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R E S E A R C H Open Access
Out of pocket expenditure to deliver at
public health facilities in India: a cross
sectional analysis
Anns Issac, Susmita Chatterjee, Aradhana Srivastava and Sanghita Bhattacharyya
*
Abstract
Background: To expand access to safe deliveries, some developing countries have initiated demand-side financing
schemes promoting institutional delivery. In the context of conditional cash incentive scheme and free maternity
care in public health facilities in India, studies have highlighted high out of pocket expenditure (OOPE) of Indian
families for delivery and maternity care. In this context the study assesses the components of OOPE that women
incurred while accessing maternity care in public health facilities in Uttar Pradesh, India. It also assesses the
determinants of OOPE and the level of maternal satisfaction while accessing care from these facilities.
Method: It is a cross-sectional analysis of 558 recently delivered women who have delivered at four public health
facilities in Uttar Pradesh, India. All OOPE related information was collected through interviews using structured
pre-tested questionnaires. Frequencies, Mann-Whitney test and categorical regression were used for data reduction.
Results: The analysis showed that the median OOPE was INR 700 (US$ 11.48) which varied between INR 680 (US$
11.15) for normal delivery and INR 970 (US$ 15.9) for complicated cases. Tips for getting services (consisting of gifts
and tips for services) with a median value of INR 320 (US$ 5.25) contributed to the major share in OOPE. Women
from households with income more than INR 4000 (US$ 65.57) per month, general castes, primi-gravida, complicated
delivery and those not accompanied by community health workers incurred higher OOPE. The significant predictors
for high OOPE were caste (General Vs. OBC, SC/ST), type of delivery (Complicated Vs. Normal), and presence of ASHA
(No Vs. Yes). OOPE while accessing care for delivery was one among the least satisfactory items and 76 % women
expressed their dissatisfaction.
Conclusion: Even though services at the public health facilities in India are supposed to be provided free of cost,
it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain
delivery care.
Keywords: Out of pocket expenditure, Tips for getting services, Delivery care, Public health facilities, India
Abbreviations: ASHA, Accredited social health activist; JSSK, Janani Shishu Suraksha Karyakram; JSY, Janani Suraksha
Yojana; OBC, Other backward caste; OOPE, Out of pocket expenditure; SC/ST, Scheduled caste/scheduled tribe
* Correspondence: sanghita@phfi.org
Public Health Foundation of India, Plot no. 47, Sector 44 Institutional Area,
Gurgaon 122002, Haryana, India
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Issac et al. Reproductive Health (2016) 13:99
DOI 10.1186/s12978-016-0221-1
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Plain English summary
Some developing countries have introduced promo-
tional schemes for institutional delivery so that they
could improve women’s access to safe delivery care. In
India, there is a scheme, titled Janani Shishu Suraksha
Karyakram, which entitles women to free delivery care
at public health facilities. However, a few studies sug-
gested that the women had to pay for obtaining services
even at the public health facilities. To understand the
different components of cost of care, the present study
conducted a survey of 558 women who had delivered at
public health facilities in two districts of Uttar Pradesh.
The majority (97 %) of the women paid from their
pocket for services, and the median cost was INR 700
(US$ 11.48); this was half the cash incentive provided by
the government scheme. This amount varied between
INR 680 (US$ 11.15) for normal delivery and INR 970
(US$ 15.9) for complicated cases. The major component
was tips for getting services (consisting of gifts and tips
for services) with a median value of INR 320 (US$ 5.25).
Women from higher income households (more than INR
4000 (US$ 65.57)/ month), general castes, those who were
the first-time mothers, complicated delivery and those not
accompanied by community health workers paid more.
The study concludes that the care from the public
health facility is in fact not free, and this can discourage
women opting for institutional delivery.
Background
Developing countries suffer from unacceptably high
rates of maternal and infant mortality, accounting for
99% of global maternal deaths [1]. One of the primary
reasons for this is the lack of access to safe deliveries,
especially among the poor, where healthcare access often
imposes a considerable financial burden on families [2].
To expand access to safe deliveries and reduce the risk
of maternal and newborn emergencies, some developing
countries have initiated demand-side financing schemes
to promote institutional delivery. Among the South
Asian countries, Nepal has the cash incentive scheme
and Bangladesh and Pakistan have voucher schemes [3].
Several studies from low and middle-income countries
have shown that the cost of care is a major determinant
of maternal care utilization and satisfaction with institu-
tional delivery care [4, 5]. Significant associations of cost
or affordability of care with maternal satisfaction and the
utilization of care in institutional births were found in
studies in Nigeria, Zambia, Kenya, Egypt, India, Gambia
and Ghana [6–13].
With a high maternal mortality ratio of 178, saving
maternal and newborn lives is a key concern in India [14].
The Government of India launched the conditional cash
transfer scheme of Janani Suraksha Yojana (JSY) in 2005
to promote institutional deliveries, offering a monetary in-
centive of INR 1400 (US$ 22.95)
1
to women delivering in
public or accredited private facilities. The program is
supported by the Accredited Social Health Activist
(ASHA), a community health worker who motivates
women to deliver at public facilities and also accom-
panies them to the facilities [15]. The delivery services,
including medicines, tests and food are provided free of
cost to encourage women to opt for institutional deliv-
ery and offset their related expenditure burden [16].
Later, JSY was modified to Janani Shishu Suraksha
Karyakram (JSSK), which included additional services
such as support for travel to and from the facility and
medical treatment for sick newborn [17, 18].
As a consequence of JSY and JSSK, institutional de-
liveries in India have increased from 40.7% in 2005-06
to 72.9% in 2009-10 [19, 20]. However, several studies
show a persistent and unaccounted high level of out-
of-pocket expenditure (OOPE) on maternal care (ante-
natal, delivery and postnatal), similar to expenditure
on other public hospital based services [21–23]. The
high OOPE is especially catastrophic for poor house-
holds, who are often pushed into further poverty and
indebtedness on account of this [24–28]. Though some
studies have highlighted OOPE for delivery care, there
is less attention to explore the components of OOPE
during delivery care at public health facilities.
Our objective was to assess the OOPE incurred by
rural Indian women while accessing institutional delivery
services at public health facilities and to examine com-
ponents of OOPE. We also assessed the determinants of
OOPE and the level of maternal satisfaction with the
OOPE on delivery care. For this study, OOPE refers to
all the direct expenditure for delivery care including
transportation and services availed from private pharma-
cies and laboratories due to lack of provision at the pub-
lic health facility.
Methods
The present analysis is part of a larger study on
women’s experience of care and their levels of satisfac-
tion with maternal services from secondary health care
facilities in India. The study followed a mixed-method
design with a literature review and qualitative phase
preceding the quantitative phase. The literature review
aided in exploring the determinants and themes of care
from developing countries [4]. This informed the quali-
tative phase in which perspectives from both the
women and healthcare providers were sought. The
quantitative phase consisted of a community survey
and focused entirely on women’s perspective of delivery
care at health facilities. The data presented in this paper
is part of the cross-sectional survey.
Issac et al. Reproductive Health (2016) 13:99 Page 2 of 9
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Study area
The community survey was conducted during July -
August 2014 in two poor performing districts in Uttar
Pradesh, one of the high-focus states in India with poor
health indicators. The state has high infant mortality
rate (50 per 1000 live births) [29], maternal mortality
ratio (292 per 100000 live births) and a low percentage
of institutional deliveries (45.6 %) [30]. The selected
districts had a maternal mortality ratio of 330. The
infantmortalityratewas80and82forthetwodistricts
whereas the percent of institutional delivery was 35.2
and 42.4 respectively [30]. The survey was aimed at
capturing the experience of women with maternal care
from secondary level health facilities. Secondary level
health facilities are designated to manage complications
with childbirth and have provisions for surgical care,
blood transfusion and newborn care. These facilities
function as the first referral unit for primary level facil-
ities. There were four functional secondary level health
facilities in the two study districts.
Study instrument
The survey instrument comprised of two parts: the first
part was a structured interview schedule capturing
women’s experience of accessing care from the facility
including OOPE on reaching the facility till discharge,
and the second part comprised of a scale to assess their
satisfaction with care. Based on the literature review and
the qualitative study that preceded the survey, items in
the instrument were derived from the determinants of
structure, process and outcome of care. Among structural
determinants, physical environment, cleanliness, availabil-
ity of human resources, medicines and supplies were
included. Determinants of the process of care included
interpersonal behavior, privacy, promptness, cognitive
care, perceived provider competency and emotional
support. Outcome related determinants were the health
status of the mother and newborn.
A set of queries focused exclusively on the expend-
iture across nine categories viz. transportation (hiring
vehicle to and from the facility), medicines and supplies
(prescribed from the facility), laboratory and diagnostic
services, blood transfusion (expenditure for arranging
blood), newborn care (in case of neonatal complication,
while the mother was still admitted in the facility),
expenses on food during her stay in the facility, tips for
getting services (in cash or kind: gifts and sweets to
facility staff, tips to ambulance driver and facility staff
for their services), and other category includes all the
expenditure that the women could not classify under
the specific categories.
The instrument also included information on socio-
economic status and reproductive history of women. In
terms of social profile in India, general caste means the
non-vulnerable groups and the vulnerable category in-
cludes the backward, scheduled and caste and tribe. The
maternal satisfaction scale is a 5- point Likert scale with
ratings ranging from fully satisfied, somewhat satisfied,
neither satisfied nor dissatisfied, somewhat dissatisfied
and fully dissatisfied. The scale used had 14 items for
understanding satisfaction and included items pertaining
to structural, technical and interpersonal aspects of care.
The study instrument, prepared originally in English, was
translated into the local language (Hindi) of the study
area. Translation and back translation was carried out to
ensure the exactness of meaning of items in the survey
instrument and it was pretested among 20 women in a
setting similar to that of the study area.
Sampling and data collection
The study included women who had delivered at the
secondary level health facilities and discharged seven to
42 days prior to the interview. Only women with live
births were included in the study. A list of the women
with their home address who fulfilled the inclusion cri-
teria was collected from the delivery records of the four
secondary facilities in the two study districts. The list
contained 2130 women, who had given birth between
20
th
June and 20
th
July, 2014. The sample size calculated
for the study was 550 with 80% power and 95% confi-
dence interval. The participants were chosen randomly
and the randomization sequence was generated using
Excel. A sample of 600 women was selected for survey;
oversampling was to address dropouts. There were 10
refusals and 32 women could not be traced due to incor-
rect address. The dropout rate was seven percent. Total
558 women participated in the study. This included both
normal and complicated delivery, and there was no
stratification on type of delivery during the sampling.
The survey was conducted at women’s residences by
female researchers who had knowledge of the research
topic and local dialect.
Data analysis
The study refers to OOPE as all the direct expenditure
incurred by the women in availing delivery care at the
health facility including transportation, all of which are
provisioned to be free. This excludes mandatory pay-
ments, but includes payment for services from private
providers (for transportation, laboratories and pharmacies,
etc.) due to shortage or non-functioning of respective
services at the public health facility. The costs incurred by
relatives or those who accompanied the women were
not considered during analysis. Since the women were
not aware of all the OOPE related to their deliveries,
interviewers sought the help of family members present
duringthesurveytocompletetheinformation.Data
were collected to calculate direct expenditure only. The
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total expenditure was calculated by adding all the
category-wise expenditure mentioned by the respon-
dents. In order to verify the information, cross ques-
tions such as “did you pay from your own pocket for
medicine”etc. were included in the instrument. Any
discrepancy in the data was noted at the site and clari-
fied from the respondents. Since the respondents were
unable to distinguish between mandatory fee and
others, information on stipulated fees for services was
collected from the respective health facilities.
Survey data were analyzed using IBM SPSS version 19.
Data analysis included frequencies, Mann-Whitney test
(for comparing the difference between the median ex-
penditure of two groups) and categorical regression (to
identify the predictors of OOPE where the dependent
variable is on numeric scale while independent variables
are on nominal & numeric scales). As the average
monthly income and OOPE data were highly skewed,
log transformation was done to make the distribution
normal.
Results
All the women paid a registration cost of one rupee at
the health facility and this was not included for analysis
as it was a mandatory payment specified by the govern-
ment. Among the 558 women surveyed for the study,
total 540 women paid for one or the other type of ser-
vices from the public health facilities. Hence the present
analysis is confined to the sample size of 540.
Profile of the respondents
The characteristics of the respondents are given in Table 1.
The mean age of the women was 25 years. Majority of the
women were housewives (98.1 %) and belonged to lower
socio-economic strata. For the majority, their husbands
were daily wage laborers (43.9 %). Majority women in the
sample had a normal vaginal delivery (93.0 %) and were
multi-gravida (64.8 %). A significant proportion of them
had to travel more than five kilometers to access the
health facility (79.8 %). On an average, the women stayed
at the facility for two days after delivery.
Out of pocket expenditure (OOPE)
The median OOPE incurred for delivery at the public
health facility was INR 700 (US$ 11.48) (Table 2). There
was wide variation in the amount paid and it ranged
from INR 15 (US$ 0.25) to INR 14400 (US$ 236.07).
The women were entitled to receive free transportation
to and from the facility; however, in majority of the
cases, they had to arrange own transport due to non-
responsiveness of government ambulance service. Even
among those who availed the service, it was restricted
toonesidetravel.Hencethetotalexpenditurefor
transportation varied from INR 20 (US$ 0.33) to INR
1634 (US$ 26.79) with a median expenditure of INR
142.5 (US$ 2.34). Expenditure for newborn care, if he/
she was referred to a private facility, ranged from INR
100 –2000 (US$ 1.64 –32.79) depending on the nature
of complication. More than half of the women spent on
medicines, cotton pads, syringes and saline, which they
bought from private pharmacies. The laboratory facility
was not functional round the clock, leading to users
relying on private laboratories in the vicinity of the hos-
pital. Tips for getting services, which 86% of women
had to incur, included tips to avail government ambu-
lance,andbribeseitherincashorkind(forexample,
distributing sweets) to facility staff for their services.
Overcrowding in the facility led to women paying the
Table 1 Socio-demographic and reproductive profile of
respondents (N = 540)
Characteristics Respondents,
n (%)
Age (years) Mean (SD) 24.9 (4.01)
Education of woman Illiterate 259 (48.0)
Literate 281 (52.0)
Mean years of schooling (SD) 8.4 (3.44)
Religion Hindu 479 (88.7)
Muslim 59 (10.9)
Sikh 2 (0.4)
Caste General 109 (20.2)
Other backward caste 232 (43.0)
Scheduled caste/scheduled
tribe
199 (36.9)
Type of household Nuclear 220 (40.7)
Joint 320 (59.3)
Occupation of woman Homemaker 530 (98.1)
Other work 10 (1.9)
Occupation of husband Cultivator 149 (27.6)
Casual labourer 237 (43.9)
Salaried workers 59 (10.9)
Self-employed in petty trade/
small scale industry
91 (16.9)
Unemployed 4 (0.7)
Average monthly
household income (INR)
a
≤4000 299 (55.4)
>4000 241 (44.6)
Gravidity 1 190 (35.2)
2 or more 350 (64.8)
Delivery Normal vaginal 502 (93.0)
C-section & breech 38 (7.0)
Duration of stay (days) Mean (SD) 2.1 (1.7)
Distance to health facility Upto 5 km 109 (20.2)
More than 5 km 431 (79.8)
a
Median income is INR 4000
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staff for obtaining a bed in the antenatal and postnatal
care wards.
The classification of ‘normal’refers to normal vaginal
delivery, and ‘complicated’indicates all the caesarian and
breech deliveries along with maternal complications
post-delivery. There was a noticeable difference in the
expenditure incurred for normal and complicated cases.
Complicated cases had higher OOPE for most of the
items compared to normal cases. The difference was
striking for laboratory investigations with median INR
450 (US$ 7.38) for complicated cases and only INR 20
(US$ 0.33) for normal cases.
Determinants of OOPE
Table 3 presents the total OOPE against selected socio-
economic and reproductive variables. The significant
variables were caste, income, gravidity, type of delivery,
and presence of Accredited Social Health Activist
(ASHA). The OOPE for other castes was higher than
the vulnerable groups of ‘other backward caste, sched-
uled caste/tribe’taken together. Similarly, those in the
higher income group (above INR 4000 per month) paid
more compared to lower income group. The OOPE for
multi-gravida was less compared to primi-gravida. The
complications associated with delivery (such as C-section
and breech cases as well as health complications of
mother soon after delivery) incurred higher OOPE than
normal delivery. Presence of ASHA during delivery led to
less OOPE as the median expenditure was INR 680
compared to INR 980 for the women when ASHA was
not present.
Regression analysis for OOPE provided three signifi-
cant predictors for OOPE viz. caste, type of delivery and
presence of ASHA during delivery (Table 4).
Level of maternal satisfaction with OOPE
Level of satisfaction with delivery care at the secondary
level public health facilities was assessed using the
Maternal Satisfaction Scale (Table 5). Out of pocket
expenditure was one of the least satisfied items marked
by the women. Only three percent women were fully
satisfied with it. Similarly, the dissatisfaction score was
strikingly high with 18.7% which was the second high-
est among the enquired items.
Discussion
The study estimated the OOPE incurred by rural Indian
women while accessing institutional delivery services at
secondary level public health facilities and also examined
Table 2 Item-wise expenditure for delivery care (N = 540)
Items (n) Median expenditure in INR (min-max)
Normal (n = 461) Complicated (n = 79) Total (N = 540)
Transportation (n= 458) 130 (20-1500) 150 (20- 1634) 142.5 (20 –1634)
Medicines and supplies (n= 298) 100 (15-1200) 110 (35-8000) 100 (15 –8000)
Laboratory investigations (n= 13) 20 (10-200) 450 (100 –1700) 100 (10 –1700)
Blood transfusion (n= 2) - 500 (500 –500) 500 (500 –500)
Newborn care in private facility (n=3)
aa
200 (100 –2000)
Tips for getting services (n= 466) 300 (10-2000) 400 (20-7000) 320 (10 –7000)
Food (from the facility) (n= 15) 200 (20-500) 225 (30-500) 200 (20 –500)
Any other (n= 265) 300 (20-3000) 400 (20-6000) 300 (20 –6000)
Total expenditure (n= 540) 680 (15-5200) 970 (20-14400) 700 (15 –14400)
a
Number of cases are not enough to calculate median as they are divided between normal (1) and complicated (2) categories
US$ 1 = 61 INR
Table 3 Total expenditure for care across selected variables
(N=540)
Variable Median expenditure in INR (IQR)
Age (Years) <25 680 (520)
≥25 740 (665)
Education of woman Illiterate 670 (510)
Literate 730 (600)
Religion Hindu 700 (550)
Non-Hindu 600 (540)
Caste*** General 850 (780)
OBC, SC/ST 670 (535)
Income (INR)** ≤4000 620 (520)
>4000 750 (550)
Gravida** Primi 785 (678)
Multi 660 (495)
Sex of baby Female 655 (493)
Male 720 (569)
Type of delivery*** Normal 680 (510)
Complicated 970 (1050)
Presence of ASHA*** Yes 680 (510)
No 980 (1675)
**p< 0.01, ***p<0.001
Significance level is determined using Mann- Whitney test
US$ 1 = 61 INR
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its item-wise composition. The study revealed that the ser-
vices from the government health facility were not free for
the women. The OOPE varied from INR 680 to 970 (US$
11.15 - 15.90) depending on delivery complications. The
major component of OOPE was tips for getting services,
which comprised of tips for services and gifts in cash or
kind. Women from higher income group, general caste,
primi-gravida and those without ASHAs paid more com-
pared to their counterparts.
Similar findings have been highlighted in several other
studies in which they discussed the high OOPE for insti-
tutional delivery in India [28, 31–34]. Recent national
level statistics in India revealed that rural population
spent on an average INR1587 (US$ 26.0) and urban
population INR 2117 (US$ 34.7) to deliver at public fa-
cilities [35]. Similar observations were made from other
developing countries also. For instance, a study from
Bangladesh reported the expenditure for services at
government health facilities to be US$ 31.9 for a normal
delivery and US$ 117.5 for a caesarean delivery [36]. The
median OOPE calculated in the present study was INR
700 (US$ 11.48) with wide variation between normal
(INR 680 –US$ 11.15) and complicated cases (INR 970
(US$ 15.90). Based on the data from district level house-
hold survey, the estimated mean OOPE for delivery in
public health facilities in India is US$ 39 [32]. They
found that the OOPE for C-section delivery is six times
higher than that for normal vaginal delivery. With the
same data, another study showed that median OOPE in
public health facilities is INR 1000 (US$ 16.39) and
INR 4045 (US$ 66.31) for normal and caesarian deliver-
ies respectively [28]. A study in Uttar Pradesh also
found that families pay between INR 500 and 700 (US$
8.20 –11.48) to hospital staff at the time of admission
or when they have a newborn [22]. The OOPE became
Table 4 Categorical regression for OOPE
Variable Standardized Beta Standard error
Age (Years) <25 0.035
≥25 0.016
Education Illiterate 0.025
Literate 0.011
Religion Hindu 0.052 0.034
Non-Hindu
Caste* General 0.098 0.041
OBC, SC/ST
Income (INR)
a
0.025 0.043
Gravida Primi 0.047
Multi 0.065
Sex of baby Female 0.024
Male 0.002
Type of delivery*** Normal 0.060
Complicated 0.199
Presence of ASHA* Yes 0.049
No 0.103
*p< 0.05, ***p< 0.001
a
Natural log of income has taken
Table 5 Maternal satisfaction with delivery care (N= 540)
Item Level of satisfaction (%)
Fully satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Fully dissatisfied
Lack of physical abuse 23.0 1.0 1.3 0.4 1.0
Privacy inside labour room 15.9 10.6 4.3 1.0 0.4
Cleanliness of labour room 13.3 12.9 5.1 1.5 1.0
Comfort of bedding 8.9 13.2 8.7 3.7 1.7
Information on progression of labour 8.7 12.1 6.4 5.1 3.8
Waiting time 6.5 7.7 12.6 5.2 4.0
Timely availability of medicine 6.2 9.6 7.6 11.8 2.9
Care and sympathy in labour room 4.2 10.1 14.9 6.2 2.4
Pain relief 3.4 7.4 13.5 9.8 4.0
Out of pocket expenditure 3.0 2.4 2.6 9.0 18.7
a
11.9 5.0 7.2 19.1 56.9
Advise on breastfeeding 2.6 4.3 3.8 14.1 13.2
Health advice on cord care 2.0 2.0 2.8 11.3 18.5
Health check-up soon after delivery 1.6 2.4 3.3 10.2 19.1
Opportunity to clarify health concern 0.8 4.2 13.3 10.6 9.2
Total 100 100 100 100 100
a
Row-wise per cent
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catastrophic to families as it surpasses the JSY incentive
(INR 1400) in several instances. A study from Orissa
highlighted that the JSY incentive accounted to only
25.5% of total maternal expense in rural and 14.3% in
urban areas [31].
However, large data sets do not generally allow any de-
tailing to understand the areas where women are paying
more. Therefore, the detailed analysis requires in-depth
studies utilizing the strengths of mixed methods, like the
present study. The major component in OOPE was tips
for getting services which include buying gifts to facility
staff and tips for services. The median of tips for getting
services was INR 320 (US$ 5.25) with a wide range of
INR 10 –7000 (US$ 0.16 –114.75). The OOPE for
complicated cases was higher due to the need for
specialized services. In such cases women had to pay for
medicines and supplies, laboratory and diagnostic ser-
vices, blood transfusion and newborn care in private
facilities as these services were not fully functional at the
public health facilities. A few other studies also reported
similar findings and they highlighted how the hospital
staff sent family members to nearby private medical
shops to buy intramuscular injections of oxytocin and
epidosin to speed delivery and also to private diagnostic
clinics to conduct ultrasound test [37, 38].
ThereisdifferenceinOOPEbasedonsocio-
demographic characteristics. Those from the general
caste and higher income group paid more compared to
backward castes and lower income group. In addition
to this, the OOPE for primi-gravida was higher than
that of multi-gravida. A study from Bulgaria on informal
payment in health facilities also found that wealthier,
better educated, younger respondents tend to pay more
for obtaining better-quality treatment [39]. Studies from
India also reported that mean OOPE on delivery was
found to be higher among women with higher education
and those belonging to a higher wealth quintile, as they
have the ability to pay for better quality of service [28–32].
One of the key aspects of promoting institutional deliv-
ery, is the role of community health worker- ASHA, in
not only motivating the woman to deliver at a health facil-
ity but also to accompany her and stay during the entire
delivery process [15]. Being familiar with the health sys-
tem, she is an important link between the community and
the health services. The main reason for her to accompany
the woman is to inform the woman about the services
she is entitled for and also provide emotional support
in an unfamiliar environment. In spite of her presence,
the study showed that women had incurred OOPE,
thoughitwaslesswhentheASHAwaspresentduring
delivery care. In some of our qualitative interviews, the
ASHAs in fact negotiated with the facility staff in aiding
women to avail timely services [40]. There are studies
that have highlighted how ASHAs are used by hospital
staff to facilitate tips for getting services, and being
lower in the health system hierarchy, how they are
compelled to negotiate such transaction [22].
The OOPE was among the items rated the least satis-
factory on the maternal satisfaction scale. Among the
respondents, 76% were dissatisfied (both somewhat dis-
satisfied and fully dissatisfied) with the payments they
made while accessing care at the facility. The remaining
24% included those who were satisfied (both somewhat
satisfied and fully satisfied) and also who did not have
any particular opinion about the expenditure. The low
level of satisfaction with expenditure while accessing
healthcare is reported in other studies also [41]. Some
studies have reported that attitude to tips for getting ser-
vices varies from strongly negative to tolerant depending
on whether the payment is solicited by the facility staff
or offered by the users themselves [39]. Evidence from
large-scale population-based surveys in India highlighted
the issue of non-utilization of maternal health services
due to the cost [42]. As women can evaluate and express
their satisfaction with regard to expenditure related to
their care, it has implications on utilization of public
health facilities for delivery in the future.
Limitations
The major limitation with the study was the recall bias
in reporting the exact expenditure for delivery care at
the health facility. In most instances, the male member
or the older women who accompanied the pregnant
women handled the monetary aspects. Hence, responses
from other family members were also recorded. Another
difficulty was the inability of some respondents to distin-
guish between official and unofficial payments. This was
clarified with the help of information collected from the
respective health facilities on official fees.
Conclusions
The study highlighted that the services from the public
health facilities for delivery care, which were supposed
to be free as per safe delivery program of the govern-
ment, were in fact not free. The women had to incur
high OOPE, which varied according to complications
associated with the delivery. The item-wise analysis re-
vealed that the major component of OOPE was tips for
getting services, followed by expenditure for purchasing
medicine, supplies and diagnostic care, which were
otherwisemandatedtobeprovidedbythehealthfacil-
ities. The findings emphasize the need for a mechanism
to curtail tips for services and to improve the availabil-
ity of medicine and supplies, laboratory and diagnostic
services and provision of food from the facility. Though
the presence of ASHA helped in reducing the OOPE,
they could not eliminate it. There is limited evidence
on the areas where women have to incur OOPE within
Issac et al. Reproductive Health (2016) 13:99 Page 7 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
health facilities, which calls for further studies in differ-
ent geographic locations, to understand the nature and
prevalence of OOPE. The very purpose of conditional
cash transfer scheme will be lost if a woman has to pay
almost half of the monetary incentive in accessing
services that are supposed to be free of cost. OOPE on
accessing care at public health facilities is one of the
key determinants of service utilization, and if not
addressed by the health system, can deter women from
delivering in public health facilities in future in spite of
the cash incentive scheme.
Endnotes
1
One US$ = 61 INR (during the time of field work -2014)
Acknowledgements
We acknowledge the technical guidance and input provided by Dr. Bilal
Avan of London School of Hygiene and Tropical Medicine in conceptualizing
the study, instrument development and analysis. Dr. Arpita Ghosh of Public
Health Foundation of India provided inputs during data analysis.
Funding
The study was supported by the Wellcome Trust Capacity Strengthening
Strategic Award to the Public Health Foundation of India and a consortium
of United Kingdom universities.
Availability of data and materials
The data are available from the authors upon request.
Authors’contributions
AI carried out data collection, analyzed the data and drafted the manuscript.
SC contributed towards study design, analysis and revision of the
manuscript. AS reviewed the literature and contributed in drafting and
reviewing the manuscript. SB conceptualized and designed the study,
provided overall guidance and reviewed the manuscript. All authors have
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Ethical approval for this study was granted by the Institutional Ethics
Committee of the Public Health Foundation of India (TRC-IEC-187/13). A
written permission from district Chief Medical Officer was obtained and the
cooperation from head of respective secondary level health facilities was
sought. The purpose of the study was explained and verbal consent was
sought from women. Anonymity of identity and confidentiality of
information was assured to all the participants during analysis.
Received: 4 March 2016 Accepted: 18 August 2016
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