Bihar is a socioeconomically backward state with a persistently poor record with respect to maternal and child health indicators. Based on data from the National Sample Surveys on healthcare, this article evaluates the impact of the National Rural Health Mission (NRHM) on improving utilisation of maternal healthcare services in Bihar. It shows that NRHM has been effective in augmenting the utilisation of these services and reducing out-of-pocket expenditure on institutional deliveries in public facilities.

Bihar is a socioeconomically backward state with a persistently poor record with respect to maternal and child health (MCH) indicators. At the start of the National Rural Health Mission (NRHM)¹ in 2005, it was identified as a state requiring special focus and placed among the ‘empowered action group (EAG) states’². Although NRHM has been acknowledged to be a success at the national level, it is important to assess the progress made at the regional level, particularly in EAG states like Bihar and tailor-make suitable mopping-up strategies for each of these states.

The study

In this article, we attempt to analyse the level of maternal healthcare utilisation in the state of Bihar, with three main objectives:

• Identify the factors affecting the utilisation of maternal care services and choice of facility between the pre- and post-NRHM periods;
• Assess the effectiveness of Janani Suraksha Yojana³ (JSY) in enhancing institutional delivery, particularly in public facilities; and
• Estimate the out-of-pocket expenditure (OOPE) on maternal care⁴ (on institutional delivery and all the three components of care – antenatal care (ANC), institutional delivery, and postnatal care (PNC) separately) in the pre- and post-NRHM periods according to type of facility (public and private). Also identify the factors affecting OOPE.

We use the unit-level data collected using Schedule 25 of the 60th (2004) and 71st (2014) rounds of the National Sample Survey (NSS) to carry out the analysis⁵. These two years represent pre-NRHM and post-NRHM periods, respectively.

Results

Table 1 describes the receipt of ANC, delivery, and PNC, and the magnitude of OOPE in the pre- and post-NRHM periods by type of provider. The uptake of every component of maternal care increased dramatically between 2004 and 2014 in Bihar. For example, receipt of ANC services increased from 54.8% to 96.2%, while the uptake of institutional delivery increased nearly four-times – from a mere 18.5% to 70.8% during the study period.

Table 1. Uptake of maternal care and OOPE (%) in Bihar by type of provider, 2004 and 2014

Source: Calculated from NSS data by the authors.

The utilisation of public health facilities in seeking maternal care increased manifold during 2004-2014, whereas the utilisation of private facilities either declined or increased marginally during the same period. For example, institutional delivery in public facilities increased by 13 times (4.1% to 52.5%), while it increased marginally in private facilities – from 14.4% to 18.3%. The uptake of ANC increased nearly eight times in public facilities, while it declined from 45.8% to 26.5% in private facilities. Simultaneously, the utilisation of all three maternal care services from public facilities increased substantially from 0.4% to 26% during 2004-2014, while it increased marginally from 7.4% to 8.4% in private facilities during the study period.

The Table also reveals that, although the OOPE on institutional delivery in public facilities declined from US$34 to US$25, it increased nearly four times from US$32 to US$126 in the private facilities during 2004-2014. However, OOPE on all the three components of maternal care increased three-fold (from US$12 to US$37) in public facilities and more than four-fold (from US$51 to US$221) in private facilities.

We found that the likelihood of institutional delivery has increased by 11.73 times during 2004-2014 even after controlling for a range of potential confounders. The probability of institutional delivery has also increased significantly with age, urban residence, secondary or higher levels of educational attainment, and an increased level of household affluence; however, it has declined among minorities and socially marginalised sections.

It has also been revealed that urban, educated, and affluent women are significantly more likely to deliver in private facilities, while older women and those belonging to minority communities and socially marginalised sections, are significantly less likely to deliver in private facilities. Compared to public facilities, the probability of institutional delivery in private facilities declined by 90% during 2004-2014.

Table 2 reports the results obtained from decomposition⁶, which reveals that 94% of the increase in institutional delivery – broken into 96% increase in public institutions and 36% decline in private institutions – can be attributed to JSY, the year of survey, and omitted variables. Given that institutional delivery in Bihar had increased by only 10 percentage points in the 13 years before the implementation of JSY, while it has increased by almost three times in the next decade (when NRHM was introduced), we may argue that, without JSY, the substantial increase of institutional delivery could not have been possible in Bihar.

Table 2. Understanding effects of Janani Suraksha Yojana (JSY) on child birth in Bihar: A decomposition analysis

Note: The decompositions were carried out by year (2004 and 2014) by employing (probit) regression models after controlling for the variables included in the models for child birth.
Source: Calculated from NSS data by the authors.

Our findings suggest that the OOPE on institutional delivery in the post-NRHM period in public facilities was 30% lower than that of the pre-NRHM period; however, the OOPE on all the three components of maternal care in the post-NRHM period in public facilities have increased by 13% compared to the pre-NRHM period. Compared to OOPE in public facilities for institutional delivery in the pre-NRHM period, likelihood of OOPE in private facilities in post-NRHM period increased by 249%, such increase for all three maternal care components was found even more – by 322%. These indicate that OOPE in private facilities for childbirth and other maternal care related expenditure have increased substantially between 2004 and 2014.

Discussion

The salient findings of this research are as follows. First, institutional delivery ─ even after controlling other potential confounding variables ─ has increased by 11.73 times in Bihar between 2004 and 2014, while delivery in private facilities declined as much as by 90% compared to public facilities in the same period. Secondly, the JSY has been successful, particularly in bringing pregnant women in public facilities for delivery. We found that 96% increase in delivery in public institutions can be attributed to JSY, the year of survey, and omitted variables, of which year of survey plays a minimal role. Thirdly, although the OOPE on all three components of maternal care increased by 13% compared to the pre-NRHM period, the OOPE on institutional delivery in the post-NRHM period in public facilities declined by 30% even after controlling for a range of confounding variables. Finally, the OOPE on maternal healthcare in private facilities in the post-NRHM period experienced a quantum jump in the resource-poor state of Bihar.

Our study, however, points out a significant inequity regarding the choice of providers in the utilisation of maternal healthcare in Bihar. Women belonging to the urban, educated, affluent sections, and upper-caste Hindu households are more likely to opt for institutional delivery in both public and private facilities, compared to their rural, non-literate, poor, Scheduled Castes/Tribes, and non-Hindu counterparts.

These findings reiterate concerns related to quality of care in the public facilities and affordability of services in the private facilities (Ghosh et al. 2015, Mohanty and Kastor 2017). It may also be noted that though the uptake of ANC and institutional delivery increased significantly in public facilities, the utilisation of all three maternal healthcare services did not increase commensurately, neither in public nor in private facilities. This raises questions about the status of continuum of care of maternal health care services in Bihar, voiced in other studies (McDougal et al. 2017), and underlines the need for reorganisation of the scope of JSY in the future.

Our findings also suggest that although the OOPE on institutional delivery declined in public facilities in Bihar during the study period, an overall increase in OOPE on institutional delivery was entirely driven by manifold increase in OOPE in private facilities. This is consistent with the trend observed at the national level (Mohanty and Kastor 2017, Goli et al. 2016). Further, the OOPE on ANC and PNC has increased in the post-NRHM period, even in public facilities. This possibly indicates a rise in the cost of transportation, non-availability of drugs and diagnostic tests, and other informal payments in such facilities in Bihar. The overall increase in OOPE on delivery care may be attributed to the fact that a significantly higher proportion of caesarean sections are conducted in private facilities in Bihar, compared to public facilities (Mahapatra et al. 2018).

Based on the present findings, it may be concluded that the NRHM has been effective in Bihar in augmenting the utilisation of maternal care services and reducing OOPE on institutional deliveries in public facilities. Ensuring horizontal equity and continuum of care remain major challenges before the state. The latter may be addressed if the cash incentive under the NRHM to providers and service recipients are provided only if continuum of care is fulfilled. Further, private healthcare providers should be regulated in regard to pricing and quality of care, which in turn necessitates the vigorous implementation of Clinical Establishment Act (CEA) in Bihar (Keshri 2018). Additionally, provisioning of transportation to public facilities to ensure better access, ensuring availability of drugs and diagnostics tests within public facilities, and improvements in the quality of care would be essential for optimal utilisation of public facilities.

Notes:

1. National Rural Health Mission (NRHM) was launched in 2005 to provide affordable healthcare in rural areas, improve healthcare quality, and reduce maternal and infant mortality. In 2013, the mission was rebranded as the National Health Mission (NHM) with two components, NRHM and National Urban Health Mission (NUHM).
2. In India, the eight socioeconomically backward statesof Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal, and Uttar Pradesh – referred to as the ‘Empowered Action Group’ (EAG) states – lag behind in terms of demographic transition and have the highest infant mortality rates in the country.
3. Janani Suraksha Yojana (JSY) is a safe motherhood intervention, launched in 2005 under the National Health Mission. It is being implemented with the objective of reducing maternal and neonatal mortality by promoting institutional delivery among poor pregnant women.
4. OOPE is defined as the expenditure incurred by a woman during the uptake of different components of maternal care net of reimbursement.
5. The study was supported by a grant from the Bill and Melinda Gates Foundation.
6. The process of splitting a component of a statistical model into its constituent parts by using certain statistical techniques.

Further Reading

• Ghosh, Saswata, Md. Zakaria Siddique, Anamitra Barik and Sunil Bhaumik (2015), “Determinants of Skilled Delivery Assistance in a Rural Population: Findings from an HDSS Site of Rural West Bengal, India”, Maternal and Child Health Journal, 19(11):2470-2479.
• Goli, Srinivas, Moradhvai, Anu Rammohan, Shruti and Jalandhar Pradhan (2016), “High Spending on Maternity Care in India: What are the Factors Explaining It?”, PLoS One, Vol 11.
• Keshri, VR (2018), ‘Government Stewardship for Health Care: A Scoping Review of Regulatory Frameworks for Health Care Providers’, Working Paper 03/2018, The Centre for Health Policy, Asian Development Research Institute, Patna, Bihar.
• McDougal, Lotus, Yamini Atmavilas, Katherine Hay, Jay G Silverman, Usha K Tarigopula and Anita Raj (2017), “Making the Continuum of Care Work for Mothers and Infants: Does Gender Equity Matter? Findings from a Quasi-experimental Study in Bihar, India”, PLoS One, 12(2).
• Mohanty, Sanjay K and Anshul Kastor (2017), “Out-of-pocket Expenditure and Catastrophic Health Spending on Maternal Care in Public and Private Health Centres in India: A Comparative Study of Pre and Post National Health Mission Period”, Health Economics Review, 7(31):1-15. Available here.
• Mahapatra, S, A Raj, A Das and T Mahapatra (2018), ‘Distribution and Determinants of Caesarean Section Deliveries in Rural Bihar’, Working Paper 05/2018, The Centre for Health Policy, Asian Development Research Institute, Patna, Bihar.