Inequity in costs of seeking sexual and reproductive health services in India and Kenya

Abstract

ObjectiveThis study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending.MethodsData for this study were collected as a part of the situational analysis for the “Diagonal Interventions to Fast Forward Enhanced Reproductive Health” (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income.ResultsThe results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03–7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were “receiving [money] from partner or household members” (69 %) and “using own savings or regular income” (44 %), respectively.ConclusionHighly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.

Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya

“…This measure of equity in expenditure assumes that individuals in the lowest wealth quintile have less capacity to pay and thus if they spend the same or more as those in the highest quintile, this represents a greater proportion of income and constitutes regressive spending 24. Quintile ratios were calculated by comparing mean expenditure in the wealthiest and poorest wealth quintiles and testing for differences using an adjusted Wald-type test of non-linear hypotheses based on the delta method, attributing significance at a 95% confidence level 4 24 25. We define expenditure as weakly pro-rich if there was no significant difference in mean payment between the poorest and wealthiest users and strongly pro-rich if the poorest users paid significantly more than the wealthiest users (quintile ratio <1) 4 24…”

“…In Kenya, unmet need for FP is highest among the poor, with a documented 8–14 percentage point increase in modern contraception use with each increase in household wealth quintile 3. A study in Kenya and India found that poor households spend a significantly higher proportion of their income on reproductive healthcare (including FP), with the poorest households in Kenya spending 10 times the proportion spent by the least poor 4. Many government financial protection policies focus on inpatient events where healthcare expenditure is likely to be catastrophic, yet the greater frequency of outpatient expenses—including for contraceptive services, which affect women in particular—can also push households into poverty5 or reduce care-seeking among the poor 3 6…”

Minding the gaps: health financing, universal health coverage and gender

“…A study covering Mombasa in Kenya and Mysore in India (2012–13) confirms the highly regressive nature of spending on sexual and reproductive health services. The poorest households spent 2 times as much and 10 times as much as the least poor in India and Kenya, respectively ( Haghparast-Bidgoli et al 2015 ).…”

Financial burden of survivors of medically-managed myocardial infarction and its association with selected social determinants and quality of life in a lower middle income country

“…This is an era that the whole world is concerned about the equity issues in relation to health financing. Different income inequality measures are available in the literature such as; Gini coefficient, Atkinson index, generalized-entrophy index, Kakwani index [ 44 – 46 ]. It is timely that lower-middle-income countries like Sri Lanka encourage more scientific literature on these regards.…”