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

Who benefits from the donor-supported malaria programme in Enugu State, Nigeria? A benefit incidence analysis

Nigeria bears the highest global burden of malaria, accounting for 25% of cases and 19% of deaths worldwide. Development partners provide substantial support for malaria prevention and treatment in Nigeria. This study examines the financial burden of malaria on households and the benefit incidence of donor-supported bed net services in Enugu State, Nigeria. We conducted an interview-administered household survey in urban, semi-urban and rural regions in Enugu State in 2020. We collected data on the use of malaria services and out-of-pocket (OOP) payments. Socioeconomic status (SES) was estimated using household assets ownership. The benefits of malaria services were calculated by multiplying the unit cost of services while the net benefit was calculated by subtracting OOP payment from the benefits. A concentration index was used to assess equity in spending on malaria across socioeconomic quintiles. We estimated the gross and net benefit incidences for malaria services by deducting the OOP payment from the gross benefits. Most respondents were women, married, and had attained secondary education. Over 53.9% of surveyed households owned bed net. About 31.6% of households used malaria drugs in the past months. All users paid OOP for malaria drugs, sprays and lab services and over one-third of households incurred OOP costs for bed nets. The total OOP expenditure for malaria in the past month was $0.53 per household. The gross benefit incidence for malaria services was $1836.7. The net benefit and donor benefit were $1679.5 and $705.4, respectively. Both gross and net benefit for malaria services favored less-poor households. Households in Enugu State incur OOP expenses for malaria diagnosis and treatment, and less-poor households benefit more from government- and donor- subsidized malaria services, including bed nets. It is imperative to improve the accessibility and affordability of malaria diagnosis and treatment in Nigeria to ensure equitable access to malaria services.

Trends in Financial Affordability of Healthcare Among Tribal Women of Reproductive Age: A Cross-Sectional Study From India

BACKGROUND

Universal health coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. UHC is one of the targets of Sustainable Development Goal (SDG) 3 which India is trying to achieve with various initiatives and health programs. Tribal communities form an integral part of India's population. Due to various geographic barriers to access to the location of their settlements, it becomes problematic to provide essential services including healthcare without good expenditure. Moreover, as a result of various disadvantages, employment and subsequently the affordability for tribal groups poses an issue for availing healthcare services or those which are affordable are far away from the usual reach. With this study we would like to track the progress towards SDG 3 for the tribal communities in India.

OBJECTIVES

To assess the trends of ability to afford healthcare for self among tribal women in India over five years and to assess the determinants of this affordability among the same population.

METHODS

We used the Individual Recode (IR) datasets of Demographic & Health Surveys (DHS) data of Fourth and Fifth round for secondary data analysis. 670,384 and 689,454 cases from National Family Health Survey (NFHS) 4 and 5 were included for analysis. Under "svy" command, design adjusted chi square test was used, followed by binary logistic regression to derive unadjusted and adjusted odds ratio for various determinants.

RESULTS

6.38% and 6.23% of women belonged to tribal communities during NFHS 4 and NFHS 5 respectively. Only 0.24% and 0.35% had education above secondary education during NFHS 4 and NFHS 5. Majority of the tribal women were married during both surveys and around 0.3% were pregnant during the interviews. Consequently, most of the women were the wife of the head of household. Majority of the tribal women were followers of the Hindu religion and resided in the rural areas of the country. During NFHS 4, the major proportion of women belonged to the East zone and during NFHS 5, they belonged to the Northeast zone of India. For women in the age group of 25 to 29 years the odds of facing difficulty was the highest (aOR: 1.55 during NFHS 4 and 1.88 during NFHS 5). Moreover, those with no education showed highest odds of facing difficulty in arranging money for healthcare for self during both surveys (aOR: 1.69 during NFHS 4 and 1.45 during NFHS 5) when compared with those with higher education. In addition, the odds of facing affordability issues had increased from NFHS 4 to NFHS 5 for poorest tribal women (aOR 6.65 during NFHS 4 to aOR 8.91 during NFHS 5). There has been significant decrease in odds of facing affordability as a barrier among tribal women residing in Northeast zone of India (aOR: 5.01 during NFHS 4 and aOR: 3.45 during NFHS 5). The odds for facing affordability issues for tribal women residing in rural areas remained similar during both surveys.

CONCLUSION

There has been a slight decrease in the proportion of tribal women facing financial affordability as a barrier to accessing healthcare. Further factors like middle age groups of 25 to 29 years, no education, divorced or separated marital status, and belonging to poorest category of the Wealth Index were significant determinants due to which financial affordability has become a barrier to avail healthcare for self.

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Are institutional deliveries equitable in the southern states of India? A benefit incidence analysis

BACKGROUND

Despite a commendable rise in the number of women seeking delivery care at public health institutions in South India, it is unclear if the benefit accrues to wealthier or poorer socio-economic groups. The study's aim was to investigate at how the public subsidy is distributed among Indian women who give birth in public hospitals in the southern regions.

METHODS

Data from the Indian Demographic Health Survey's fifth wave (NFHS-5, 2019-21) was used in this study. A total of 22, 403 were institutional deliveries across all the southern states of India were included. Out-of-pocket expenditure (OOPE) on childbirth in health institutions was the outcome variable. We used summary statistics, Benefits Incidence Analysis (BIA), concentration index (CI), and concentration curve (CC) were used.

RESULTS

Most women in the lowest, poorest, and medium quintiles of wealth opted to give birth in public facilities. In contrast, about 69% of mothers belonging to highest quintile gave birth in private health institutions. The magnitude of CI and CC of institutional delivery indicates that public sector usage was concentrated among poorer quintiles [CIX: - 0.178; SE: 0.005; p < 0.001] and private sector usage was concentrated among wealthier quintiles [CIX: 0.239; SE: 0.006; p < 0.001]. Benefit incidence analyses suggest that middle quintile of women received the maximum public subsidy in primary health centres (33.23%), followed by richer quintile (25.62%), and poorer wealth quintiles (24.84%). These pattern in the secondary health centres was similar.

CONCLUSION

Poorer groups utilize the public sector for institutional delivery in greater proportions than the private sector. Middle quintiles seem to benefit the most from public subsidy in terms of the median cost of service and non-payment. Greater efforts must be made to understand how and why these groups are being left behind and what policy measures can enhance their inclusion and financial risk protection.

Universal health coverage and the poor: to what extent are health financing policies making a difference? Evidence from a benefit incidence analysis in Zambia

BACKGROUND

Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014.

METHODS

We conducted a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies at three time points. We combined data from household surveys and National Health Accounts.

RESULTS

Results showed that public (concentration index of - 0.003; SE 0.027 in 2006 and - 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and - 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services.

CONCLUSION

Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care.

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.

Institutional deliveries in India's nine low performing states: levels, determinants and accessibility

Background

Despite the implementation of several national-level interventions, institutional delivery coverage remains unsatisfactory in India’s low performing states (LPS), leading to a high burden of maternal mortality.

Objective

This study investigates the levels, differentials, and determinants of institutional deliveries in LPS of India. The study also delineates a holistic understanding of barriers to delivery at health facilities and the utilization of the Janani Suraksha Yojana (JSY) specifically designed to improve maternal and child health of disadvantaged communities.

Methods

A cross-sectional study was conducted using data from the National Family Health Survey (NFHS)-4, 2015–16. The study was carried out over India’s nine LPS utilizing 112,518 women who had a living child in the past five years preceding the survey. Bivariate and multivariate regression analysis techniques were used to yield findings.

Results

Of the study sample, nearly three-quarters (74%) of women delivered in a health institution in the study area, with the majority delivered in public health facilities. The multivariate analysis indicates that women who lived in rural areas, belonged to disadvantaged social groups (e.g. Scheduled caste/tribes and Muslims), and those who married early (before 18 years) were less likely to utilize institutional delivery services. On the other hand, women’s education, household wealth, and exposure to mass media were found to be strong facilitators of delivering in a health facility. Meeting with a community health worker (CHW) during pregnancy emerged as an important predictor of institutional delivery in our study. Further, interaction analysis shows that women who reported the distance was a ‘big problem’ in accessing medical care had significantly lower odds of delivering at a health facility.

Conclusions

The study suggests emphasizing the quality of in-facility maternal care and awareness about the importance of reproductive health. Furthermore, strengthening sub-national policies specifically in underperforming states is imperative to improve institutional delivery coverage.