Horizontal inequity in the utilisation of Continuum of Maternal Health care Services (CMHS) in India: an investigation of ten years of National Rural Health Mission (NRHM)

Background Continuum of Maternal Health Care Services (CMHS) has garnered attention in recent times and reducing socio-economic disparity and geographical variations in its utilisation becomes crucial from an egalitarian perspective. In this study, we estimate inequity in the utilisation of CMHS in India between 2005 and 06 and 2015-16. Methods We used two rounds of National Family Health Survey (NFHS) - 2005-06 and 2015-16 encompassing a sample size of 34,560 and 178,857 pregnant women respectively. The magnitude of horizontal inequities (HI) in the utilisation of CMHS was captured by adopting the Erreygers Corrected Concentration indices method. Need-based standardisation was conducted to disentangle the variations in the utilisation of CMHS across different wealth quintiles and state groups. Further, a decomposition analysis was undertaken to enumerate the contribution of legitimate and illegitimate factors towards health inequity. Results The study indicates that the pro-rich inequity in the utilisation of CMHS has increased by around 2 percentage points since the implementation of National Rural Health Mission (NRHM), where illegitimate factors are dominant. Decomposition analysis reveals that the contribution of access related barriers plummeted in the considered period of time. The results also indicate that mother's education and access to media continue to remain major contributors of pro-rich inequity in India. Considering, regional variations, it is found that the percentage of pro-rich inequity in high focus group states increased by around 3% between 2005 and 06 and 2015-16. The performance of southern states of India is commendable. Conclusions Our study concludes that there exists a pro-rich inequity in the utilisation of CMHS with marked variations across state boundaries. The pro-rich inequity in India has increased between 2005 and 06 and high focus group states suffered predominantly. Decentralisation of healthcare policies and granting greater power to the states might lead to equitable distribution of CMHS.