Benefit Incidence Analysis of Institutional Child Delivery in India, 2004–2014: Improving Equity Through the National Health Mission?

Abstract

BackgroundThe National Health Mission (NHM) aims to improve maternal and child health by community mobilisation, increased health workforce and structural strengthening of health infrastructure, especially in high-focus Empowered Action Group (EAG) and North East (NE) states. NHM focuses on the continuum of care approach, particularly by increasing institutional deliveries. Increasing fund allocation from central and state governments has operationalised NHM interventions. Little is known about the utilisation, equity and distribution of benefits of public sector deliveries. This study presents a benefit incidence analysis of childbirth subsidies in EAG, NE and other Indian states, before and after NHM implementation.MethodsBenefit incidence analysis of childbirth in public hospitals was estimated using nationally representative data collected by the National Sample Survey Organization from 73,868 (2004) and 65,932 (2014) households. Information on childbirth by public and private facilities was used to estimate childbirth utilisation rates, net subsidy of public utilisation (private minus public prices) and benefit incidence. Net benefit was estimated by mean public and private-sector childbirth expenditures disaggregated by region, economic quartile and rural/urban residence. Benefit incidence was estimated for household expenditure quintiles for EAG, NE, and other states, separately for 2004 and 2014.ResultsIn 2004, 76% of total deliveries in EAG, 61% in NE and 32% in other states occurred at home. In the same year, 11% of all deliveries in EAG, 21% in NE and 33% in other states were attended in public facilities. In 2014, public institutional deliveries (as a share of total deliveries) increased to 56% in EAG, 74% in NE and 47% in other states. Mean out-of-pocket spending on childbirth in public facilities declined from INR 1163 in 2004 to INR 815 in 2014 (at a constant 2004 prices). In 2004, childbirth utilisation rates were highest in the third and the fourth economic quintiles in NE, the first and the second economic quintiles in EAG, and the second and the third economic quintiles in other states. In 2014, highest public facility utilisation rates were in the first economic quintile in all states. In NE states, there was a 78% increase in utilisation in the first quintile and 47% increase in the second quintile. In EAG states, highest increase in utilisation was in the middle quintile. In all other states, there was 61% increase in the first quintile utilisation rates. For the poorest (the first and the second) quintiles, the share of benefit incidence increased from 16% to 47% in NE, 31% to 47% in EAG, and 16% to 60% in other states, between 2004 and 2014. Nationally, this increased from 20% to 53%. In NE states, the majority share of benefit incidence was by the fourth quintile in 2004 (34%), which reduced to 17% with the highest share by the lowest quintile (28%) in 2014. In EAG states, the lowest quintile share of benefit incidence increased from 13% to 27% while the share of the second lowest quintile...

Benefit incidence analysis in public health facilities in India: utilization and benefits at the national and state levels

“…With regard to the resuls shown above, it is interesting to note that utilization, with respect to delivery services, is the most pro-poor. One plausible cause of this trend could be some of the initiatives under the National Health Mission (NHM), which have reduced maternal and child health expenditures [6]. One such initiative is Janani Suraksha Yojana (JSY), implemented in 2005 to decrease disparities in access to institutional deliveries.…”

“…Deliveries refer to child births which may be home deliveries or at primary or seconday facilities. Deliveries were separated at the national level due the prioritization of policy attempting to reduce maternal mortality through incentivizing facility-based delivery in India [2, 6].…”

“…Due to this property, BIA has been used in a number of developing settings including Nigeria, Vietnam, Pakistan and Jordan to provide quantitative evidence of how health care services, as well as their accompanying costs, are allocated to different members of the population based on their socioeconomic status [3–8]. BIA has also been applied at the sub-national level in India to address specific questions of equity relating to public health or child delivery care utilization [6, 9].…”

Equity in distribution of public subsidy for noncommunicable diseases among the elderly in India: an application of benefit incidence analysis

“…NSS also reports usual3 monthly expenditure of the households. Following Cain et.al., (2010) and Srivastava et.al., (2016) [27, 28], the Organization for Economic Co-operation and Development (OECD) equivalence scale has been applied to construct the monthly per capita expenditure (MPCE) class from the household expenditure [27]. Specifically, we have divided the total monthly expenditure of a household (T) by the square-root of the household size (N) to get the MPCE4 (= T/√N).…”

Caesarean sections in the in the context of the Chiranjeevi Yojana public private partnership program to promote institutional birth in Gujarat, India; does the embedded disincentive for caesarean section work?

“…Over the last 20 years, India has experienced a significant rise in institutional childbirth [8] which has also increased CS rates from two % in 1995 [6] to 19.3% in 2010 [7]. This phenomenon has been driven by increasing CS rates largely among the wealthiest part of the population, [6] who live mainly in urban settings.…”