Data: NFHS-5 Results Indicate a Slight Reduction in Average OOPE Per Delivery in a Public Health Facility
Sai Krishna Muthyanolla
September 1, 2023
Data from the National Family Health Surveys (NFHS) indicates that the Out-of-pocket expenditure (OOPE) per delivery in a public health facility at all-India level reduced slightly from Rs. 3,197 during NFHS-4 to Rs. 2,916 during NFHS-5. However, wide variations exist in various states & districts.
The National Family Health Surveys (NFHS), conducted under the supervision of the Ministry of Health & Family Welfare, have assumed a pivotal role in furnishing the Government of India and associated stakeholders with reliable information for overseeing the advancement of several flagship health initiatives, and in realizing the objectives outlined in the National Health Policy. Over the course of time, the NFHS has broadened its purview and reach to address the existing gaps in relevant data not only for government bodies but also for external researchers.
The insights garnered from NFHS have consistently furnished valuable indicators for evaluating the efficacy of various services extended by the Government, with a special focus on Maternal and Child Health (MCH). This, in turn, provides essential metrics to enhance these programs and highlight areas that require other strategies and interventions.
In this first part on NFHS data stories, the primary focus will be on Maternal Health.
Out of Pocket expenditure per delivery in a public health facility
Maternal health is an important indicator of overall women’s health. The process of achieving safe motherhood can push households into poverty. Approximately 47% of mothers are pushed into poverty as per a study done by researchers from Jawaharlal Nehru University and the Indian Institute of Technology, Roorkee. While maternal healthcare services are intended to be provided free of charge in public health facilities, the process of giving birth in these establishments frequently results in a range of direct medical and indirect non-medical expenses for individuals.
Hence, reducing out-of-pocket expenditure (OOPE) and increasing institutional births have become one of the crucial areas of action for governments. The Government of India enacted Janani Suraksha Scheme in 2005 which provides cash assistance to institutional births. The Out-of-pocket expenditure per delivery in a public health facility at the all-India level stood at Rs. 3,197 during NFHS-4 and Rs. 2,916 during NFHS-5.
Compared to NFHS-4, many districts have exceeded the Indian average OOPE in NFHS-5. Even states that have well-developed public health systems, particularly southern states like Kerala, Telangana, Karnataka, and Tamil Nadu had higher OOPE than the national average.
3 out of 5 top districts that saw decline in OOPE are from West Bengal.
The district-level analysis of OOPE per delivery reveals that Murshidabad district in West Bengal tops the OOPE in India at Rs. 31,457 followed by Jalna in Maharashtra with Rs. 24,453 and Kolkata at Rs. 22,187 during NFHS-4. During NFHS-5, the OOPE for these districts fell to Rs. 2,662, Rs. 4,178 and Rs. 1,969 respectively.
Except for North-Eastern states, Haveri district in Karnataka saw the highest rise, followed by Lakhi Sarai in Bihar, and Bellary in Karnataka. They recorded an increase from Rs. 2,886, Rs. 1084, and Rs. 4,413 during NFHS-4 to Rs. 11,573, Rs. 9,523, and Rs. 12,348 respectively in NFHS-5.
Mildly negative correlation between OOPE and institutional births
Out-of-pocket expenditure per delivery can be majorly from two possible ways- institutionalization of delivery, and type of delivery. Deliveries that occur within healthcare facilities, known as institutional births, have a significant impact on decreasing maternal and neonatal mortality rates. Promoting the idea of all births happening in such institutional settings is a key approach to lowering maternal mortality. Nonetheless, it’s essential to acknowledge that institutional births also involve associated expenses. From transportation to laboratory services to medicines, institutional deliveries have a cost element attached to them. While the above should be free in a public health facility, owing to the lack of availability/non-functionality, many women spend money to get them from private service providers. To make matters even worse, for a public health facility, another element adds up – “tips/bribes to get services” in addition to these. As a result, institutional births at public facilities often tend to inflate the ‘Out-of-Pocket’ expenditures.
The percentage of Institutional births at public health facilities at the all-India level grew from 52.1% to 61.9% between NFHS-4 and NFHS-5.  At the same time, the average out-of-pocket expenditure per delivery at public health facilities declined from Rs. 3,197 during NFHS-4 to Rs. 2,916 during NFHS-5. There exists a negative correlation between these variables as can be seen from the below graph, however, it is very negligible.
Southern states have higher percentage of deliveries by caesarean section.
A Caesarean delivery, commonly known as a C-section, involves surgically delivering a baby through an incision made in the mother’s abdomen and uterus. Higher rates of C-section deliveries have been linked to greater out-of-pocket expenditures (OOPE), which, in turn, are contributing to financial hardships. Literacy levels, wealth, and the rise in institutional births are some of the reasons behind the growing C-section deliveries.
It is observed that, at an all-India level, the percentage of births in a public health facility that was delivered by caesarean section was 11.9% in NFHS-4, which rose to 14.3% during NFHS-5. District-level analysis reveals that almost all districts in southern states have greater C-section births than the national average. The socioeconomic skewness of C-sections in India towards urban and better-off population, with an overwhelming concentration in South India.
If we look at the distribution of OOPE and C-section births, it can majorly be observed that the greater the percentage of C-section births is, the greater is the OOPE.
Kottayam and Jalandhar saw highest rise in deliveries by caesarean section.
A further drill down on districts shows that districts such as Kottayam and Jalandhar saw the greatest rise in deliveries in public health facilities by caesarean section, followed by Patiala, Thiruvarur, and Tirunelveli. Almost all these districts have one out of every two deliveries by C-section from earlier one out of every five deliveries. All these districts rose by more than 20% in NFHS-5 as compared to NFHS-4.
Further, districts such as Mahe, Nellore, Idukki, Kollam saw a greater reduction in deliveries by C-section, with almost all districts witnessing a decline by more than 15%.
Featured Image: NFHS-5 Results