Trends in Financial Affordability of Healthcare Among Tribal Women of Reproductive Age: A Cross-Sectional Study From India.

Background: Universal health coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. UHC is one of the targets of Sustainable Development Goal (SDG) 3 which India is trying to achieve with various initiatives and health programs. Tribal communities form an integral part of India's population. Due to various geographic barriers to access to the location of their settlements, it becomes problematic to provide essential services including healthcare without good expenditure. Moreover, as a result of various disadvantages, employment and subsequently the affordability for tribal groups poses an issue for availing healthcare services or those which are affordable are far away from the usual reach. With this study we would like to track the progress towards SDG 3 for the tribal communities in India.

Objectives: To assess the trends of ability to afford healthcare for self among tribal women in India over five years and to assess the determinants of this affordability among the same population.

Methods: We used the Individual Recode (IR) datasets of Demographic & Health Surveys (DHS) data of Fourth and Fifth round for secondary data analysis. 670,384 and 689,454 cases from National Family Health Survey (NFHS) 4 and 5 were included for analysis. Under "svy" command, design adjusted chi square test was used, followed by binary logistic regression to derive unadjusted and adjusted odds ratio for various determinants.

Results: 6.38% and 6.23% of women belonged to tribal communities during NFHS 4 and NFHS 5 respectively. Only 0.24% and 0.35% had education above secondary education during NFHS 4 and NFHS 5. Majority of the tribal women were married during both surveys and around 0.3% were pregnant during the interviews. Consequently, most of the women were the wife of the head of household. Majority of the tribal women were followers of the Hindu religion and resided in the rural areas of the country. During NFHS 4, the major proportion of women belonged to the East zone and during NFHS 5, they belonged to the Northeast zone of India. For women in the age group of 25 to 29 years the odds of facing difficulty was the highest (aOR: 1.55 during NFHS 4 and 1.88 during NFHS 5). Moreover, those with no education showed highest odds of facing difficulty in arranging money for healthcare for self during both surveys (aOR: 1.69 during NFHS 4 and 1.45 during NFHS 5) when compared with those with higher education. In addition, the odds of facing affordability issues had increased from NFHS 4 to NFHS 5 for poorest tribal women (aOR 6.65 during NFHS 4 to aOR 8.91 during NFHS 5). There has been significant decrease in odds of facing affordability as a barrier among tribal women residing in Northeast zone of India (aOR: 5.01 during NFHS 4 and aOR: 3.45 during NFHS 5). The odds for facing affordability issues for tribal women residing in rural areas remained similar during both surveys.

Conclusion: There has been a slight decrease in the proportion of tribal women facing financial affordability as a barrier to accessing healthcare. Further factors like middle age groups of 25 to 29 years, no education, divorced or separated marital status, and belonging to poorest category of the Wealth Index were significant determinants due to which financial affordability has become a barrier to avail healthcare for self.