Insights into Maternal Health Expenditure from Mumbai Slums: Catastrophe and Coping

Rationale: Poorer households may find it difficult to plan for, and meet, the costs of maternal care. The ability to meet these costs can act as a significant barrier to service access and even be a determinant of maternal and neonatal morbidity and mortality. In the absence of formal health insurance to smooth consumption and reduce the risk of catastrophic health spending, households may adopt a range of alternative financing strategies. These strategies have implications for the extent to which health payments impact on consumption, poverty and the long-run burden of delivery care payments. Objectives: We analyze direct and indirect maternal health expenditure in urban slum communities in Mumbai. The first objective is to understand what proportion of maternal health expenditure is due to formal and informal payments, and how this proportion varies by socioeconomic status (SES). The second objective is to analyze the sources of finance used to meet these expenditures. Finally, we analyse the relative impact of maternal health expenditure on current consumption, to estimate the incidence of catastrophic payments. Methodology: We use data on delivery care expenditures, sources of finance and socioeconomic characteristics, collected by the Society for Nutrition, Education and Health Action (SNEHA) during post-partum patient interviews conducted between 2005-2006. Data come from a pro-poor sample collected from 1200 participants in slum communities in Mumbai, as part of the City Initiative for Newborn Health. We divided the analysis into two steps. Firstly, we aggregated different categories of maternal health expenditure and distinguished between the formal and informal payments made within those categories. Using data on education, ownership and structure of the house, source of water and sanitation facilities, we obtained socioeconomic status score which was applied to analysis of whether delivery care expenditures varied significantly by SES. Secondly, following the approach adopted by Flores et al. 2008*, using data on maternal health expenditures and coping strategies (e.g. wages or earnings, reduced food purchases, borrowing, savings, sales of assets) we calculated the relative disruption to current consumption due to maternal health expenditure Pi=(i-i)/(xi-i), where i represents delivery care expenditures, xi total household expenditure and i the amount of expenditure financed with coping strategies. This measure allowed us to identify a) catastrophic payments incurred by a household and b) the prevalence of catastrophic payments in the population. Using data on coping strategies, we then identified the “hidden poor” and “transient poor”** and postulated that a reduction of informal out-of-pocket delivery care expenditures could potentially reduce the number of “transient poor”