Out of pocket expenditure on maternal and child health care services

among rural households in Dedaye Township, Myanmar

Wai Wai Hant, Saw Sawt, Hla Mya Thwe Einda, Nyi Nyi Zayart,
Phyu Phyu Aye, Hnin Lae Yi Khaingv and Myo Thurein Lattv

Abstract
This study was conducted with the aim of assessing the out-of-pocket expenditures
(OOPE) of households on maternal and child health care services in rural areas. It was a
cross-sectional study conducted in rural areas of Dedaye Township, Ayeyarwady Region
in December 2015. Face-to-face interview using a pre-tested structured questionnaire
was carried out with 331 households having mothers of under-one year old children. The
OOPE on maternal and child health care incurred by the households during 2014 and 2015
were estimated. In analysis, the households were disaggregated into five quintiles based
on their annual expenditure per capita. On average, the households spent 6% of their
total household expenditure only for maternal and child health care. The average OOPE
for antenatal care in government and private hospitals were 6,014 kyats and 12,051 kyats
per visit respectively. Depending on the type of birth attendant, the households incurred
12,750 to 20,737 kyats for home delivery. The households had to expense 86,416 kyats
to 228,255 kyats for delivery at government hospital and 176,340 kyats to 335,063 kyats
at private hospital. The institutional delivery costs approximately seven times more than
home delivery. The average cost for hospitalization of under one year old children was
120,900 kyats. The OOPE for maternal and child health care caused financial catastrophe
in 9.4% of the households if the cutoff point is at 40% of non-food expenditures of
the households. Financial burden was high among households where the women had
undergone institutional delivery. No considerable difference was noted in the share of
household expenditure spent for maternal and child health care between the poorest
households and richer households (17.2% and 17.5% respectively) indicating that the
financial burden was highest in the poorest households. As out of pocket expenditures
on maternal and child health care alone can cause financial catastrophe among the
households, it should be considered as a priority area in establishing financial protection
mechanisms. Furthermore, financial burden of institutional delivery on the households
should be taken into account while strengthening institutional delivery.

t Department of Medical Research

Maternal and Reproductive Health Division, Department of Public Health
v Relief International

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Introduction
Myanmars health care services are largely financed by out of pocket payment
(80%) at the point of care[1]. High out of pocket expenditures make the population difficult
to access the health care services including antenatal care, care for child birth, post-natal
care, neonatal care and child health care[2]. The costs incurred at the point of referral are
also a barrier to accessing emergency care which are grouped into the following categories
for convenience; meals (including caretaker), treatment and drugs, laboratory and other
investigations, and finally administration fees[2]. Providing financial support for patients
needing to access emergency care is essential in particular for the most vulnerable
members of a community and communities that are defined as hard to reach. In order
to increase health care utilization and reduce the financial burden of the poor, user fee
exemption mechanism was applied in almost all of the governmental health facilities in
Myanmar nearly two years ago.

In addition, maternal and child health (MNCH) programme aiming to improve

maternal and child healthcare through the strengthening of the township health system
was implemented in six townships in Ayeyarwaddy Regions since 2011. The programme
works on both supply and demand side interventions supporting: management and
administration, planning and coordination, supervision and monitoring, training, outreach
sessions, essential medicine and medical supplies, activities at community level, health
facility investment and operational research.

Previous qualitative studies done in some townships of Ayeyarwaddy Region have

found that financial barrier to access health care was still existing even after implementation
of MNCH programme and introducing user fees exemption mechanisms[3]. A few studies
have evaluated the out-of-pocket expenditure on health care after applying user fee
exemption mechanism; all of them, however, were hospital based studies conducted at
the tertiary hospitals[4, 5]. There is no information about household spending on maternal
and child health care in rural area. Furthermore, the study will provide information that
can be utilized in establishing financial protection mechanism for maternal and child
health care.

This study was conducted with the aim of assessing the out of pocket expenditures
of household on maternal and child health care services in rural areas.

General Objective
To determine the out of pocket expenditure for maternal and child health care
services among the rural households in Dedaye Township

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Specific Objectives
Among the rural households in Dedaye Township,
1. To find out the utilization of maternal and child health care services
2. To assess the out of pocket expenditure for maternal and child health care services
3. To identify the proportion of catastrophic health expenditure due to utilization of
maternal and child health care services

Methodology
Study design: This was a cross-sectional descriptive study conducted in the rural area of
Dedaye Township during December 2015.
Study area: The study was carried out in 24 villages of three RHC catchment areas of
Dedaye Township, namely, Thauk Kya, Boe Toke and Hmaw Eing.
Study population: Households having mothers who had delivered within one year, and
have children aged one year or less at the time of data collection
Operational definition
1. Skilled health personal: Healthcare providers are doctors, nurses, lady health visitors,
health assistants and midwives.
2. Informal providers: Informal providers include traditional birth attendants, traditional
healers and quacks
3. Institutional delivery: Delivery taken place at government hospitals, private hospitals,
rural health centers (RHC) and sub rural health centers (sub RHC)

Sampling and sample size: A multi-stage sampling method was used to select the
sample. Firstly, three RHC catchment areas were selected randomly. Then villages from
each selected RHCs were identified based on the number of mothers who have children
aged one year or less. Eight villages from each RHC were selected. All mothers who have
children aged one year or less were interviewed from 24 villages. A total of 331 households
were involved in this study. As we did not find two or more eligible mothers from a single
household, we interviewed one mother per household.

Data collection: A structured interview was prepared for the data collection and pre-
tested in a village from Kone Chan Kone township before the actual survey. Maternal and
child health care services in this study was defined as antenatal care, delivery, postnatal
care, care for pregnancy related health problems, health care for illnesses of under one
year old children and childhood immunization.

Out of pocket expenditures (OOPE) are the payments incurred by the households
for health services without compensations from a third party[6]. We categorized OOPE
incurred by the households for maternal and child health care services into the direct

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medical and non-medical cost. Direct medical cost included cost for medicines, investi-
gations, operation charges and fees to health care providers. Direct non-medical cost
comprised cost of registration, informal payments for health care providers and trans-
portation and meal for both patient and an attendant. Information of maternal and child
health care utilization and OOPE for maternal and child health care were obtained from
the mothers. But both mothers and their family members were asked to obtain household
income and expenditure data.

Data analysis: Descriptive statistics (mean and percent distribution) was carried out to
understand the differentials in out of pocket expenditure for utilization of maternal and
child health services. Catastrophic health expenditure (CHE) was estimated using WHO
recommended method in which CHE was defined as OOPE for health care 40% of
households capacity to pay (non-food expenditure)[7]. The unit of analysis was a household,
as the study included information of both mothers and children. The households were
disaggregated into five quintiles based on their annual expenditure per capita. At the time
of survey, 1295 kyats was equivalent to one USD.

Ethical consideration: Ethics approval was obtained from Ethics Review Committee,
Department of Medical Research. All the participants were explained thoroughly about
the purpose of the study, and written informed consent was obtained prior to the
interview. Privacy of their responses was maintained. In order to ensure confidentiality,
code numbers were assigned on the questionnaire instead of the participants name. Only
investigators had access to the data.

Results
Background information of mothers and children
Background characteristics of mothers and children are shown in Table (1). Mean
age of the mothers is 29 6.4 years with a range of 17 to 45 years. Mean age of the
children was 6 3.6 months. The median annual household income and expenditure were
1,200,000 kyats and 1,990,100 kyats respectively. The average household size was 5 1.7.

Table 1. Socio-demographic characteristics of mothers and children involved in the study

(n = 331)

Variable Number Percent

Education of mothers
Illiterate 15 4.6
Read/write 86 26.0
Primary school 158 47.7
Middle school 46 13.9
High school 9 2.7
Graduate 17 5.1

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Occupation of mothers
Dependent 187 56.5
Farm works 24 7.3
Fishery 10 3.0
Selling 8 2.4
Odd jobs 102 30.8

Annual family income

60,000 - 800,000 88 26.6
> 800,000 - 1,200,000 84 25.4
> 1,200,000 - 1,800,000 86 26.0
> 1,800,000 - 15,000,000 73 22.0

Number of family members

2 to 5 members 228 68.9
6 to 12 members 103 31.1

Gender of children
Male 167 50.5
Female 164 49.5

Expenditure quintile
Lowest (539,300 - 1,395,400) 66 20
Second (> 1,395,400 - 1,797,600) 66 20
Third (> 1,797,600 - 2,235,000) 66 20
Forth (> 2,235,000 - 3,156,840) 66 20
Highest (> 3,156,840 - 8,872,400) 67 20

Utilization of antenatal care, delivery and post natal care services

Almost all mothers (313, 94.6%) reported that they sought antenatal care from
skilled health personals during their last pregnancy, and (231, 73.8%) received skilled
antenatal care for at least four times. Delivery with skilled birth attendants was found
among 225 (68.0%) mothers and 150 (45.3%) had institutional delivery. Among 313
mothers who sought postnatal care, 232 (74.1%) received postnatal care from skilled
health providers for at least one time.

Out-of-pocket expenditure (OOPE) on MNCH care

The OOPE for antenatal care and pregnancy related illnesses: The OOPE for getting
antenatal care and out-patient care for pregnancy related health problems among
mothers are shown in table (2). The average OOPE for accessing antenatal care ranged
from 551 to 12,051 kyats and that for receiving out-patient care was 300 to 19,492 kyats
depending on the health facilities and type of illnesses. Nine mothers (5%) were admitted
to government hospital due to illnesses such as pre-eclampsia, eclampsia, anaemia and
ante-partum hemorrhage (APH). The total cost per visit of hospitalization ranged from
3,333 kyats to 151,667 kyats (mean = 62,444 kyats). The direct medical costs were 0 to

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116,667 kyats (mean = 29,092 kyats). The direct non-medical costs incurred were from
3,333 kyats to 69,000 kyats (mean = 33,351 kyats).

Table 2. Out-of-pocket expenditure on antenatal care, out-patient care for pregnancy related
illnesses, illnessesof mothers during postnatal period and illnesses among children

Health facilities Mean costs in kyats (per visit) for antenatal care

Direct medical Direct non-medical Total cost

Government hospital 2,862 3,179 6,041
RHC/sub RHC 362 421 783
Private facilities 6,119 5,932 12,051
Informal providers 275 276 551

Illness and health facilities No. of mothers Mean cost in kyats (per visit) for
pregnancy related illnesses

Direct medical Direct non- Total

medical

Eclampsia
Gov. hospital 11 17,613 1,879 19,492
RHC/sub RHC 12 1,583 250 1,833
Private facility 8 6,500 4,750 11,250

Anaemia
Gov. hospital 7 3,414 2,857 6,271
RHC/sub RHC 25 1,772 760 2,532
Private facility 14 7,056 2,440 9,496

APH
Gov. hospital 1 6,000 2,000 8,000
RHC/sub RHC 1 750 2,250 3,000
Private facility 1 0 300 300

PROM
Gov. hospital 1 0 4,000 4,000
RHC/sub RHC 4 1,500 375 1,875
Private facility 0 NR NR NR

Pre eclampsia
Gov. hospital 26 13,389 4,225 17,614
RHC/sub RHC 13 545 720 1,265
Private facility 5 7,500 6,000 13,500

Minor illnesses
Gov. hospital 0 NR NR NR
RHC/sub RHC 30 2,287 1,055 3,342
Private facility 29 6,953 6,611 13,564

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Health facilities No. of mothers Mean cost in kyats (per visit) for postnatal
illnesses among mothers
Direct medical Direct non- Total
medical
Gov. hospital 10 6,167 3,190 9,357
RHC/sub RHC 21 2,476 532 3,008
Private facility 7 6143 2071 8214
Informal providers 22 6679 114 6793
Health facilities No. of children Mean cost in kyats (per visit) for illnesses
among children
Direct medical Direct non- Total
medical
Gov. hospital 24 19,580 13,029 32,609
RHC/sub RHC 40 1,349 458 1,807
Private facility 56 6,735 4,549 11,284
Informal providers 37 3,632 1,622 5,254

The OOPE for delivery: There were 181 (54.7%) home deliveries and 150 (45.3%) instit-
utional deliveries. Most of the home deliveries were attended by midwives (74, 40.9%),
Auxiliary Midwives (22, 12.2%) and traditional birth attendants (80, 44.2%). The average
provider payment incurred by the households for the home delivery with a midwife was
20,473 kyats (range 0-50,000 kyats), with an Auxiliary Midwife was 15,682 kyats (range
0-25,000 kyats) and with a traditional birth attendant was 12,750 (range 5,000-25,000
kyats). The transportation charges spent by the households to bring the birth attendants
to their home ranged from 500 kyats to 20,000 kyats (mean = 3,325 kyats). There was only
one mother who delivered her last child by Lady Health Visitor (LHV) and the fee for birth
attendants was 30,000 kyats. Four home deliveries were attended by their own mothers.
There were five mothers who delivered their last child at RHC or sub RHC with midwives
and the fees for health care providers ranged from 10,000 kyats to 20,000 kyats.

Table 3. Out-of-pocket payment for delivery at hospitals

Facility and Mean OOPE in kyats

type of Direct Transport Meal Informal Travel and Total
delivery medical payment meal costs for
attendants
Gov. hospital
Normal (n = 59) 43,429* 12,728 16,042 20,457 28,603 121,259
LSCS (n = 67) 93,225* 15,897 33,924 31,022 54,187 228,255
Assisted (n = 6) 30,167* 12,500 10,000 18,666 15,083 86,416
Private hospital
Normal (n = 5) 117,100** 15,600 9,000 8,000 26,640 176,340
LSCS (n = 8) 217,750** 19,188 14,375 5,000 78,750 335,063
* Direct medical cost incurred at government hospitals included drug costs and costs for
investigations

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** Direct medical cost incurred at private hospitals included drug costs, cost for investigations and
fees for health care providers

Table (3) presents the OOPE incurred by the households for delivery at hospitals.
One hundred and forty five deliveries took place at the hospitals; 132 at government
hospitals and the remaining 13 were at the private hospitals. Mann Whitney test was
applied to identify difference in average OOPE for delivery at the private hospitals and the
gove-rnment hospitals and found that the average OOPE for delivery at private hospitals
was significantly higher (P = 0.03).

The OOPE for postnatal care: We found out that there was no extra cost for postnatal care
if the mothers were healthy during their postnatal period. The OOPE for OPD care due
to health problems during postnatal period are shown in table (2). Only six mothers had
been admitted to hospital during postnatal period. The total cost per visit was 3,500 kyats
to 500,000 kyats (mean = 11,3972 kyats). The direct medical costs were 3,500 to 374,250
kyats (mean = 72,791 kyats). The direct non-medical costsincurred from 0 kyat to 18,333
kyats (mean = 10,866 kyats).

The OOPE for illnesses among under-one children and immunization: The OOPE for OPD
care due to health problems among under-one year old children are mentioned in table
(2). Nineteen (5.8%) and 13 (3.9%) of children were admitted to hospital during and after
their neonatal period respectively. On average, total OOPE for hospitalization was 120,
900 kyats, in which, direct medical cost was 75,543 kyats and direct non-medical cost was
45,375 kyats. Apart from eight children who were aged less than one month, 271, 83.9%
received childhood immunization for at least one time. There was no OOPE for childhood
immunization among our study population.

Supports for MNCH care

In the study area, various support programmes for MNCH care were being
provided by both community-based and international organizations since 2011. The main
three programmes were emergency referral support for maternal and child health care
supported by Relief International, Village Health Committees emergency referral support
programmes and Beneficiary Welfare Programme (BWP) of Pact Myanmar providing a
safety net for Pact Global Microfinance (PGMF) clients in case of death, childbirth and
natural disaster. Among 331 households, 106 (32%) reported that they had received
financial support from the above programmes for the treatment of illnesses during
pregnancy, delivery or treatment of illnesses among their children during 2014 and 2015.

Almost all (329, 99.4%) households expended out-of-pocket payment for their
MNCH care in 2015. The average OOPE due to MNCH care per year is 131,758 kyats.
Share of OOPE for MNCH care out of total household expenditure was 6.2% and that of
household non-food expenditures was 16.7% which was similar among all expenditure

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quintiles (figure 1). Reduction in share of OOPE spent for MNCH care out of household
annual non-food expenditures after getting financial support is shown in figure (1).
Figure 1. Gross and net share of OOPE for MNCH care out of non-food expenditure
by expenditure quintiles

Catastrophic Health expenditure (CHE) due to MNCH care

We found that 9.4% of households had experienced CHE for their last child
delivery in 2015. In addition, catastrophic expenditure was found in (3, 1.7%) out of 181
home deliveries and (28, 18.7%) out of 150 institutional delivery (P < 0.0001). Again, we
found catastrophic expenditure among 25 (18.9%) out of 132 deliveries at government
hospitals and 3 (23.1%) out of 13 deliveries at private hospitals. However, the difference in
facing catastrophic expenditure between deliveries at government and private hospitals
was not significant (P = 0.72). Table (4) shows the proportion of households experienced
CHE for different types of delivery at health facilities and CHE among normal delivery. The
proportion of households which faced CHE was significantly higher among those in which
mothers underwent LSCS. But comparing CHE among normal delivery, normal delivery at
health facility was significantly higher than delivery at home.
Table 4. Proportion of households which experienced CHE for different types of delivery
at health facilities and proportion of households which experienced CHE
for normal delivery at home and facilitates

Variable Catastrophic expenditure P value

Yes n (%) No n (%)
Type of delivery (n = 150)
Normal and assisted 8 (10.7) 67 (89.3)
LSCS 20 (26.7) 55 (73.3) 0.03
Normal delivery (n = 250)
At home 3 (1.7) 178 (98.3)
At health facility 8 (11.6) 61 (88.4) 0.001

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However, if the financial support received by 32% of households was taken into
account, the proportion of households which faced catastrophic expenditure declined to
5.7%.

Discussion
Antenatal care coverage, skilled birth delivery and postnatal coverage in Myanmar
in 2015 were 81%, 72% and 90%[8]. Therefore compared to national data, utilization of
these services was found to be lower in our study population.

Apart from two, almost all the households expensed out-of-pocket payments for
MNCH care were during the period of last child delivery which was within one year before
the survey. On average, they spent 6% of their total household expenditure only for
MNCH care while previous studies conducted in Myanmar indicated that the households
from rural areas spent about 5% of total household expenditure on all kinds of health care
services including MNCH care[9, 10].

Institutional delivery was the most costly health care to be received by the
study population and constituted about 8% of total household expenditure. On average,
institutional delivery cost approximately seven times that of home delivery. Catastrophic
expenditure was nine times higher for institutional delivery than home delivery. Although
there was no significant difference in facing catastrophic expenditure among deliveries
at government and private hospitals, type of delivery at health facilities greatly influence
the occurrence of catastrophe. For normal delivery, institutional delivery was significantly
associated with catastrophic expenditure. In terms of health care expenditure for the
children, hospitalization was the most expensive health care. Similar findings were also
indicated in various international studies from many low and middle income countries[1115].

The direct medical cost was highest for most of the health services and this is
consistent with the findings from a number of international studies[1115]. There were
two main reasons for high OOPE on direct medical items. First, although government
hospitals were supplied most of the medicines, patients still needed to buy the prescribed
medicines because supply of medicines at that time was to some extent incompatible with
the hospital needs[16]. Second, households have to expense the cost for investigations.
Again, in many settings including our study, informal charges are a significant cost of
MNCH care especially at the public health facilities[11, 16]. Informal charges are unofficial or
illegal payments made to service providers to obtain publicly financed services or goods
that should be available without charge to the patient[11].

In 2014, Myanmar Government has launched user fee exemption for most of
the health care services available at the public hospitals. As our study was carried out
at the end of 2015, most of the households involved in our study utilized MNCH care
services after initiation of user fee exemption mechanism. However, almost all of our

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study population had paid OOPE for MNCH care. Additionally, direct medical expenses
consumed largest share of household expenditures. Therefore it can be assumed that
the governments attempt on the exemption of user fee did not have much impact on
reducing OOPE on MNCH care until the end of 2015, even on the costs for medicines and
investigations.

Again, there was a disparity in spending for MNCH care among the households.
The share of non-food expenditure spent for MNCH among the households from lowest
quintile did not differ much from that of high quintiles and it indicated that the financial
burden due to MNCH care was highest in the poorest households. Although the financial
supports from various MNCH care programmes helped to reduce the share of non-food
expenditure spent for MNCH among the households, there was no significant difference
in the reduction between the lowest and higher quintiles, denoting that the selection
criteria of the support programmes would pay less attention on the wealth status of the
beneficiaries.

We found out that OOPE for MNCH care caused financial catastrophe in 9.4% of
households. A literature review on the impact of maternal and child health care on house-
hold expenditure also revealed that, in many low income countries, household spending
on maternal and child health care can even impoverish households and represent
catastrophic levels of spending[8]. Therefore, MNCH care is one important area to be
prioritized while implementing financial protection mechanisms.

Strengths and limitations of the study

The studys strengths included representative sampling for the Dedaye Township
as all eligible households from randomly selected villages were interviewed and the use
of a tool which was previously validated and used in Myanmar context. Additionally,
being a community based survey, this study lessen the possibility of under-reporting the
health care expenditure by the respondents. However, recall and response bias could be
a limitation of this study. In order to reduce recall bias, we collected expenditure data not
only from the mothers but also from her family members.

Conclusion and recommendations

To our knowledge, there is very little or no study assessing OOPE on MNCH care
services among rural households in Myanmar. This study highlighted that MNCH care alone
can cause financial catastrophe. Financial burden was high for the households in which
women had undergone institutional delivery. There was a discrepancy in expenditure on
MNCH care across the expenditure quintile indicating that the financial burden was highest
among poorest households. Additionally, current initiations on financial protection are
not sufficient enough to protect households from financial catastrophe. Therefore, this
study would like to recommend:

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1. As out of pocket expenditures on maternal and child health care alone can cause
financial catastrophe, MNCH care should be considered as a priority area in establishing
financial protection mechanisms
2. Financial burden of institutional delivery on the households should be taken into
account while strengthening institutional delivery
3. Further study exploring providers perspective on OOPE for MNCH care should be
carried out
4. Maternal and child health care support programmes should prioritize the poor in their
target population

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