IMPACT OF SEX COMPOSITION OF LIVING CHILDREN AND COUPLES' AGREEMENT ON SUBSEQUENT FERTILITY IN INDIA.

The desire for children could be considered a reliable predictor of subsequent fertility. At the same time, the sex composition of surviving children, along with other demographic and socioeconomic factors, may affect a couple's fertility desire and, therefore, their subsequent fertility. This study examined the impact of the sex composition of living children and a couple's agreement on fertility desire on their subsequent fertility in India using data came from two rounds of nationally representative surveys: the India Human Development Survey (IHDS)-I (2004-05) and IHDS-II (2011-12). To understand which factors affect the chances of an additional pregnancy or childbirth, a random effects logistic regression model was applied to the panel data. It was found that the fertility desires of both marital partners were important in determining the chances of subsequent fertility. About 35% of the couples wanting to limit children had undergone pregnancy or childbirth, while 76% of the couples wanting more children had conceived or given birth to children. In the case of discordance between the spouses, subsequent fertility was found to remain intermediate between those agreeing to continue childbirth and those wanting to limit it. The findings also affirmed that child sex preference, specifically son preference, still persists in Indian society. More than 80% of the couples with only daughters in IHDS-I mutually wanted to have additional children, whereas in families that only had sons, the chance of a subsequent pregnancy was inversely associated with the number of sons. Strong patriarchal settings, combined with cultural and socioeconomic factors, affect the persistence of sex preference in India. Programmes aimed at increasing family planning use need to address son preference and should include components that promote the value of girl children.

TO WHAT EXTENT DO COUPLES' PRE-MARITAL COMMUNICATIONS AFFECT THEIR POST-MARITAL FERTILITY BEHAVIOUR IN INDIA?

Reproduction in India is mainly confined to within marriage. The fertility preferences of spouses will not necessarily be the same, but discussion between couples creates scope for understanding between spouses after marriage. Knowing each other's opinions facilitates decision-making on sensitive matters such as contraception use and desired family size. This study used data from the India Human Development Survey-II (2011-12), and was based on a sample of 31,276 currently married women. The aim was to understand the role of pre-marital communication, studied through the choosing of husbands, mutual communication before marriage and duration of time spouses knew each other before marriage on the fertility preferences of couples post-marriage. These preferences included contraception use, who has most say on the number of children and the gap between desired and actual number of offspring. The results showed that wives who knew their husbands or who had any kind of communication with them before marriage had a greater chance of being involved in fertility decisions. However, most fertility decisions were found to be male-driven. Wives who knew their husbands for more than a month before marriage took more decisions on number of children (27%) than those who only knew their husbands from the day of their wedding (20%). Wives were less likely to have more children/sons/daughters than desired if they had some communication with their husbands before marriage. A better understanding of fertility preferences between spouses might help to curb unwanted births through delaying or limiting births by contraception use. Families in India could encourage couples to interact before marriage so they can make collective decisions on contraception use and/or the number of children they have.

Disease and age pattern of hospitalisation and associated costs in India: 1995-2014.

OBJECTIVES: The prime objective of this study is to examine the trends of disease and age pattern of hospitalisation and associated costs in India during 1995-2014. DESIGN: Present study used nationally representative data on morbidity and healthcare from the 52nd (1995) and 71st (2014) rounds of the National Sample Survey. SETTINGS: A total of 120 942 and 65 932 households were surveyed in 1995 and 2014, respectively. MEASURES: Descriptive statistics, logistic regression analyses and decomposition analyses were used in examining the changes in patterns of hospitalisation and associated costs. Hospitalisation rates and costs per hospitalisation (out-of-pocket expenditure) were estimated for selected diseases and in four broad categories: communicable diseases, non-communicable diseases (NCDs), injuries and others. All the costs are presented at 2014 prices in US$. RESULTS: Hospitalisation rate in India has increased from 1661 in 1995 to 3699 in 2014 (per 100 000 population). It has more than doubled across all age groups. Hospitalisation among children was primarily because of communicable diseases, while NCDs were the leading cause of hospitalisation for the 40+ population. Costs per hospitalisation have increased from US$177 in 1995 to US$316 in 2014 (an increase of 79%). Costs per hospitalisation for NCDs in 2014 were US$471 compared with US$175 for communicable diseases. It was highest for cancer inpatients (US$942) followed by heart diseases (US$674). Age is the significant predictor of hospitalisation for all the selected diseases. Decomposition results showed that about three-fifth of the increase in unconditional costs per hospitalisation was due to increase in mean hospital costs, and the other two-fifth was due to increase in hospitalisation rates. CONCLUSION: There has been more than twofold increase in hospitalisation rates in India during the last two decades, and significantly higher rates were observed among infants and older adults. Increasing hospitalisation rates and costs per hospitalisation are contributing substantially to the rising healthcare costs in India.

Disease-specific out-of-pocket and catastrophic health expenditure on hospitalization in India: Do Indian households face distress health financing?

BACKGROUND: Rising non-communicable diseases (NCDs) coupled with increasing injuries have resulted in a significant increase in health spending in India. While out-of-pocket expenditure remains the major source of health care financing in India (two-thirds of the total health spending), the financial burden varies enormously across diseases and by the economic well-being of the households. Though prior studies have examined the variation in disease pattern, little is known about the financial risk to the families by type of diseases in India. In this context, the present study examines disease-specific out-of-pocket expenditure (OOPE), catastrophic health expenditure (CHE) and distress health financing. METHODS AND MATERIALS: Unit data from the 71st round of the National Sample Survey Organization (2014) was used for this study. OOPE is defined as health spending on hospitalization net of reimbursement, and CHE is defined as household health spending exceeding 10% of household consumption expenditure. Distress health financing is defined as a situation when a household has to borrow money or sell their property/assets or when it gets contributions from friends/relatives to meet its health care expenses. OOPE was estimated for 16 selected diseases and across three broad categories- communicable diseases, NCDs and injuries. Multivariate logistic regression was used to understand the determinants of distress financing and CHE. RESULTS: Mean OOPE on hospitalization was INR 19,210 and was the highest for cancer (INR 57,232) followed by heart diseases (INR 40,947). About 28% of the households incurred CHE and faced distress financing. Among all the diseases, cancer caused the highest CHE (79%) and distress financing (43%). More than one-third of the inpatients reported distressed financing for heart diseases, neurological disorders, genito urinary problems, musculoskeletal diseases, gastro-intestinal problems and injuries. The likelihood of incurring distress financing was 3.2 times higher for those hospitalized for cancer (OR 3.23; 95% CI: 2.62-3.99) and 2.6 times for tuberculosis patients (OR 2.61; 95% CI: 2.06-3.31). A large proportion of households who had reported distress financing also incurred CHE. RECOMMENDATIONS: Free treatment for cancer and heart diseases is recommended for the vulnerable sections of the society. Risk-pooling and social security mechanisms based on contributions from both households as well as the central and state governments can reduce the financial burden of diseases and avert households from distress health financing.

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.

BACKGROUND: The National Health Mission (NHM), one of the largest publicly funded maternal health programs worldwide was initiated in 2005 to reduce maternal, neo-natal and infant mortality and out-of-pocket expenditure (OOPE) on maternal care in India. Though evidence suggests improvement in maternal and child health, little is known on the change in OOPE and catastrophic health spending (CHS) since the launch of NHM. AIM: The aim of this paper is to provide a comprehensive estimate of OOPE and CHS on maternal care by public and private health providers in pre and post NHM periods. DATA AND METHOD: The unit data from the 60th and 71st rounds of National Sample Survey (NSS) is used in the analyses. Descriptive statistics is used to understand the differentials in OOPE and CHS. The CHS is estimated based on capacity to pay, derived from household consumption expenditure, the subsistence expenditure (based on state specific poverty line) and household OOPE on maternal care. Data of both rounds are pooled to understand the impact of NHM on OOPE and CHS. The log-linear regression model and the logit regression models adjusted for state fixed effect, clustering and socio-economic and demographic correlates are used in the analyses. RESULTS: Women availing themselves of ante natal, natal and post natal care (all three maternal care services) from public health centres have increased from 11% in 2004 to 31% by 2014 while that from private health centres had increased from 12% to 20% during the same period. The mean OOPE on all three maternal care services from public health centres was US$60 in pre-NHM and US$86 in post-NHM periods while that from private health center was US$170 and US$300 during the same period. Controlling for socioeconomic and demographic correlates, the OOPE on delivery care from public health center had not shown any significant increase in post NHM period. The OOPE on delivery care in private health center had increased by 5.6 times compared to that from public health centers in pre NHM period. Economic well-being of the households and educational attainment of women is positively and significantly associated with OOPE, linking OOPE and ability to pay. The extent of CHS on all three maternal care from public health centers had declined from 56% in pre NHM period to 29% in post NHM period while that from private health centres had declined from 56% to 47% during the same period. The odds of incurring CHS on institutional delivery in public health centers (OR .03, 95% CI 0.02, 06) and maternal care (OR 0.06, 95% CI 0.04, 0.07) suggest decline in CHS in the post NHM period. Women delivering in private health centres, residing in rural areas and poor households are more likely to face CHS on maternal care. CONCLUSION: NHM has been successful in increasing maternal care and reducing the catastrophic health spending in public health centers. Regulating private health centres and continuing cash incentive under NHM is recommended.