|Year : 2017 | Volume
| Issue : 2 | Page : 67-73
Out-of-Pocket health expenditure and sources of financing for delivery, postpartum, and neonatal health in urban slums of Bhubaneswar, Odisha, India
Kirti Sundar Sahu1, Bhavna Bharati2
1 Teaching Assistant, Indian Institute of Public Health Bhubaneswar (PHFI), Bhubaneswar, Odisha, India
2 Project Officer (Planning and Quality Assurance) Directorate of Health and Family Welfare, Bhubaneswar, Odisha, India
|Date of Web Publication||2-Jun-2017|
Kirti Sundar Sahu
Plot No. 2132 A/6, Nageswar Tangi, Old Town, Bhubaneswar - 751 002, Odisha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Out-of-pocket expenditure (OOPE) is an obstacle in the path of getting universal health coverage in India. Objective: This study aimed to explore the OOPE, sources of funding, and experience of catastrophic expenditure (CE) for healthcare related to delivery, postpartum, and neonatal morbidity. Methods: A community-based, cross-sectional survey was conducted among a sample of 240 recently delivered women from the slums of Bhubaneswar, Odisha. Information on background, details of delivery, expenditure on delivery and on morbidities, and sources of funding was collected using a structured interview schedule. Results: Only 29.6% of the households incurred OOPE, and the others incurred either nil OOPE or had a net income because of benefits received from Janani Shishu Suraksha Karyakram (JSSK), Janani Suraksha Yojana (JSY), and “Mamata” schemes of the government. The median total OOPE was found to be 2100 INR (100–38,620). Multivariate analysis found parity, place of delivery, type of delivery, and presence of morbidity to be significantly associated with incurring any OOPE. Nearly 15% of the households incurred OOPE exceeding 40% of the reported monthly household income including 9%, whose OOPE was 100% or more of the reported household monthly income. Conclusion: While mechanisms such as JSSK, JSY, and Mamata had benefitted the vast majority, around half of those who did incur OOPE experienced CE. Additional insurance facility for cesarean section delivery might reduce the excessive financial burden on households.
Keywords: Catastrophic expenditure, distress financing, healthcare financing
|How to cite this article:|
Sahu KS, Bharati B. Out-of-Pocket health expenditure and sources of financing for delivery, postpartum, and neonatal health in urban slums of Bhubaneswar, Odisha, India. Indian J Public Health 2017;61:67-73
|How to cite this URL:|
Sahu KS, Bharati B. Out-of-Pocket health expenditure and sources of financing for delivery, postpartum, and neonatal health in urban slums of Bhubaneswar, Odisha, India. Indian J Public Health [serial online] 2017 [cited 2019 Dec 9];61:67-73. Available from: http://www.ijph.in/text.asp?2017/61/2/67/207402
| Introduction|| |
Universal health care is now a global goal that countries seek to achieve. However, significant sections of the population incur large out-of-pocket expenditure (OOPE) for health services due to limited public funding, high cost of hospitalization, cost of drugs, lack of insurance, and dominance of private health service providers. Formal and informal fees act as barriers in accessing healthcare services for maternal health., Education in OOP is essential to move toward universal coverage and financial protection and to facilitate achievement of the Fifth Millennium Development Goal., Various schemes have been introduced such as Janani Suraksha Yojana (JSY) in 2005 and Janani Shishu Suraksha Karyakram (JSSK) in 2011 to provide financial coverage not only to the pregnant woman but also to neonate and eliminate or reduce OOPE. Odisha is one of the eight low-performing states of India in terms of health and stands far behind the national picture in terms of availability of health infrastructure. The burden of OOPE is high all through Odisha's health sector, which is also true for maternal health, specifically for child delivery. Within Odisha, JSY  was launched in 2006 and JSSK  was launched in 2011. Odisha state government also has implemented initiatives such as “Free medicine distribution scheme” in 2013 and the conditional cash transfer scheme “Mamata” in 2011 for the reduction of OOPE in maternal healthcare and to improve nutritional status. It provides monetary support from the antenatal period to 9 months postdelivery in a step-wise manner. The beneficiary receives a total incentive of INR 5000 in four installments subject to the fulfillment of specific conditions. There appear to be a few studies available estimating OOP health expenditure for delivery, postpartum, and neonatal health in Bhubaneswar or even Odisha either through primary data or using secondary data. Eligibility for receiving cash assistance in JSY is all pregnant women delivering in all the government health facilities or accredited private institutions for Odisha; after coming to the institution, all types of services are provided free of cost as per the JSSK. Similarly, all pregnant women of 19 years and above for the first two live births, except government employee, are covered for Mamata. The JSY is completing its 9th year, JSSK and Mamata their 3rd year, and it was relevant at this juncture to study the extent to which these schemes helped reduce OOP health expenditure and eliminate catastrophic health expenditure of the urban poor community in the slums of Bhubaneswar.
The present study aimed to examine the extent of OOPE for maternal and neonatal health services in one of the low-income population groups within Odisha, namely, the urban slum dwellers of Bhubaneswar. The objectives of the study were to document the average OOP health expenditure for delivery, postpartum, and neonatal healthcare services in the urban slums of Bhubaneswar; to examine the sources of funds to meet the OOP health expenditure; to compare the difference in OOPE between private and public health sector; and to find out the extent of financial burden experienced by households as a result of OOPE in delivery, postpartum, and neonatal healthcare services.
| Materials And Methods|| |
This was a community-based, cross-sectional study among recently delivered women from the urban slums of Bhubaneswar Odisha. As per the Bhubaneswar Municipality Corporation, currently, there are 436 slums in Bhubaneswar with more than 3 lakh population in 80,000 households approximately. Sampling frame of the study was created by listing all pregnant women who have registered with the record of the Department of Women and Child Development from all slums of Bhubaneswar having expected date of delivery within the time period from May 2014 to July 2014. Participants were selected through simple random sampling using without replacement from the sampling frame. From the list of 616 eligible mothers, 250 participants (approximately 40%) were selected as per the feasibility in terms of time and resource. Inclusion criteria for the study were all women in the age group 18–49 years, who had delivered within a period of 6 weeks before the date of interview, should be present at the study area during data collection time period, and should be willing to participate in the study.
Ethical clearance was obtained from the Institutional Ethics Committee (SCT/IEC/604/JUNE-2014) of SCTIMST data collection was done within June 2014 to August 2014 by the primary investigator at the residence of the study participants after obtaining written informed consent from each respondent. Respondents were either the recently delivered woman or her spouse or any other family members who have the detailed information about the expenditure. Care was taken to ensure the privacy and confidentiality of the participants and their households. Special care has been taken during data collection in case of any emotional trauma due to any abnormal outcome of the health event like still birth. A structured interview schedule was prepared in Odia for the data collection. Data entry was performed by Epi-data version 3.1 software and analysis was performed by “R” version 3.1.1 using the package “Epicalc.”
Outcome and predictor variables
The outcome variables were healthcare expenditure which was calculated for a total period of 6 weeks following childbirth. This information was self-reported by the respondents and validity of the information has been cross-checked with ASHA and Anganwadi workers.
Medical expenditure for delivery or morbidity was the combination of various important subcomponents such as payment for hospital staying, laboratory investigations, drugs and medicines, payment for cesarean section, and any expenditure for blood and other related things. Nonmedical expenditure included payments for transportation either for mother, baby, or any attendants, food for mother and attendants, and informal payments such as bribe or under the table payments. Total expenditure for delivery has been calculated by adding all the medical and nonmedical expenses for the delivery. Total expenditure for morbidity for mother and neonate has been calculated adding all medical and nonmedical expenditures.
OOPE is the expenditure after deducting the payments received from different government schemes. This has been divided into two steps as the “Mamata” scheme is distributed for 1 year with four installments. In the first step till the time of survey, OOPE has been calculated, and in the second step, the final OOPE assuming all installments has been received from schemes not including bribe or under the table payments if any paid to receive the benefits from “Mamata” scheme. Interest rate of 10% per month has been added as observed from the respondents during the data collection if the respondents have borrowed money for the event.
In this study, catastrophic expenditure (CE) is calculated using reported monthly household income as the denominator. CE occurs if total OOPE/reported monthly household income ≥ 0.4 whereas severe CE occurs if total OOPE/reported monthly household income ≥1, where total OOPE was OOPE for delivery and all morbidity after all reimbursement and interest incurred due to borrowing.
In predictor variables, three categories of variables were used in this study. Individual and household characteristics can influence the expenditures in a household; the third set of variables includes different parameters of delivery. All predictor variables were self-reported.
| Results|| |
The survey was completed by 240 women who had recently delivered. Of the 240 mothers, 10 had availed further healthcare services for various postpartum morbidities, and of 235 neonates, 82 had experienced morbidities and availed healthcare services. [Table 1] describes background information of the household, individual, and details of delivery.
|Table 1: Background information of the study participants and details of delivery (n=240)|
Click here to view
Median expenditure for the delivery was around 1100 INR whereas the difference between the private and public healthcare institutions differed by more than 12 times. Similarly, irrespective of place of delivery, it is the caesarean section where the median expenditure was significantly higher than the expenditure for normal delivery by 5 times or more. In case of morbidity, the expenditure was more for maternal and whenever there was need of hospitalization. [Table 2] describes the details of expenditure. It is to be noted that within private healthcare facilities, no one has received any financial benefit from government.
|Table 2: Expenditure details for delivery and morbidity of the study participants|
Click here to view
Sources of funding
The money spent for the delivery and morbidity was from three major sources: government schemes, savings, and borrowing money from others with or without interest. There are two different schemes, JSY and Mamata, through which direct cash transfer occurs to households to compensate for wage loss and expenses related to delivery. More than 77% of the households benefitted from JSY, 70% of the households from Mamata scheme, 8.8% of the households did not receive benefit from either scheme, whereas 56% of the households received benefit from both the schemes. The sources were only saving 84.1%, only borrowing 4.1%, and both 11.6%.
[Table 3] describes OOPE for the delivery after deduction of monetary benefit from the government schemes. Median OOPE for delivery and morbidity was INR 1760 after delivery and increased to INR 2100 after a period of 9 months as the respondents were incurring interest for the money borrowed.
|Table 3: Calculation of out of pocket expenditures for delivery, maternal and neonatal morbidity at different levels of compensations from government|
Click here to view
Multivariate analysis found that parity, type of delivery, place of delivery, and presence of morbidity were significantly associated with OOPE after adjustment of other variables. [Table 4] describes the association in details.
|Table 4: Factors associated with presence or absence of out-of-pocket expenditure for delivery and neonatal and maternal morbidities|
Click here to view
The respondents who were spending more than 40% of their reported monthly household expenditure were said to have CE which comes around more than 15% and who were spending more than 100% of their monthly income were in severe CE which comes around 9%.
The odds of experiencing positive OOP was more than 7.8 for cesarean section in comparison to normal delivery whereas odds for getting OOP due to delivery in private healthcare facility was around 13 in comparison to public healthcare facility. Similarly, morbidity either to baby or mother also leads to OOP significantly (odds ratio 3.585).
| Discussion|| |
Previous studies on OOPE for maternal and neonatal healthcare have used either secondary data ,, or primary data ,,, at the national or local level. The present study sought to find the extent of OOPE incurred and its financial consequences for a low-income population in Bhubaneswar city, Odisha.
From the study, it was found that JSSK, which targets to reduce OOP to nil, is not fully successful to date. It is because of other conditional cash transfer schemes that OOPE and CE owing to OOPE reduced considerably. Had the JSY or Mamata not been in place the situation would have been worse.
All the households incurred some amount of OOPE at the place of service delivery which was reduced to 43.7% of the households with a median expenditure of 1760 INR after payments by government schemes within a short span of time after delivery. Even after getting direct monetary benefit from all schemes, more than 25% of the households incurred OOPE with a median amount of 2100 INR. Within this situation, it is the private healthcare facilities where people spend median expenditure of 12,600 INR which is around 12 times more than public healthcare facilities. The gap between public and private healthcare facilities was mainly due to more payment for hospital stay, medicines, fee for surgery within the medical expenditure, whereas it is the transportation and food expenditure contributing for the high OOPE. It is highest for those who have delivered the child in private healthcare facilities and who have delivered through cesarean section procedure.
Within the time span of 10 years (2004–2014), the pattern of expenditure shows median expenditure for delivery in India was 1634 INR. Delivery expenditure for India was 25 USD (~1200 INR) for public healthcare facilities whereas 105 USD (~5000 INR) in private facilities. As per the DLHS3 2007–2008 data, median OOPE for delivery in India was 1624 INR in public facilities as opposed to 4458 INR in private facilities for normal delivery. Similarly, for cesarean section, the median expenditure was 5934 INR in public facilities and 14,276 INR in private facilities. Delhi study in 2008–2009 had shown that the mean expenditure for delivery was 12,400 INR with public 3000 INR and private 52,000 INR. Gupta studied the expenditure for delivery in five states of India in 2010 and had shown that the mean expenditure was 2166 INR and for public healthcare facilities was 1800 INR and for private healthcare facilities was 8673 INR whereas home delivery was the cheapest with expenditure of 695 INR. The study in Mumbai slum in 2010 showed that the median expenditure for delivery was 3200 INR (0–75,000 INR).
Similarly, at state level for Odisha in 2004, the median expenditure for delivery was 3112 INR that is much more than national level, highest OOP among all states in India. Expenditure for delivering in public healthcare facilities was 873 INR and private was 5634 INR. After implementation of JSY in 2007–2008 for a normal delivery in Odisha, median expenditure was 500 INR with interquartile range 0–1650 INR. Expenditure for normal delivery was 1700 INR in public facilities and 3300 INR in private facilities. For cesarean section delivery in Odisha, the median expenditure was 3300 INR in public facilities and 10,020 INR in private facilities.
The present study shows that after implementation of JSY, JSSK schemes OOPE are not zero. Considering that the OOPE in our study includes postpartum and neonatal morbidity, its extent appears to be lower or comparable to the above studies [Figure 1].
|Figure 1: Distribution of expenditures for the delivery by site of delivery and mode of delivery.|
Click here to view
For CE, out of 240 households, 75 (31.2%) of the households would have faced CE by incurring OOPE of 40% or more of monthly household income, in the absence of any government support scheme. This proportion was reduced to 15% because of the JSY and Mamata schemes. Out of all households, 23 (9.6%) households would have been in severe CE (incurring OOPE of 100% or more of the total monthly household income) in the absence of any scheme, and this was reduced to 9% of the household after all monetary benefits [Figure 2]. In other words, for those who spent very large sums, the schemes did not help mitigate their CE. A study in Odisha in 2012 for healthcare expenditure had shown 25% of the households face hardship in financing for all types of health problems. Here, in our study, it is much less as the expenditure is subsidized by many government schemes. The prevalence of CE is similar to studies from other states and has reduced after JSY. For sources of funding, it is the JSY, 77% of the households got benefited by an amount of 1000 INR in contrast to 40% households in the year 2010 while for “Mamata” which is a state government run scheme 70% of the households got benefited by 5000 INR, respectively. Besides, there were savings of the households, which was the main source of funding, and secondarily 16% of the households borrowed to cope with the current expenditure which was much less than the proportion of 65% in the year 2007–2008 from the study where all Empowered Action Group states of India participated. Economic condition of the slums in Bhubaneswar is not good; hence, there is need for efficient poverty alleviation programs which will indirectly help reduce the health-related CE.
Limitations and strengths of the study
There may be some unregistered pregnancies. The study cannot be generalized for whole city or for all types of socioeconomic status, but it may be representative of the lower socioeconomic groups from different cities of India having similar characteristics of the city Bhubaneswar. Due to recall bias for information associated with expenditure, the values are nearly rounded, so the exact amount could not be traced. The study did not analyze the relationship between the OOPE and factors responsible with adjusting with the socioeconomic status. The data collection was done by a single investigator, so inter-investigator biases were eliminated. This study done in Bhubaneswar slums for OOPE 3 years after launching of Mamata scheme and 5 years after launching of JSY scheme may indirectly contribute to assessing the impact of those schemes. The information collected from the respondents was cross-checked by the ASHAs, so the validity of the data has increased. As the benefits of JSSK are within the hospital merged with regular services, subjects are not able to say what benefits they got exactly and the costs of it; hence, JSSK benefits not taken into account.
| Conclusion|| |
Around 9% of households spend more than their entire reported monthly household income due to OOPE for delivery, postpartum, and neonatal healthcare expenditure despite central and state government initiated cash transfer schemes. Without the government schemes, 31.2% of the households would have spent more than 40% and 9.6% of the households would have spent more than 100% of reported monthly household income. Thus, the government schemes such as JSY, JSSK, and Mamata have been a boon to many (more than half) low-income households who are now able to have an institutional delivery without any OOPE. At the same time, many of those who do incur OOPE have to face severe CE spending 100%–500% of their monthly household income.
Foremost, I would like to thank my guide Dr. T. K. Sundari Ravindran, Professor, AMCHSS, for her supervision, advice, and guidance which kept me steering throughout the course of the dissertation from its conception to completion. I would like to thank all the faculties at AMCHSS for providing their valuable suggestions to improve the study. I am thankful for all the study subjects, ASHAs, AWWs participated in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Anderson I, Axelson H, Tan BK. The other crisis: The economics and financing of maternal, newborn and child health in Asia. Health Policy Plan 2011;26:288-97.
Sharma S, Smith S, Sonneveldt E, Pine M, Dayarantna V, Sanders R. Formal and informal fees for maternal health care services in five countries: Policies, practices, and perspectives. POLICY Project Washington DC: POLICY Working Paper Series No. 16. 2005.
World Health Organization. Health Financing Strategy for the Asia Pacific Region (2010-2015). Manila, Philippines: World Health Organization, South-East Asia Region and Western Pacific Region; 2009. p. 43.
Ahmed S, Khan MM. Is demand-side financing equity enhancing? Lessons from a maternal health voucher scheme in Bangladesh. Soc Sci Med 2011;72:1704-10.
Rao MG, Choudhury M. Health care financing reforms in India. Working paper no. 2012-100. National Institute of Public Finance and Policy, 2012.
R Core Team. R: A Language and Environment for Statistical Computing. Vienna Austria; 2014. Available from: http://www.R-project.org/
. [Last accessed on 2014 Sep 20].
Mohanty SK, Srivastava A. Out-of-pocket expenditure on institutional delivery in India. Health Policy Plan 2013;28:247-62.
Modugu HR, Kumar M, Kumar A, Millett C. State and socio-demographic group variation in out-of-pocket expenditure, borrowings and Janani Suraksha Yojana (JSY) programme use for birth deliveries in India. BMC Public Health 2012;12:1048.
Ved R, Sundararaman T, Gupta G, Rana G. Program evaluation of the Janani Suraksha Yojna. BMC Proc 2012;6 Suppl 5:O15.
Skordis-Worrall J, Pace N, Bapat U, Das S, More NS, Joshi W, et al
. Maternal and neonatal health expenditure in Mumbai slums (India): A cross sectional study. BMC Public Health 2011;11:150.
Dhar RS, Nagpal J, Sinha S, Bhargava VL, Sachdeva A, Bhartia A. Direct cost of maternity-care services in South Delhi: A community survey. J Health Popul Nutr 2009;27:368-78.
Das S, Bapat U, More NS, Chordhekar L, Joshi W, Osrin D. Prospective study of determinants and costs of home births in Mumbai slums. BMC Pregnancy Childbirth 2010;10:38.
Ajay VS. Expenditure Pattern, Perceived Quality and Financing Sources for Pregnancy and Delivery Services in Rural Thiruvananthapuram, Kerala. SCTIMST, Kerala; 2002.
Leone T, James KS, Padmadas SS. The burden of maternal health care expenditure in India: Multilevel analysis of national data. Matern Child Health J 2013;17:1622-30.
Bonu S, Bhushan I, Rani M, Anderson I. Incidence and correlates of 'catastrophic' maternal health care expenditure in India. Health Policy Plan 2009;24:445-56.
Gupta N. Out of pocket expenditure in health care; result of study in five states of India. Rajasthan: Prayas; 2011.
Berer M. Maternal mortality or women's health: Time for action. Reprod Health Matters 2012;20:5-10.
Mukherjee S. Maternity or catastrophe: A study of household expenditure on maternal health care in India. Health (N
Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: An impact evaluation. Lancet 2010;375:2009-23.
Das PS, Meher KC, Noida G. A Critical Analysis of Economic Activities of Slum Dwellers: A Study of Khurda District, Odisha. Available from: http://www.theijm.com/vol1issue2/The%20IJM%204.pdf
. [Last accessed on 2014 Sep 20; Last cited on 2014 Oct 19].
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]