With institutional healthcare being prohibitively expensive, more women in rural India are choosing to deliver at home than in hospitals and healthcare facilities, says a new report brought out by Chittorgarh-based NGO, Prayas, in partnership with Oxfam India.

The 'Study of the trends in out-of-pocket payments in healthcare during National Rural Health Mission period (2005-2010)', released on October 12 in the national capital, was conducted across five Indian states - Assam, Jharkhand, Rajasthan, Tamil Nadu and Uttarakhand.

According to the report, women, on average, spend Rs 2,166 per childbirth. In government healthcare institutions, the expenditure per delivery totals Rs 1,801. The figure - at Rs 8,763 - is five times higher if a woman delivers in a private institution.

Women in Uttarakhand spend the most per childbirth in the country, the study found. They spend Rs 2,497 in government institutions and Rs 11,100 in private ones for each delivery.

The average expenditure incurred on antenatal and post-natal care in government institutions is Rs 270 and Rs 380 respectively, whereas in private institutions it is Rs 1,744 and Rs 964, respectively.

The report defines out-of-pocket expenditure (oope) as the total spending of a household on healthcare providers, medicines, therapeutic devices or any other goods and services as part of treatment, on restoration or improvement of the health status of an individual or a group. It is essentially a private expenditure and is an important determinant to gauge the accessibility of health services for a citizen.

The report also noted that the in the absence of assistance in bearing healthcare costs, illnesses and hospitalisation not only retard welfare directly, they also increase the risk of impoverishment for individuals and households due to high expenditure on treatment and healthcare.

Amit Mohan Prasad, joint secretary at the uninon health and family welfare ministry, acknowledged the government's abysmal spending in the health sector, in his speech at the release. Prasad said, " Spending by the government of India on healthcare is only 0.9 percent of the total expenditure while it should ideally be 10-20 percent.

The low government spending has a direct bearing on the health of vulnerable sections, especially women who are finding it increasingly difficult to access healthcare as evidenced by the report's findings on institutional delivery.The high cost of institutional delivery leads to higher incidence of home deliveries in rural areas due to lack of access to delivery care at a nominal cost. At present, only one-third of the deliveries in India take place in a health facility/institution, while the remaining are home deliveries

Prasad said that the norms for setting up public health facilities were set in sixth five year plan, but the government has not been able to keep pace with the growing population. "For example, for every population of 30,000, there should be a primary health centre (PHC), but it’s not the case in different states. In northeastern states, a PHC caters to 9,000 people, while in states like Jharkhand and Bihar, it caters to much more than 30,000 people," he noted, adding that health policies should not serve only the poor but also low and middle income groups because the case of borrowing for health care is higher in these income groups.

He claimed that the Janani Shishu Surakhsha Karyakram, a central scheme with funding for states to encourage institutional delivery, is working well.  However, he said that the two goals of  achieving 80 percent institutional deliveries and 100 percent safe deliveries would need much more efforts.

Dr P R Sodani of Indian Institute of Health Management and Research, advocated inclusion of the cost of travelling and diagnostic costs in the calculation of oope.

Gautam Chakrobarty of National Health Systems Resource Center emphasised on greater accessibility to medicines. Acknowledging the fact that medicines are major component of oope, he said that people spend 40 percent on medicines though government institutions provide free medicine for pregnant women. He stated that there is a need for better methods of capturing drugs expenditure in household surveys.

The report advocated a reduction of the dependence of the health system on out of pocket payments.