District-Level Patterns of Health Insurance Coverage and Out-of-Pocket Expenditure on Caesarean Section Deliveries in Public Health Facilities in India

R. Kamath*, H. Brand, N. Nayak, V. Lakshmi, R. Verma, P. Salins

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Reducing catastrophic out-of-pocket expenditure (OOPE) and increasing the rates of institutional deliveries are part of the Sustainable Development Goals (SDGs). India has made significant progress on the maternal and child health front in recent years. India's National Health Mission (NHM) has been able to increase rates of institutional deliveries. In the present study, we aim to ascertain district-level patterns of percentage of health insurance coverage in the National Family Health Surveys NFHS 4 and NFHS 5. We also aim to ascertain district-level patterns of out-of-pocket expenditure on C-section deliveries in public health facilities in NFHS 4 and NFHS 5. The present study explores district-level data associated with health insurance coverage (%) and out-of-pocket expenditure in a public health facility (in INR) observed across NFHS 4 and NFHS 5. A spatial analysis was carried out using QGIS 3.26 (Mac version) and GeoDA A visual assessment of the maps across NFHS 4 and NFHS 5 shows improvement in insurance coverage at the district level across the two surveys. Despite an increase in insurance coverage, North East India has experienced an increase in OOPE for C-section deliveries. Rajasthan and various parts of South India have experienced a decrease in OOPE for C-section deliveries. Kerala has experienced a rise in insurance coverage and OOPE for C-section deliveries. Univariate LISA cluster and significance maps revealed that Kerala and Tamil Nadu, the eastern coast of India and parts of Mizoram are hot spots, whereas Jammu and Kashmir and parts of Uttar Pradesh and Gujarat are cold spots. Both these findings are significant. Rajasthan emerges as a significant hot spot along with parts of Assam and a few districts on the eastern coast of India in Tamil Nadu and Andhra Pradesh. Jammu and Kashmir, Ladakh, parts of Uttar Pradesh, Maharashtra, and Karnataka have emerged as significant cold spots. The South Indian states of Kerala and Tamil Nadu are no longer hot spots indicating geospatial variations across time. An increase in the number of hot spots across NFHS 4 and NFHS 5 indicates rising out-of-pocket expenditure for C-sections despite growth in health insurance coverage. The present study does not offer any evidence to suggest that health insurance coverage decreases OOPE on C-section deliveries at government facilities. With RSBY having been launched in 2008 and Ayushman Bharat in 2018, high levels of OOPE on C-section deliveries at government facilities raise serious concerns about the efficacy of PFHIs in reducing OOPE. The government would need to plug the well-documented weaknesses of PFHIs, such as fraud, double charging, poor enrolment, and lack of awareness in addition to the unfortunate phenomena of "tips" and "tie ups" mentioned earlier that plague the public healthcare system, if we are to see any reduction in OOPE in the foreseeable future.
Original languageEnglish
Article number4608
Number of pages17
Issue number5
Publication statusPublished - 1 Mar 2023


  • district-level patterns
  • health insurance coverage
  • out-of-pocket expenditure
  • caesarean section deliveries
  • public health facilities in India

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