Understanding equity of institutional delivery in public health centre by level of care in India: An assessment using Benefit Incidence Analysis

Abstract

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 in India has improved the health care utilization and health outcomes across states and socio-economic groups, 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 five 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. 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.

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

“…This could be because the user fee removal policy in Zambia is only applicable at lower levels of the public healthcare delivery system. In line with a study from India [51] and Zambia [19]; our findings indicate that health spending for both curative services and institutional deliveries at public health centres and mission health facilities, which operate at a lower level of healthcare and mostly in rural areas, tended to become more pro-poor over time likely due to the user fee removal policy. It should be emphasised that we observe a greater effect in increased equity in health facilities mostly located in rural (e.g.…”

Universal health coverage and the poor: To what extent are health financing policies making a difference? Evidence from a Benefit Incidence Analysis in Zambia

“…This could be because the user fee removal policy in Zambia is only applicable at lower levels of the public healthcare delivery system. In line with a study from India [47] and Zambia [12]; our ndings indicate that health spending for both curative services and institutional deliveries at public health centres and mission health facilities, which operate at a lower level of healthcare and mostly in rural areas, tended to be more propoor following the user fee removal policy. The performance-based nancing scheme, which was implemented between 2012 and 2014 at public health centres in some districts with a focus on maternal and child services-could have also contributed to greater equality of health bene ts at the lower level of healthcare provision [19,25].…”

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

“…Safe delivery care (Institutional delivery/delivery by skilled health attendant [SBA]) is an important component of the continuum of maternal healthcare that averts preventable maternal and neonatal deaths with adequate health-seeking and good quality of care [ 11 ]. Although India’s achievements toward utilization of institutional delivery services have been substantial over the years (increased from 41% in 2005–06 to 79% in 2015–16) with large-scale public health investments, studies suggest that usage of facility-based skilled delivery care is uneven across states, socio-economic strata, and rural-urban residence [ 5 , 6 , 12–15 ]. A large amount of expenditure incurred at the point of healthcare use through high out-of-pocket payments (OOPs) and associated catastrophic health expenditure (CAH) (increased from 11% in 1995 to 25% in 2014) hinder beneficiaries (especially from marginalized communities) from delivering at health facilities and forcing them to uptake unsafe home deliveries [ 6 , 16 , 17 ].…”

“…Although India’s achievements toward utilization of institutional delivery services have been substantial over the years (increased from 41% in 2005–06 to 79% in 2015–16) with large-scale public health investments, studies suggest that usage of facility-based skilled delivery care is uneven across states, socio-economic strata, and rural-urban residence [ 5 , 6 , 12–15 ]. A large amount of expenditure incurred at the point of healthcare use through high out-of-pocket payments (OOPs) and associated catastrophic health expenditure (CAH) (increased from 11% in 1995 to 25% in 2014) hinder beneficiaries (especially from marginalized communities) from delivering at health facilities and forcing them to uptake unsafe home deliveries [ 6 , 16 , 17 ]. Place of delivery has been observed to be significantly associated with maternal and child health outcomes where home deliveries (in absence of SBA) increase the likelihood of delivery complications with adverse maternal and perinatal outcomes [ 18–20 ].…”