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Introduction: Although India has made significant progress in institutional delivery after the implementation of the National Rural Health Mission under which the Janani Suraksha Yojana (JSY) is a sub-programme which played a vital role in the increase of institutional delivery in public facilities. Therefore, this paper aims to provide an understanding of the JSY coverage at the district level in India. Further, it tries to carve out the factors responsible for the regional disparity of JSY coverage at district levels. Methods: The study used the National Family Health Survey data, which is a cross-sectional survey conducted in 2015–16, India. The sample size of this study was 148,145 women aged 15–49 years who gave last birth in the institution during 5 years preceding the survey. Bivariate and multivariate regression analysis was used to fulfill the study objectives. Additionally, Moran's I statistics and bivariate Local Indicator for Spatial Association (LISA) maps were used to understand spatial dependence and clustering of JSY coverage. Ordinary least square, spatial lag and spatial error models were used to examine the correlates of JSY utilization. Results: The value of spatial-autocorrelation for JSY was 0.71 which depicts the high dependence of the JSY coverage over districts of India. The overall coverage of JSY in India is 36.4% and it highly varied across different regions, districts, and even socioeconomic groups. The spatial error model depicts that if in a district the women with no schooling status increase by 10% then the benefits of JSY get increased by 2.3%. Similarly, if in a district the women from poor wealth quintile, it increases by 10% the benefits of JSY also increased by 4.6%. However, the coverage of JSY made greater imperative to understand it due to its clustering among districts of specific states only. Conclusion: It is well reflected in the EAGs states in terms of spatial-inequality in service coverage. There is a need to universalize the JSY programme at a very individual level. And, it is required to revisit the policy strategy and the implementation plans at regional or district levels. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Economic burden to households due to out-of-pocket expenditure (OOPE) is large in many Asian countries. Though studies suggest increasing household poverty due to high OOPE in developing countries, studies on association of multidimensional poverty and household health spending is limited. This paper tests the hypothesis that the multidimensionally poor are more likely to incur catastrophic health spending cutting across countries. Data and methods: Data from the Poverty and Vulnerability Assessment (PVA) Survey carried out by the International Center for Integrated Mountain Development (ICIMOD) has been used in the analyses. The PVA survey was a comprehensive household survey that covered the mountainous regions of India, Nepal and Myanmar. A total of 2647 households from India, 2310 households in Nepal and 4290 households in Myanmar covered under the PVA survey. Poverty is measured in a multidimensional framework by including the dimensions of education, income and energy, water and sanitation using the Alkire and Foster method. Health shock is measured using the frequency of illness, family sickness and death of any family member in a reference period of one year. Catastrophic health expenditure is defined as 40% above the household's capacity to pay. Results: Results suggest that about three-fifths of the population in Myanmar, two-fifths of the population in Nepal and one-third of the population in India are multidimensionally poor. About 47% of the multidimensionally poor in India had incurred catastrophic health spending compared to 35% of the multidimensionally non-poor and the pattern was similar in both Nepal and Myanmar. The odds of incurring catastrophic health spending was 56% more among the multidimensionally poor than among the multidimensionally non-poor [95% CI: 1.35-1.76]. While health shocks to households are consistently significant predictors of catastrophic health spending cutting across country of residence, the educational attainment of the head of the household is not significant. Conclusion: The multidimensionally poor in the poorer regions are more likely to face health shocks and are less likely to afford professional health services. Increasing government spending on health and increasing households' access to health insurance can reduce catastrophic health spending and multidimensional poverty. [ABSTRACT FROM AUTHOR]

Background: The incidence of hip fractures in older adults in India is likely to increase dramatically in the coming decades as a result of an aging population and increasing life expectancy. Currently, more than 600,000 adults over 60 years of age suffer a hip fracture annually in India. This paper outlines a protocol for a qualitative study investigating the care seeking behavior of older adults with hip fractures: to determine the processes in decision making, identify causes for delay in obtaining care, and identify potential barriers and facilitators to seeking appropriate care in time. Methods and design: The planned study will consider Odisha, an eastern state in India with limited health care facility, as a suitable case study. It is proposed to conduct 30 in-depth interviews in two administrative districts of Odisha. The participants will be patient and their carers in seven health facilities- four public hospitals, two private hospitals and one traditional bone-setting facility. The study relies on a purposive sampling strategy. Ethics permission will be sought from each participating institution and participants. The participants will be adults aged 50 years or older of both sexes arriving at the recruiting centers with a history of fall or injury, pain in the hip region and inability to walk and X-ray confirmed diagnosis of proximal femoral fracture and their primary carer. Trained qualitative research team will conduct these interviews. A thematic framework approach will be used to analyze the data using NVivo 9 software. The data collected from the interviews will be analysed to explore the cause of the hip fracture, events following the injury, the experiences of patients from the time of sustaining the injury, pain relief measures, decision to seek care, understanding of the urgency for treatment, causes for delay in receiving treatment, funding sources, cost liabilities for the family, financing mechanisms for out of pocket expenditure and the burden for caring. Discussion: The findings of this study will provide an increased understanding of the care seeking behaviors of older adults with hip fracture, and inform contextually appropriate changes in healthcare program and policy aimed at improving health outcomes. [ABSTRACT FROM AUTHOR]

Background: The government of Gujarat, India runs a large public private partnership program to widen access to emergency obstetric care (EmOC). The program include a disincentive for Cesareans section (CS) which are capped at seven per 100 women. In this paper, we study if the disincentive works by comparing CS rates among similar groups of women who deliver within and outside the program. Methods: Community-based panel study in three districts of Gujarat, India. Sample size: 2123 women. Data was analyzed using multivariable logistic regression. Results: Overall seven point seven % (164/2123) of the all women in the study had a CS. After adjusting for confounding factors women within the program had 62% (AOR 0.38, 95% CI 0.22–0.44) lower odds of having a CS than to non-beneficiaries. In a separate model of predictors of CS among women giving birth only in program accredited hospitals, we found that CY program beneficiaries had lower odds of having a CS birth than non-beneficiary women (paying clients) (AOR 0.40, 95% CI 0.24–0.67). Conclusions: The Gujarat government is trying to ensure access to EmOC (including CS) for its vulnerable population through CY. The embedded disincentive to prevent unnecessary cesareans by private obstetricians is a novel one, and appears to work, though one could argue it works 'over-efficiently' by depriving some women who need CS from receiving one under the program. The state needs to revisit and review what is happening in the program periodically, and have oversight over whether women who need CS under the program actually receive the care that they need. [ABSTRACT FROM AUTHOR]

Background: Benefit Incidence Analysis (BIA) is used to understand the distribution of health care utilization and spending in comparison to income distribution. The results can illustrate how effectively governments allocate limited resources towards meeting the needs of the poor. In analyzing the distribution of public spending on inpatient, outpatient, and deliveries, this paper represents the most recent BIA completed in India. Methods: In order to conduct the BIA statistical analysis for this project, 2014 utilization data from the most recently completed Indian National Sample Survey (NSS) was used. Unit costs were estimated for primary care, hospital inpatient, hospital outpatient, and deliveries. Concentration curves and concentration indices were estimated both at the national and state levels. Analyses were reported for overall utilization, as well as for the gross and net benefits for inpatient, outpatient, and deliveries. Results: According to the results, utilization of government inpatient and delivery services is pro-poor. When gross and net benefits are included in the analysis, services become more equal and less pro-poor. Gross benefits, which are measured with state-level unit costs, are virtually equal for all services. Although there are some pro-poor gross benefits trends for national outpatient services, the results also show that the equality of national gross benefits trends hides a significant disparity across Indian States. While a number of Indian States have outpatient gross benefits that are pro-poor, few show pro-poor benefits for inpatient and delivery services. Net benefits, which considers both unit costs for each respective service, and out-of-pocket (OOP) expenditures, trend similarly to gross benefits. In addition, those who use public facilities spend considerable OOP to supplement government services. Conclusions: This BIA reveals that government spending on public health care has not resulted in significantly pro-poor services. While some progress has been made relative to deliveries and outpatient services, inpatient stays are not pro-poor. In addition, national results mask significant disparities across Indian states. [ABSTRACT FROM AUTHOR]