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The caste system is a complex social stratification system which has been abolished, but remains deeply ingrained in India. Scheduled Caste (SC) women are one of the historically deprived groups, as reflected in poor maternal health outcomes and low utilisation of maternal healthcare services. Key government schemes introduced in 2005 mean healthcare-associated costs should now be far less of a deterrent. This paper examines the factors contributing to this low use of maternal health services by investigating the perceptions, health-seeking behaviours and access of SC women to maternal healthcare services in Bihar, India. Eighteen in-depth, semi-structured interviews were conducted with SC women in Bihar. Data were analysed using Framework Analysis and presented using the AAAQ Toolbox. Main facilitating factors included the introduction of accredited social health activists (ASHAs), free maternal health services, the Janani Shishu Suraksha Karyakram (JSSK), and changes in the cultural acceptability of institutional delivery. Main barriers included inadequate ASHA coverage, poor information access, transport costs and unauthorised charges to SC women from healthcare staff. SC women in Bihar may be inequitably served by maternal health services, and in some cases may face specific discrimination. Recommendations to improve SC service utilisation include research into the improvement of postnatal care, reducing unauthorised payments to healthcare staff and improvements to the ASHA programme. [ABSTRACT FROM AUTHOR]

Background: Equity and justice in healthcare payment form an integral part of health policy and planning. In the majority of low and middle-income countries (LMICs), healthcare inequalities are further aggravated by Out of Pocket Expenditure (OOPE). This paper examines the pattern of health equity and regional disparities in healthcare spending among Indian states by applying Andersen's behavioural model of healthcare utilization. Methods: The present study uses data from the 66th quinquennial round of Consumer Expenditure Survey, of the National Sample Survey Organization (NSSO), conducted in 2009-10 by Ministry of Statistics and Programme Implementation (MoSPI), Government of India (GoI). To measure equity and regional disparities in healthcare expenditure, states have been categorized under three heads on the basis of monthly OOPE i.e., Category A (OOPE > =INR 100); Category B (OOPE between INR 50 to 99) and Category C (OOPE < INR 50). Multiple Generalised Linear Regression Model (GLRM) has been employed to explore the effect of various socio-economic covariates on the level of OOPE. Results: The gap in the ratio of average healthcare spending between the poorest and richest households was maximum in Category A states Category B (richest/poorest = 14.60), followed by (richest/poorest 11.70) and Category C (richest/poorest 11.40). Results also indicate geographical concentration of lower level healthcare spending among Indian states (e.g., Odisha, Chhattisgarh and all the north-eastern states). Results from the multivariate analysis suggest that people residing in urban areas, having higher economic status, belonging to non-Muslim communities, non-Scheduled Tribes (STs), and non-poor households spend more on healthcare than their counterparts. Conclusions: In spite of various efforts by the government to reduce the burden of healthcare spending, widespread inequalities in healthcare expenditure are prevalent. Households with high healthcare needs (SCs/STs, and the poor) are in a more disadvantaged position in terms of spending on health care. It has also been observed that spending on healthcare was comparatively lower among backward or isolated states. No doubt, the overall social security measures should be enhanced, but at the same time, looking at the regional differences, more priority should be assigned to the disadvantaged states to reduce the burden of OOPE. It is proposed that there is need to increase government spending, especially for the disadvantaged states and population, to minimise the burden of OOPE. [ABSTRACT FROM AUTHOR]