Ensuring financial protection (FP) against health expenditures is a key component of Sustainable Development Goal (SDG) 3.8, which aims to achieve Universal Health Coverage (UHC). While the proportion of households with catastrophic health expenditures exceeding a proportion of their total income or consumption has been adopted as the official SDG indicator, other approaches exist and it is unclear how useful the official indicator is in tracking progress toward the FP subtarget across countries and across time. This paper evaluates the usefulness of the official SDG indicator to measure FP using the RACER framework and discusses how alternative indicators may improve upon the limitations of the official SDG indicator for global monitoring purposes. We find that while all FP indicators have some disadvantages, the official SDG indicator has some properties that severely limit its usefulness for global monitoring purposes. We recommend more research to understand how alternative indicators may enhance global monitoring, as well as improvements to the quality and quantity of underlying data to construct FP indicators in order to improve efforts to monitor progress toward UHC.

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Introduction: Energy shortages are a common challenge in many low- and middle-income countries and can disrupt the operation of healthcare facilities, which can compromise patient outcomes and affect health service utilization. Maternal healthcare use, in particular, has been found to be negatively correlated with power outages in other contexts. The following study investigates the association between state-level energy shortages and institutional delivery rates in India and how the association varies according to women’s socio-economic status. Methods: Using data from the 1998-99 and 2005-06 India Demographic and Health Surveys, along with information on power outages from India’s Central Electricity Authority, we estimate the association between energy shortages and institutional delivery rates using both logistic and multinomial regressions. Results: Energy shortages were associated with reduced rates of institutional delivery: a 10% increase in the shortage level corresponded to a 1.1% decline in the percentage of women giving birth in a healthcare facility. Deliveries in public health facilities were more likely to be disrupted by energy shortages than deliveries in private facilities. Conclusion: Energy shortages are an important determinant of institutional delivery in India. Given that increasing institutional delivery rates is likely important to reduce maternal mortality, policymakers should work to mitigate the impact of energy disruptions on healthcare seeking behaviours.