarean births, improving the availability of medicine and diagnostic services can reduce the extent of distress financing in India.