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 has improved the health care utilization and health outcomes across states and socio-economic groups in India, 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 5 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. However, 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.…”

Gestión del presupuesto público para la salud materna infantil: Una revisión sistemática

“…Por otro lado, Mohanty et al(2020) examinaron el patrón de utilización y el beneficio neto del subsidio público para el parto institucional por nivel de atención en la India. Encontrando que la entrega institucional de los centros de salud pública en la India es favorable a los pobres y tiene un fuerte gradiente económico.…”

Are institutional deliveries equitable in the southern states of India? A benefit incidence analysis

“…India is still spending the lower proportion of GDP on health, despite a rising trend of public health investment, than the south-east Asian countries, like Thailand and Indonesia, whose proportion of GDP is spent on public health is 3.8% and 2.9%, respectively in 2019 [ 4 ]. This relatively low spend is directly related to large and growing levels of catastrophic health expenditure (CHE) and financial hardship in India [ 5 ].…”