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BACKGROUND: A vast array of literature has established that high maternity expenditure precludes women from accessing health services. Further, this maternity expenditure takes catastrophic form, forcing individuals or households to significantly lower their standard of living now or at some time in future. The present study analyses expenditure on childbearing in rural areas of one of the richest and top performer states on health parameters in India, namely Punjab along with examining the determinants of catastrophic expenditure. It also attempts to examine the implementation of Janani Shishu Suraksha Karyakaram (JSSK) which entitles pregnant women to free maternity services in public health facilities. METHODS: A cross-sectional study was conducted in rural areas of Punjab involving 420 recently delivered women, who were questioned about their socio-economic attributes and expenditure incurred in the process of childbearing using face to face, semi-structured interviews. Employing logistic regression, an attempt has been made to understand the determinants of catastrophic maternity expenditure, i.e., expenditure exceeding 10% of annual household income. RESULTS: Of the 420 respondents surveyed, 96.7% reported bearing expenditure on childbearing, irrespective of the type of health facility used and 25% respondents spent catastrophically. On an average, respondents have spent US$62.87 on antenatal care, US$112.86 on delivery and US$6.55 on postnatal care. The results of multivariable analysis reveal that respondents belonging to general category (non reserve category), lower wealth quintiles and using private health facilities have higher odds of incurring catastrophic expenditure. At the same time, poor quality of care at government hospitals and inability of public health staff to provide timely treatment are the driving forces for utilizing private health facilities. Even in the presence of free maternity scheme at government hospitals, respondents on an average spent US$55.22 on availing maternity services. CONCLUSION: The study shows that risk of bearing catastrophic expenditure and being pushed down to abject poverty is higher for respondents who are already at the bottom of wealth quintiles. The policy imperative has to swing towards upgrading the creaky health infrastructure and addressing the issues of poor accountability and corruption at government hospitals, along with thwarting unregulated expansion of private health sector.

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RESUMEN

BACKGROUND: One of the constraints in the utilisation of maternal healthcare in India is the out-of-pocket expenditure. To improve the utilisation and to reduce the out-of-pocket expenditure, India launched a cash incentive scheme, Janani Suraksha Yojana (JSY), which provides monetary incentive to the mothers delivering in public facility. However, no study has yet examined the extent to which the JSY payments reduce the maternal healthcare induced catastrophic out-of-pocket expenditure burden of the households. This paper therefore attempts to examine the extent to which the JSY reduces the catastrophic expenditure estimate household expenditure on maternity, i.e., all direct and indirect expenditure. MATERIALS AND METHODS: The study used data on 396 mothers collected through a primary survey conducted in the rural areas of the Varanasi district of Uttar Pradesh state in 2013-2014. The degree and variation in the catastrophic impact of households' maternity spending was computed as share of out-of-pocket payment in total household income in relation to specific thresholds, across socioeconomic categories. Logistic regression was used to understand the determinants of catastrophic expenditure and whether the JSY has any role in influencing the expenditure pattern. RESULTS: Results revealed that the JSY beneficiaries on an average spent about 8.3% of their Annual Household Consumption Expenditure on maternity care. The JSY reimbursement could reduce this share only by 2.1%. The study found that the expenditure on antenatal and postnatal care made up a significant part of the direct medical expenditure on maternity among the JSY beneficiaries. The indirect or non-medical expenditure was about four times higher than the direct expenditure on maternity services. The out-of-pocket expenditure across income quintiles was found to be regressive i.e. the poor paid a greater proportion of their income towards maternity care than the rich. Results also showed that the JSY reimbursement helped only about 8% households to escape from suffering catastrophic burden due to maternity payments. CONCLUSIONS: It can be concluded that the JSY appeared to have achieved only a limited success in reducing the economic burden due to maternity. To reduce the catastrophic burden, policy makers should consider increasing the JSY reimbursement to cover not only antenatal and postnatal services but also non-medical expenditure due to maternity. The government should also take appropriate measures to curb non-medical or indirect expenditure in public health facilities.