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

Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India

INTRODUCTION

India's progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health, and socioeconomic contextual changes, drove these mortality reductions.

METHODS

The study's mixed-methods design integrated quantitative trend analyses of mortality, intervention coverage and equity since the 1990s, using the sample registration system and national surveys, with interpretive understandings from policy documents and 13 key informant interviews.

RESULTS

India's maternal mortality ratio (MMR) declined from 412 to 103 maternal deaths per 100 000 live births between 1997-1998 and 2017-2019. The neonatal mortality rate (NMR) declined from 46 to 22 per 1000 live births between 1997 and 2019. The average annual rate of mortality reduction increased over time. During this period, coverage of any antenatal care (57%-94%), quality antenatal care (37%-85%) and institutional delivery (34%-90%) increased, as did caesarean section rates among the poorest tertile (2%-9%); these coverage gains occurred primarily in the government (public) sector. The fastest rates for increasing coverage occurred during 2005-2012.The 2005-2012 National Rural Health Mission (which became the National Health Mission in 2012) catalysed bureaucratic innovations, additional resources, pro-poor commitments and accountability. These efforts occurred alongside smaller family sizes and improvements in macroeconomic growth, mobile and road networks, women's empowerment, and nutrition. These together reduced high-risk births and improved healthcare access, particularly among the poor.

CONCLUSION

Rapid reduction in NMR and MMR in India was accompanied by increased coverage of maternal and newborn health interventions. Government programmes strengthened public sector services, thereby expanding the reach of these interventions. Simultaneously, socioeconomic and demographic shifts led to fewer high-risk births. The study's integrated methodology is relevant for generating comprehensive knowledge to advance universal health coverage.

Determinants of public institutional births in India: An analysis using the National Family Health Survey (NFHS-5) factsheet data

Background

Institutional births ensure deliveries happen under the supervision of skilled healthcare personnel in an enabling environment. For countries like India, with high neonatal and maternal mortalities, achieving 100% coverage of institutional births is a top policy priority. In this respect, public health institutions have a key role, given that they remain the preferred choice by most of the population, owing to the existing barriers to healthcare access. While research in this domain has focused on private health institutions, there are limited studies, especially in the Indian context, that look at the enablers of institutional births in public health facilities. In this study, we look to identify the significant predictors of institutional birth in public health facilities in India.

Method

We rely on the National Family Health Survey (NFHS-5) factsheet data for analysis. Our dependent variable (DV) in this study is the % of institutional births in public health facilities. We first use Welch's t-test to determine if there is any significant difference between urban and rural areas in terms of the DV. We then use multiple linear regression and partial F-test to identify the best-fit model that predicts the variation in the DV. We generate two models in this study and use Akaike's Information Criterion (AIC) and adjusted R2 values to identify the best-fit model.

Results

We find no significant difference between urban and rural areas (P = 0.02, α =0.05) regarding the mean % of institutional births in public health facilities. The best-fit model is an interaction model with a moderate effect size (Adjusted2 = 0.35) and an AIC of 179.93, lower than the competitive model (AIC = 183.56). We find household health insurance (β = -0.29) and homebirth conducted under the supervision of skilled healthcare personnel (β = -0.56) to be significant predictors of institutional births in public facilities in India. Additionally, we observe low body mass index (BMI) and obesity to have a synergistic impact on the DV. Our findings show that the interaction between low BMI and obesity has a strong negative influence (β = -0.61) on institutional births in public health facilities in India.

Conclusion

Providing households with health insurance coverage may not improve the utilisation of public health facilities for deliveries in India, where other barriers to public healthcare access exist. Therefore, it is important to look at interventions that minimise the existing barriers to access. While the ultimate objective from a policy perspective should be achieving 100% coverage of institutional births in the long run, a short-term strategy makes sense in the Indian context, especially to manage the complications arising during births outside an institutional setting.

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.

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.

Why do Mothers from Remote Rural Areas opt for Cesarean Delivery: An Observational Analytical Study from West Bengal, India

Background

The percentage of cesarean section (C-section) deliveries has doubled in the last two decades in India. Although C-section delivery is a life-saving intervention, multiple maternal and neonatal morbidities are often associated with this procedure, adversely affecting the quality of life of both the mother and child.

Material and Methods

This community-based cross-sectional study was conducted to assess the point of view of mothers who delivered from January 2020 to June 2021.

Results

The mean (standard deviation (SD)) age of the 866 study participants at delivery was 24.5 (4.8) years, and 60.2% were primigravidas. A total of 613 (70.8%; 95% CI: 67.8-73.8) C-sections were conducted, of which 65.9% (n = 404) were planned and 21.9% were done on maternal request. C-sections were significantly associated with private institutes (adjusted prevalence ratio (aPR) 1.90; 95% CI: 1.70-2.11), at-risk pregnancy (aPR 1.37; 95% CI: 1.26-1.49), and primigravida (aPR 1.16; 95% CI: 1.05-1.29). About 55.3%, 29.8%, and 14.9% of women considered vaginal delivery to be risky, painful, and inconvenient, respectively.

Conclusion

It is imperative to generate awareness regarding modes of delivery during antenatal care (ANC) so that mothers can make better-informed choices.

Trends in out-of-pocket expenditure on facility-based delivery and financial protection of health insurance: findings from Vietnam's Household Living Standard Survey 2006-2018

Much of the existing empirical literature on the association between health insurance and out-of-pocket (OOP) expenditures on facility-based delivery in low- and middle-income countries is cross sectional in nature. Comparatively little is known about the dynamic shifts in OOP expenditures and the health insurance nexus. Using seven biennial waves of Vietnam's Household Living Standard Survey covering the period 2006-2018 and a generalized linear model this study examines trends in OOP expenditures on facility-based delivery and financial protection afforded by Vietnam's social health insurance system. Over the period under consideration, the pattern of health facility utilization among the insured shifted steadily from commune health centers towards higher-level government hospitals. Real OOP for delivery was 52.7% higher in 2018 than in 2006-2008 and insurance reduced OOP expenditures by 28.5%. Compared to district hospitals, giving birth at higher-level government hospitals increased OOP expenditures by 72.3% while giving birth at commune health centers reduced OOP expenditures by 55.7%. Additional analysis involving interactions between insurance status, types of public health facility and year dummies suggested a drop in financial protection of insurance, from 48% to 26.9% among women delivering at district hospitals and from 31.2 to 18.7% among those delivering at higher-level government hospitals. The modest financial protection of health insurance and its declining trend calls for policy measures that would strengthen the quality of maternal care at primary care institutions, strengthen financial protection and curb the provision of two-tiered clinical services and charges.

Does government health insurance protect households from out of pocket expenditure and distress financing for caesarean and non-caesarean institutional deliveries in India? Findings from the national family health survey (2019-21)

OBJECTIVE

Institutional deliveries have been promoted in India to reduce maternal and neonatal mortality. While the institutional deliveries have increased, they tend to involve large out of pocket expenditure (OOPE) and distress financing for households. In order to protect the families from financial hardship, publicly funded health insurance (PFHI) schemes have been implemented in India. An expanded national health insurance scheme called the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched in 2018. The current study was aimed at evaluating the performance of PFHI in reducing the OOPE and distress financing for the caesarean and non-caesarean institutional deliveries after the launch of PMJAY. This study analysed the nationally representative dataset of the National Family Health Survey (NFHS-5) conducted in 2019-21.

RESULTS

Enrollment under PMJAY or other PFHI was not associated with any reduction in out of pocket expenditure or distress financing for caesarean or non-caesarean institutional deliveries across India. Irrespective of the PFHI coverage, the average OOPE in private hospitals was five times larger than public hospitals. Private hospitals showed an excessive rate of using caesarean-section. Utilization of private hospitals was significantly associated with incurring larger OOPE and occurrence of distress financing.

Is rising pharma market a new burden? Introspecting the implications of India’s healthcare journey from public to a private good

Purpose

The paper demonstrates prejudicial effects of the rising private participation and the lacuna of state in ensuring the accessibility and affordability of healthcare.

Design/methodology/approach

Secondary data analysis from national and international databases is employed to demonstrate the low government spending and the alternate healthcare financing mechanisms in the country. The company reports of six Indian pharma companies are examined to map the profits and revenues, and also taking into account the sales growth and return on investment.

Findings

The paper observes the pharmaceutical sector, via its spiralling drug prices, is the primary contributor to the huge out-of-pocket expenses borne by households. The study findings indicate that there is an increased divergence between the out-of-pocket expenses of households and exorbitant profits of the private drug companies in the country over the years.

Research limitations/implications

Amidst debates on the importance of public health in the aftermath of the pandemic, the paper examines the rising hands of private sector in healthcare, and implores – who benefits? The authors study the implications via looking into the rise in the wealth of pharma giants; at the time of crisis when the lives of common citizens in the country were at stake.

Originality/value

The paper emphasises the repercussions of the higher markup of the pharma industry in raising the healthcare costs of households. The authors emphasise that the nonregulation of the pharma sector leads to high medical debts/poverty, in the wake of growing out-of-pocket expenditures of the citizens.

People's Perspective on Out-of-Pocket Expenditure for Healthcare: A Qualitative Study From Pune, India

Background Out-Of-Pocket Expenditure (OOPE) directly reflects the burden of health expenses that households bear. Despite the availability of social security schemes providing healthcare benefits, a high proportion of Indian households are still incurring OOPE. In order to recognize the reasons behind OOPE, a comprehensive understanding of people's attitudes and behavior is needed. Methodology By purposive sampling, 16 in-depth interviews were conducted using an interview guide in the catchment area of urban and rural health centers of a tertiary healthcare hospital. Interviews were conducted in Marathi and Hindi and were audio tape-recorded after taking informed consent. The interviews were transcribed and translated into English, followed by a thematic analysis. Results Although most participants knew that government hospitals provide facilities and experienced doctors, inconvenience and unsatisfactory quality deter them from utilizing government facilities. A few had experiences with government schemes; almost all concur that the formality and procedure of claiming insurance are cumbersome and all have had bad experiences. Cost of medications and consultation accounted for the majority of the healthcare expenditures. While some participants had benefitted from insurance, few regretted not enrolling in one. Conclusion The awareness regarding government schemes was derisory. Government-financed health insurance schemes and their utilization are crucial to reducing OOPE. Efforts should be made to increase accessibility to public healthcare services. Nevertheless, there is potential to redress the barriers to improve scheme utilization.

Economic burden of beta-thalassaemia major receiving hypertransfusion therapy at a public hospital in Mumbai

Background Treating beta-thalassaemia major may entail high costs with considerable out-of-pocket expenditure. Therefore, determination and valuation of the economic costs of a common haemoglobinopathy such as beta-thalassaemia major in India may provide insights to evolve policies for reduction or elimination of the disease. We estimated economic burden of beta-thalassaemia major in Mumbai in terms of cost to the family and the healthcare system. Methods This single-centre, prospective, cross-sectional, non-interventional study included children <12 years of age treated at the thalassaemia day care centre of a public hospital in Mumbai. The demographic data and treatment-related information was recorded. Cost of illness was studied from a societal perspective by the prevalence-based approach. Direct (medical and non-medical), indirect (loss of wages and loss of school days) and intangible costs (closed-ended iterative bidding) were calculated for each patient by interview. Results The total annual cost of treating 130 children with beta-thalassaemia major in Mumbai was ₹86 72 412 (US$ 127 535) or ₹66 710 (US$ 981) per patient per year and ₹12 82 30 412 (US$ 1 885 741) including intangible costs. Direct costs contributed to 94% of the cost of illness with chelation therapy (23%) and blood investigations (21%) being major contributors. Direct and indirect costs correlated significantly with duration of blood transfusion (p<0.05 and p=0.006, respectively), whereas indirect costs correlated with socioeconomic status (rho=0.25). Conclusion The majority (94%) of costs incurred by families for treatment of beta-thalassaemia major are direct costs, especially expenses for chelation and blood investigations. Even at subsidized rates, financial burden to the families from lower socioeconomic strata is likely to be considerable as these are out-of-pocket expenses. In consideration of the economic impact of treating beta-thalassaemia major in individual families, the healthcare system and society, it is prudent to promote and pursue long-term and short-term measures with urgent emphasis on prevention as a public health activity at the national level in India.

Harnessing Bourdieu's social theory to understand the deteriorating doctor-patient-nurse relationship in West Bengal government hospitals

Communication patterns between doctors, nurses and patients determine both the efficiency of healthcare delivery, and the job satisfaction of healthcare workers. Job satisfaction is important to ensure retention of the doctor and nurse populations. Incidents of assault against physicians and nurses from relatives and family members of patients have become frequent both in the pre-pandemic and COVID-19 eras. Along with appreciation for frontline healthcare workers serving during the pandemic, there is physical violence directed at them for failing to salvage infected patients. Using Bourdieu's concepts of social space, forms of capital, and habitus this paper endeavors to theorize some of the interaction patterns observed in doctor-patient, nurse-patient, and doctor-nurse encounters that contribute to the waning of the relationship between healthcare workers and wider society as observed in West Bengal, India. Primary empirical data was collected through in-person, in-depth semi-structured interviews with both open and closed-ended questions conducted throughout 2018 across 5 government hospitals in Kolkata (major metropolitan center) and 1 hospital in a suburban area with population 100,000. The respondents consisted of 51 nurses (100% women), 20 doctors (5% women), and 33 patients (33.3% women) recruited using purposive and snowball sampling. Social space analysis indicated that the cumulative patient social capital is comparable to that of the doctors, despite the doctor's higher levels of cultural and economic capital because of the high patient to doctor ratio. The patient population can thus concentrate and delegate their social capital to select agents leading to violence against healthcare workers. Through this analysis, two doctors' habitus were postulated, along with a nurse and a patient habitus. The first doctor habitus is structured by the idealized status of doctors and the second habitus is structured by their resource-limited working conditions. The nurse habitus is structured by the desire for economic empowerment along with dutifully providing care as instructed. The patient habitus is structured by the need to balance healthcare expenditures with their limited financial means. This paper establishes how the habitus of the agents and the politics of healthcare interact to exacerbate extant tensions between healthcare workers and the population they care for.

Financial Burden and Catastrophic Health Expenditure Associated with COVID-19 Hospitalizations in Kerala, South India

Introduction

Catastrophic health expenditure during COVID-19 hospitalization has altered the economic picture of households, especially in low resource settings with high rates of COVID-19 infection. This study aimed to estimate the out of pocket (OOP) expenditure and the proportion of households that incurred catastrophic health expenditure due to COVID-19 hospitalization in Kerala, South India.

Materials and Methods

A cross-sectional study was conducted among a representative sample of 155 COVID-19 hospitalized patients in Kottayam district over four months, using a pretested interview schedule. The direct medical and non-medical costs incurred by the study participants during hospitalization and the total monthly household expenditure were obtained from the respective COVID-19 affected households. Catastrophic health expenditure was defined as direct medical expenditure exceeding 40% of the household’s capacity to pay.

Results

From the study, median and mean OOP expenditure was obtained as USD 93.57 and USD 502.60 respectively. The study revealed that 49.7% of households had catastrophic health expenditure, with 32.9% having incurred distress financing. Multivariate analysis revealed being below poverty line, hospitalization in private healthcare facility, and presence of co-morbid conditions as significant determinants of catastrophic health expenditure.

Conclusion

High levels of catastrophic health expenditure and distress financing revealed by the study have unveiled major unaddressed challenges in the road to universal health coverage.

Incidence of Catastrophic Health Expenditures Amongst Hospitalized Neonates in Ekiti, Southwest Nigeria

Background

Neonatal illnesses require huge spending due to prolonged hospital stay. The management of these illnesses is usually financed by individual families which in most instances are living below the poverty line. This healthcare financing method can readily push families into catastrophic spending on health.

Aim

To ascertain the average cost of managing common neonatal illnesses and the financial burden, it constitutes to families in Ekiti State, southwest Nigeria.

Methods

We conducted a cross-sectional study on the out-of-pocket spending involved in managing neonates admitted into and discharged from the SCBU of the Ekiti State University Teaching Hospital, Ado-Ekiti, southwest Nigeria. Data collected included the monthly family income, the money spent on drugs, laboratory investigations and the hospital bill using a purposely designed structured questionnaire. Healthcare spending greater than 10% of the overall family income was described as catastrophic health spending (CHS).

Results

The medical bills for most (95%) of the 119 study participants were paid through the out-of-pocket means and 81.5% of the families spent more than 10% of their monthly earnings (CHS) to settle medical bills. Close to 50% of the families belonged to the lower social economic class. The median (IQR) duration of hospital stay was 2.75 days (3.0–8.0). The median (IQR) total expenditure was N24,500.00 (N13,615.00–N41,487.50). The median (IQR) expenditure for the treatment of prematurity was highest at N55,075.00 (USD 133.10) [N27,350.00 (USD 66.10)–N105,737.50 (USD 255.53)] and more than 60.5% of the expenses was on hospital utilities and consumables. The length of hospital stay showed a robust positive correlation with the total hospital bill (r = 0.576, P < 0.001).

Conclusion

Neonatal illnesses put many households at risk of catastrophic health spending. There is need for increased government investment in health and extension of the health insurance scheme to all the citizens of the country.

The inequalities and determinants of Households' Distress Financing on Out-off-Pocket Health expenditure in Malaysia

Background

Out-of-pocket (OOP) payments for healthcare services potentially have severe consequences on households, especially among the poor. Under certain circumstances, healthcare payments are financed through selling household assets, or borrowings. This certainly could influence households’ decision, which likely resorts to forgoing healthcare services. Thus, the focal point of this study is aimed to identify the inequalities and determinants of distress financing among households in Malaysia.

Methods

This study used secondary data from the National Health and Morbidity Survey (NHMS) 2019, a national cross-sectional household survey that used a two-stage stratified random sampling design involving 5,146 households. The concentration curve and concentration index were used to determine the economic inequalities in distress financing. Whereas, the determinants of distress financing were identified using the modified Poisson regression model.

Results

The prevalence of borrowing without interest was the highest (13.86%), followed by borrowing with interest (1.03%) while selling off assets was the lowest (0.87%). Borrowing without interest was highest among rural (16.21%) and poor economic status (23.34%). The distribution of distress financing was higher among the poor, with a concentration index of -0.245. The modified Poisson regression analysis revealed that the poor, middle, rich, and richest had 0.57, 0.58, 0.40 and 0.36 times the risk to develop distress financing than the poorest socio-economic group. Whereas, the presence of one and two or more elderly were associated with a 1.94 and 1.59 times risk of experiencing distress financing than households with no elderly members. The risk of developing distress financing was also 1.28 and 1.58 times higher among households with one and two members receiving inpatient care in the past 12 months compared to none.

Conclusions

The findings implied that the improvement of health coverage should be emphasized to curtail the prevalence of distress financing, especially among those caring for the elderly, requiring admission to hospitals, and poor socio-economic groups. This study could be of interest to policymakers to help achieve and sustain health coverage for all.

Distress financing in coping with out-of-pocket expenditure for maternity care in India

Background

The cost of maternity care is seen as the barrier in utilizing maternity care, resulting in high maternal deaths. This study focuses on the distress financing and its coping mechanisms associated with maternity care expenditure in India so that corrective measures can be taken to reduce the burden of maternity care.

Methods

This study used the National Sample Survey (NSS) data conducted in 20,014–15 (71^st round of NSS) and 2017–18(75^th round of NSS). We define distress financing as use of formal borrowing, borrowing from friends or family or sale of asser to finance maternity care. Percentage of pregnant/delivered females using distress financing were calculated.. The present study also used multinomial logistic regression with 95% to understand the impact of socio-economic variables on distress financing and concentration index to measure the inequality in maternity care expenditure.

Results

This study found that the maternity care expenditure has decreased from the INR. 9379 in 2014–15 to INR. 7835 in 2017–18. The percentage of households using distress financing is higher among the poorest (13.2%). Almost 14% of the SC households experience distress financing. Among EAG + A states, particularly in Madhya Pradesh and Uttarakhand, the percentage of households are which experience a high level of distress financing increased from 8.9 to 18.3 and 0.7 to 8.1 from 2014–15 to 2017–18 respectively. The study finds that more urban households (37%) utilized insurance than rural households (26%). Among EAG + A states, 67.9 percent of households were dependent upon household savings, and it was 63.6 percent in the non-EAG states. The households with a high burden of maternity care expenditure were at higher risk of borrowing money to finance the cost of maternity as compared to use of savings/income for the same (relative risk (RR) (R: 2.59; P < 0.01; 95% CI: 2.15–3.13). Mothers belonging to the SC caste were at significantly higher risk (RR: 1.43; P < 0.1; 95% CI: 1.07–1.91). of using borrowings as compared to the use of income/savings. Mothers with college education were 50% more likely to use health insurance as compared to those with primary education.

Conclusions

The study found that even though many programs for maternity care services are there, the maternity care expenditure, particularly the delivery care expenses, is very high in many states. The study recommends that India should increase subsidized maternity care facilities to decrease catastrophic maternity expenditure among households.

Developing a Screening Tool for Serious Health-related Suffering for Low- and Middle-Income Countries – Phase-1: Domain Identification and Item Generation

Objectives:

The Lancet Commission on Global Access to Palliative Care and Pain Relief reported significant levels of health-related suffering globally, with the highest incidence in the low- and middle-income countries. The report describes suffering as health-related when it is associated with illness or injury of any kind and suffering as serious when it cannot be relieved without professional intervention and when it compromises physical, social, spiritual, and/or emotional functioning. This paper describes the preliminary development phase of a tool for screening Serious Health-related Suffering (SHS) at individual patient level, suitable to the healthcare settings in India. The study was conducted by the National Cancer Grid-India, with support from the Indian Association of Palliative Care.

Materials and Methods:

Domain identification and item generation were conducted according to the recommendations for tool development by the American Psychological Association and World Health Organisation quality of life instrument. The consensus for domain questions and associated items was achieved using Delphi, nominal group technique, expert review, and polling.

Results:

The Phase-1 study for developing the screening tool for SHS contextualised to resource-limited settings generated a bilevel questionnaire. The initial level assesses and scores the physical, emotional, social, spiritual, and financial domains of health-related suffering. The next level assesses seriousness, through functional limitation and patient’s preference.

Conclusion:

The generation of domains, items, and screening questions for health-related suffering and its seriousness completes the preliminary phase of developing the SHS screening tool applicable to a resource-limited healthcare setting. Field testing of the tool is being conducted as Phase-2 of this study, to validate it in clinical settings.

Do the issues of religious minority and coastal climate crisis increase the burden of chronic illness in Bangladesh?

BACKGROUND

Chronic illness with disability and its out-of-pocket expenditure (OOPE) remains a big financial challenge in Bangladesh. The purpose of this study was to explore how religious minority problem and coastal climate crisis with other common risk factors determined chronic illness with a disability and its financial burden in Bangladesh. Existing policy responses, especially, social safety net programs and their governance were analyzed for suggesting better policy options that avoid distress financing.

METHODS

Binary logistic and multiple linear regression models were respectively used to identify the factors of disability, and high OOPE based on Bangladesh Household Income and Expenditure Survey 2016 data.

RESULTS

We found that disable people had relatively higher OOPE than their non-disabled counterparts and this OOPE further surges when the number of disabilities increases. In addition to the common factors, the novelty of our findings indicated that the religious minority problem as well as the coastal climate crisis have bearing on the disability burden in Bangladesh. The likelihood of having a chronic illness with a disability was 13.2% higher for the religious minorities compared to the majorities (Odds ratio (OR): 1.132, 95% confidence interval (CI): 1.033-1.241) and it was 21.6% higher for the people who lived in the exposed coast than those who lived in the non-exposed area (OR: 1.216, 95% CI: 1.107-1.335). With disabilities, people from the exposed coast incurred higher OOPE than those from the non-exposed areas. Although receiving assistance from social safety net programs (SSNPs) seemed to reduce their high OOPE and financial distress such as selling assets and being indebted, the distribution was not equitably and efficiently managed to confirm the process of inclusion leakage-free. On average, those who enrolled from the minority group and the exposed coast paid the relatively higher bribes.

CONCLUSIONS

To reduce burden, the government should strengthen and specify the existing SSNPs more for disable people, especially from the minority group and the exposed coast, and ensure the selection process more inclusive and leakage-free.

The long shadow of socioeconomic deprivation over the modern management of acute myeloid leukemia: time to unravel the challenges

Biological and non-biological variables unrelated to acute myeloid leukemia (AML) preclude standard therapy in many settings, with "real world" patients under-represented in clinical trials and prognostic models. Here, using a case-based format, we illustrate the impact that socioeconomic and anthropogeographical constraints can have on optimally managing AML in 4 different healthcare systems. The granular details provided, emphasize the need for the development and targeting of socioeconomic interventions that are commensurate with the changing landscape of AML therapeutics, in order to avoid worsening the disparity in outcomes between patients with biologically similar disease.

Measuring catastrophe in paying for healthcare: A comparative methodological approach by using National Sample Survey, India

Healthcare expenditure significantly varies among various segments of the population. The appropriate measures of catastrophic health expenditure (CHE) will help to unravel the real burden of spending among households. Present study provides a link between the theoretical insights from Grossman's model and various methodological approaches for the estimation of CHE by using data from the three rounds of nationally representative Consumer Expenditure Surveys, India. Statistical analysis has been carried out by using multivariate logistic regression to identify the major determinants of CHE. Findings indicate that the occurrence of CHE has increased during 1993-2012. Rural residents and households with varying age composition such as with higher numbers of children and elderly were at higher risk. Economic status is significantly associated with CHE and increased demand for healthcare. The measurements differ as per the methodological approaches of CHE and definition of household's capacity to pay. Approach-based variations in the results can be of key importance in determining trends and magnitude in CHE. Despite these variations in measurements, study finds a limited incidence of CHE among the disadvantaged segment of the population though a greater share was devoted to health expenditure in recent years. Better risk pooling mechanism is required to address the healthcare needs of the disadvantaged segment such as elderly, children, poor and rural population in India.

Impact of socio-economic inequity in access to maternal health benefits in India: Evidence from Janani Suraksha Yojana using NFHS data

BACKGROUND

Caste plays a significant role in Indian society and it influences women to health care access in the community. The implementation of the maternal health benefits scheme in India is biased due to caste identity. In this context, the paper investigates access to Janani Suraksha Yojana (JSY) among social groups to establish that caste still plays a pivotal role in Indian society. Also, this paper aims to quantify the discrimination against Scheduled Castes/Scheduled Tribes (SCs/STs) in accessing JSY.

METHODS

This paper uses a national-level data set of both NFHS-3 (2005-06) and NFHS-4 (2015-16). Both descriptive statistics and the Fairlie decomposition econometric model have been used to measure the explained and unexplained differences in access to JSY between SCs/STs and non-SCs/STs groups.

RESULTS

Overall, the total coverage of JSY in India is still, 36.4%. Further, it is found that 72% of access to JSY is explained by endowment variables. The remaining unexplained percentage (28%) indicates that there is caste discrimination (inequity associated social-discrimination) against SCs/STs in access to JSY. The highest difference (54%) between SCs/STs and non-SCs/STs in access to JSY comes from the wealth quintile, with the positive sign indicating that the gap between the two social groups is widening.

DISCUSSION AND CONCLUSION

It is necessary for the government to implement a better way to counter the caste-based discrimination in access to maternal health benefits scheme. In this regard, ASHA and Anganwadi workers must be trained to reduce the influence of dominant caste groups as well as they must be recruited from the same community to identify the right beneficiaries of JSY and in order to reduce inequity associated with social-discrimination.

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.

Cost of managing atonic postpartum haemorrhage with uterine balloon tamponade devices in public health settings of Maharashtra, India: an economic microcosting study

OBJECTIVE

Postpartum haemorrhage (PPH) is the worldwide leading cause of preventable maternal mortality. India offers free treatment for pregnancy and related complications in its public health facilities. Management with uterine balloon tamponade (UBT) is recommended for refractory atonic PPH cases. As part of health technology assessment to determine the most cost-effective UBT device, this study estimated costs of atonic PPH management with condom-UBT, Every Second Matters (ESM) UBT and Bakri balloon UBT in public health system of Maharashtra, India.

DESIGN

Health system cost was estimated using primary economic microcosting, data from Health Management Information System and published literature for event probabilities.

SETTINGS

Four public health facilities from the state of Maharashtra, India representing primary, secondary and tertiary level care were chosen for primary costing.

OUTCOME MEASURES

Unit, package and annual cost of atonic PPH management with three UBT devices were measured. This included cost of medical treatment, UBT intervention and PPH related surgeries undertaken in public health system of Maharashtra for year 2017-2018.

RESULTS

Medical management of atonic PPH cost the health system US$37 (95% CI 29 to 45) per case, increasing to US$44 (95% CI 36 to 53) with condom-UBT and surgical interventions for uncontrolled cases. Similar cost was estimated for ESM-UBT. Bakri-UBT reported a higher cost of US$59 (95% CI 46 to 73) per case. Overall annual cost of managing 27 915 atonic PPH cases with condom-UBT intervention in Maharashtra was US$1 226 610 (95% CI 870 250 to 1 581 596).

CONCLUSIONS

Atonic PPH management in public health facilities of Maharashtra with condom-UBT, ESM-UBT or Bakri-UBT accounts to 3.8%, 3.8% or 5.2% of the state's annual spending on reproductive and child health services. These findings can guide policy-makers to include PPH complication management in publicly financed health schemes. Economic evaluation studies can use this evidence to determine cost effectiveness of UBT in Indian settings.

Maternal Delivery at Home: Issues in India

INTRODUCTION

Maternal delivery at home without skilled care at birth is a major public health issue. The current study aimed to assess the various contributing and eliminating factors of maternal delivery at home in India. The reasons for not delivering at healthcare facilities were also explored.

METHODS

The study used the National Family Health Surveys (NFHS)-4 (2015-2016) data from states and union territories of India for analysis. A national representative sample of 699,686 women of reproductive age group (15-49 years) was used. Cross-tabulation and multivariate logistic regression analyses were performed.

RESULTS

The prevalence of home delivery in India was 22%, among which 34% of women believed that institutional delivery was not a necessity. Financial constraints, lack of proper transportation facilities, non-accessibility of healthcare institutions and not getting permission from family members were the main reasons cited by the women for delivering at home. The proportion of home deliveries was much higher among women from more disadvantaged socioeconomic areas than women from less disadvantaged socioeconomic areas. Domestic violence and partner control were essential factors contributing to the prevalence of home delivery. However, the women who owned mobile phones and used a short message service (SMS) facility delivered at home less often.

CONCLUSION

Policymakers should focus more on the women living in disadvantaged socioeconomic areas and other marginalised populations with less education and low economic levels to provide them with optimum delivery care utilisation. Strengthening of public healthcare facilities and more effective use of skilled birth attendents and their networking are essential steps. Electronic and economic empowerment of women should be emphasised to bring about a significant reduction in the proportion of home deliveries in India.