Skip to main content

The Burden of Maternal Health Care Expenditure in India: Multilevel Analysis of National Data

Maternal and Child Health Journal volume 17, pages 1622–1630 (2013)Cite this article

Abstract

To quantify the economic burden of maternal health care services on Indian households and examine the levels of expenditure incurred in public and private health care institutions at the national, state and community levels. Cross-sectional population data from the 2004 National Sample Survey Organisation were used, which considered 9,643 households for the analysis where at least one woman received maternal health care services during the year preceding the survey. Multilevel linear regression techniques were used to estimate the effect of household, cluster and state characteristics on the proportion of maternal health care expenditures over total household expenditures. Over 80 % of households reported paying for maternal health care services, with those using private care facilities paying almost 4 times more than those using public facilities. Multilevel analyses show evidence of high burden of maternal health care expenditures, which varied significantly across states according to the level of health care utilisation, and with considerable heterogeneity at the household and community levels. Maternal health care services in India are offered free at the point of delivery, yet many families face significant out-of-pocket expenditures. The recent governmental policy interventions to encourage institutional births by providing nominal financial assistance is a welcome step but this might not help to compensate mothers for other indirect expenditures, especially those living in rural areas and poorer communities who are increasingly seeking care in private facilities.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

  1. Mavalankar, D., Voraa, K., & Prakasamma, M. (2008). Achieving millennium development goal 5: Is India serious? Bulletin of World Health Organisation, 86(4), 243–244.

    Article  Google Scholar 

  2. Srinivasan, K., Shekar, C., & Arokiasamy, P. (2007). Reviewing reproductive and child health programmes in India. Economic and Political Weekly, 42(27–28), 2931–2939.

    Google Scholar 

  3. Goldie, S. J., Sweet, S., Carvalho, N., Natchu, U. C. M., & Hu, D. (2010). Alternative strategies to reduce maternal mortality in India: A cost-effectiveness analysis. PLoS Medicine, 7(4), e1000264. doi:10.1371/journal.pmed.1000264.

    Article  PubMed  Google Scholar 

  4. Rai, S. K., Dasgupta, R., Das, M. K., Singh, S., Devi, R., & Arora, N. K. (2011). Determinants of utilization of services under MMJSSA scheme in Jharkhand ‘client perspective’: A qualitative study in a low performing state of India. Indian Journal of Public Health, 55(4), 252–259.

    Article  PubMed  Google Scholar 

  5. WHO (2005). The WHO report: Make every mother and child count. WHO, Editor. Geneva: WHO.

  6. Registrar General of India (2011). Maternal mortality in India and states from special survey of deaths, registrar general of India, New Delhi (http://nrhm-mis.nic.in/).

  7. International Institute for Population Sciences and Macro International. (2007). National Family Health Survey (NFHS-3), 2005–06: India. Mumbai: IIPS.

    Google Scholar 

  8. Pathak, P. K., Singh, A., & Subramanian, S. V. (2010). Economic inequalities in maternal health care: Prenatal care and skilled birth attendance in India, 1992–2006. PLoS ONE, 5(10), e13593. doi:10.1371/journal.pone.0013593.

    Article  PubMed  Google Scholar 

  9. Sharma, S., Smith, S., Sonnavelett, E., Pine, M., Dayaratna, V., & Sanders, R. (2005). Formal and informal fees for maternal health care services in five countries: Policies, practices and perspectives. Policy working paper series No. 16, USAID. (http://www.policyproject.com/pubs/workingpapers/WPS16.pdf).

  10. Skordis-Worrall, J., Pace, N., Bapat, U., Das, S., More, N. S., Joshi, W., et al. (2011). Maternal and neonatal health expenditure in Mumbai slums (India): A cross sectional study. BMC Public Health, 11, 150. doi:10.1186/1471-2458-11-150.

    Article  PubMed  Google Scholar 

  11. Ministry of Health and Family Welfare. (2009). National Health Accounts India 2004–05. (With Provisional Estimates from 2005–06 to 2008–09), National Health Accounts Cell, Government of India, (http://planningcommission.nic.in/reports/genrep/health/National_Health_Account_04_05.pdf).

  12. Bonu, S., Bhushan, I., Rani, M., & Anderson, I. (2009). Incidence and correlates of ‘catastrophic’ maternal health care expenditure in India. Health Policy Planning, 24(6), 445–456.

    Article  PubMed  Google Scholar 

  13. Mohanty, S. K., & Srivastava, A. (2012). Out-of-pocket expenditure on institutional delivery in India, Health Policy and Planning, (published online PMID: 22709923).

  14. Balarajan, Y., Selvaraj, S., & Subramanian, S. V. (2011). Health care and equity in India. Lancet, 377, 505–515.

    Article  PubMed  CAS  Google Scholar 

  15. Selvaraj, S., & Karan, A. (2009). Deepening health insecurity in India: Evidence from national sample surveys since 1980 s. Economic & Political Weekly, 44, 55–60.

    Google Scholar 

  16. Yip, W., & Mahal, A. (2008). The health care systems of China and India: Performance and future challenges. Foreign Affairs, 27(4), 921–932.

    Google Scholar 

  17. Dilip, T. R. (2010). Utilization of inpatient care from private hospitals: Trends emerging from Kerala, India. Health Policy and Planning, 25(5), 437–446.

    Article  PubMed  CAS  Google Scholar 

  18. Garg, C. C., & Karan, A. K. (2008). Reducing out-of-pocket expenditures to reduce poverty: A disaggregated analysis at rural-urban and state level in India. Health Policy Planning, 24(2), 116–128.

    Google Scholar 

  19. Peters, D. H., Yazbeck, A. S., Sharma, R. R., Ramana, G. N. V., Pritchett, L. H., & Wagstaff, A. (2002). Better health systems for India’s poor: Findings, analysis, and options, human development network, health, nutrition and population series. Washington, DC: The World Bank.

    Book  Google Scholar 

  20. Gupta, I. (2009). Out-of-pocket expenditures and poverty: Estimates from the NSSO 61st round, Paper presented to the expert group on poverty in Planning Commission, Government of India.

  21. Krishna, A. (2006). Pathways out of and into poverty in 36 villages of Andhra Pradesh, India. World Development, 34(2), 271–288.

    Article  Google Scholar 

  22. Mondal, S., Kanjilal, B., Peters, D. H., & Lucas, H. (2010). Catastrophic out-of-pocket payment for health care and its impact on households: Experience from West Bengal, India. http://www.chronicpoverty.org/uploads/publication_files/mondal_et_al_health.pdf.

  23. Navaneetham, K., & Dharmalingam, A. (2002). Utilization of maternal health care services in Southern India. Social Science and Medicine, 55(10), 1849–1869.

    Article  PubMed  CAS  Google Scholar 

  24. O’Donnell, O., et al. (2007). The incidence of public spending on healthcare: Comparative evidence from Asia. The World Bank Economic Review, 21(1), 93–123.

    Article  Google Scholar 

  25. Mahal, A., et al. (2002). Who benefits from public sector health spending in India. New Delhi: National Council for Applied Economic Research.

    Google Scholar 

  26. Ministry of Health and Welfare (2006). Janani Suraksha Yojana, Government of India. New Delhi. (http://jknrhm.com/PDF/JSR.pdf).

  27. National Sample Survey Organisation. (2006). Morbidity, health care and condition of the aged: NSSO 60th round (January–June 2004). New Delhi: National Sample Survey Organization, Ministry of Statistics and Programme Implementation, Government of India.

    Google Scholar 

  28. Gupta, P., Malhotra, S., Singh, D. K., & Dua, T. (2006). Length of postnatal stay in healthy newborns and re-hospitalization following their early discharge. Indian Journal of Pediatrics, 73(10), 897–900.

    Article  PubMed  Google Scholar 

  29. Das, J., & Hammer, J. (2005). Which doctor? Combining vignettes and item response to measure clinical competence. Journal of Development Economics, 78(2), 348–383.

    Article  Google Scholar 

  30. Das Gupta, M. (1995). Life course perspectives on women’s autonomy and health outcomes. American Anthropologist, 97(3), 481–491.

    Article  Google Scholar 

  31. Dhar, R. S. G., Nagpal, J., Sinha, S., Bhargava, V. L., Sachdeva, A., & Bhartia, A. (2009). Direct cost of maternity-care services in south Delhi: A community survey. Journal of Health, Population & Nutrition, 27(3), 368–378.

    Google Scholar 

  32. Meenakshi, J. V., Ray, R., & Gupta, S. (2000). Estimates of poverty for SC/ST and female-headed households. Economic and Political Weekly, 35(31), 2748–2754.

    Google Scholar 

  33. United Nations Population Fund. (2009). Concurrent assessment of Janani Suraksha Yojana (JSY) in selected states. New Delhi: UNFPA India.

    Google Scholar 

Download references

Acknowledgments

We would like to acknowledge the funding of the ISSCR ESRC grant number Grant reference: RES-238-25-0009 and the support for conducting the study through the ESRC Brazil-India Pathfinder Programme for Collaborative Analysis of Microdata Resources. Grant reference: RES-238-25-0009. We would like to thank Helen Vieth for editing the document.

Author information

Authors and Affiliations

  1. LSE Health, London School of Economics, Houghton Street, London, WC2A 2AE, UK

    Tiziana Leone

  2. Population Research Centre, Institute for Social and Economic Change, Bangalore, India

    K. S. James

  3. Centre for Global Health, Population, Poverty and Policy, University of Southampton, Southampton, UK

    Sabu S. Padmadas

Authors
  1. Tiziana Leone
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. K. S. James
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sabu S. Padmadas
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tiziana Leone.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Leone, T., James, K.S. & Padmadas, S.S. The Burden of Maternal Health Care Expenditure in India: Multilevel Analysis of National Data. Matern Child Health J 17, 1622–1630 (2013). https://doi.org/10.1007/s10995-012-1174-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10995-012-1174-9

Keywords

  • Maternal health care
  • Economic burden
  • Out-of-pocket expenditures
  • Household
  • Public–private