Socioeconomic and regional determinants of out of pocket expenditure on delivery care in India: Evidence from NFHS 4

Abstract

High out of pocket health expenditure (OOPE) remains a critical barrier to achieving universal health coverage in India, undermining equity in access to care and exposing households to financial vulnerability. This study examines the socioeconomic, demographic, and regional determinants of OOPE incurred for delivery care in India using data from the fourth round of the National Family Health Survey (NFHS 4, 2015 16). Descriptive statistics and ordinary least squares (OLS) regression are used to identify the factors associated with OOPE for maternal delivery care. The findings show that household wealth and education are the strongest predictors of OOPE, and that women covered by health insurance and those using private healthcare facilities incur significantly higher out of pocket costs. Substantial regional disparities are observed, with the western region reporting the highest OOPE share alongside the lowest health insurance coverage, while southern states also report significantly higher spending relative to other regions. Working women incur higher OOPE than non working women, and general caste households report higher spending, although caste category and place of residence (rural versus urban) do not show a statistically significant effect once other factors are controlled for. These results point to a persistent shift in the maternal healthcare landscape following the introduction of the Janani Suraksha Yojana (JSY) and related schemes. The study recommends strengthening institutional delivery care access and financial protection mechanisms, particularly for economically and socially vulnerable populations, as a step toward universal health coverage in India.