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Utilisation of Health Facilities for Childbirth and Out-of-pocket Expenditure
Using data from the household surveys on health conducted by the National Sample Survey Office between 2004 and 2014, the utilisation patterns of health facilities for childbirth and the associated
out-of-pocket expenditure are analysed. The findings reveal that the utilisation of public facilities for childbirth increased three times in rural areas and almost one and a half times in urban areas between 2004 and 2014, but that most deliveries took place in district hospitals. Also, the average medical expenditure on childbirth in government health facilities declined by 36% in rural areas and by 5% in urban areas. Considerable interstate variations in regard to oop expenditure on drugs, diagnostics and transportation were also witnessed. Though government policies to promote institutional births have improved the utilisation of public facilities and reduced the overall oop expenditure, more needs to be done for the benefits to reach the vulnerable sections, especially in urban areas.
The first draft of the paper was completed when all the authors were at the National Health Systems Resource Centre. The authors are grateful to Roopali Goyanka (Delhi University), Bandana Sen (National Sample Survey Office) and Sanjiv Kumar (NHSRC) for providing their valuable inputs, and are thankful to the anonymous referee for the insightful comments on the paper.
India’s maternal mortality ratio (MMR) is a cause for concern as it constitutes 15% of the total global maternal deaths. The MMR was 280 per 1,00,000 live births in 2005 and it came down to 174 per 1,00,000 live births in 2015 (WHO et al 2015). Despite this reduction in maternal deaths, the country still lags behind the target of reducing the MMR to 140 per 1,00,000 live births as set out in the Millennium Development Goals (Kumar et al 2016). Several factors contribute to maternal deaths; important factors include the lack of skilled attendance during birth, poor access to services, low levels of utilisation of health facilities, lack of transport facilities and, above all, the inability of poor households to spend money out of their pockets on childbirth in health facilities.
Recognising the magnitude of the issue, the central government in 2005 launched the Janani Suraksha Yojana (JSY), a conditional cash transfer programme that provides cash incentives to poor pregnant women, who give birth in public health facilities and government-accredited private health facilities. Accordingly, pregnant women in rural areas receive ₹ 1,400 and those in urban areas receive ₹ 1,000 for institutional deliveries in low-performing states (National Health Portal nd).1 In the high-performing states, ₹ 700 is provided as cash incentive in rural areas and ₹ 600 in urban areas for institutional deliveries (National Health Portal nd). These amounts vary across states as many of them have implemented their own financing schemes, such as Mamata in Odisha, Sambhav Voucher Scheme in Uttar Pradesh (UP), etc, to provide free medical care for pregnant women and encourage institutional deliveries. Accredited social health activists (ASHAs) linked to these facilities are also provided cash incentives to create the link between pregnant women and health facilities, and, in turn, generate demand for maternal health services and institutional deliveries at the community level.
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