Utility In India Research Articles

Socio-Economic Determinants of Maternal Health Care Payments among Women in India

Background: Government of India initiatives through implementation of National Rural Health Mission(NRHM) and Janani Suraksha Yojna (JSY) programs from early 2005 has shown a considerable impact onmaternal health care utilization in India. Despite the fact that these programs provide the services free ofcost, utilization of maternal health care services is still considered an economic burden on some households.Keeping this into our mind, the research study analyzes the different level of payments to procure maternalhealth care for different socio-economic characteristics in India.Materials and Methods: This paper has utilized the data collected by the National Sample SurveyOrganization (NSSO) during January -June, 2014. It is a cross sectional dataset that provides information onSocial Consumption and Health scenario of the population. To carry out the research, descriptive statistics,and regression analysis has been used.Findings and Conclusion: The research reveals that women residing at urban place of residence, highereducated, affiliated to other social group and belonging to richest wealth index pay high amount for thematernal healthcare services in India. Indian government need to extend the coverage rendering the servicesat affordable costs without any further differentiation on the basis of socio-economic characteristics ofIndian women.

Commentary: Eye banking in post-COVID-19 era.

The COVID-19 (Coronavirus Disease 2019) pandemic with its multiple waves of infection has affected the normalcy of our day-to-day lives with its high infectivity and the associated mortality, especially among healthcare workers. With the progression of the pandemic, our understanding of the disease’s natural course, modes of infection, and transmissibility have evolved with time and the subsequent guidelines to reduce the spread of the infection have been modified accordingly. The annual collection of corneas and their utilization in India were significantly inadequate to address the backlog of treatable corneal blindness even before the pandemic.[1] This pandemic and its aftermath have affected eye banking in particular with a reduction in donors, potential risk of transmission to the healthcare workers during corneal retrieval and processing, and the possible risk of transmission of infection to the recipient through the donor cornea, and thereby, causing an increase in the backlog of treatable corneal blindness.[2] Also, the nationwide lockdown reduced the travel of patients to seek healthcare for non-emergency eye care procedures.[3] Over the course of this pandemic, our understanding of the disease and the pathogen has evolved, leading to modifications in the guidelines for cornea retrieval.[24] With the subsequent reduction in the number of infections, our government relaxed the lockdown guidelines in a staged manner. This helped the patients seeking eye care for emergency and non-emergency ophthalmic diseases to reach out to the eye care centers and get appropriate treatment. It is encouraging to see that eye banking and keratoplasty have been on the rise in most centers to pre-COVID-19 levels in India following the decline in the COVID-19 cases.[5] However, there is still a significant backlog of patients requiring keratoplasty and an imminent third wave of the pandemic can further worsen it. It is the responsibility of the corneal surgeons and the eye banks to reduce this backlog as we crawl toward normalcy day by day.

Identification of Techno-Economically Viable Crop Residue Utilization in India

India generates more than 140 million tonnes of surplus crop residue every year In Haryana, the agricultural sector alone produces 24.64 million tonnes of residue annually; of which only 71% is consumed in various domestic and commercial activities within the state. The rest of the material is burned causing severe contamination of air with smoke. There is an urgent need to identify suitable and sustainable conversion technologies that are efficient, eco-friendly as well as cost-effective for managing the huge available biomass not only in the state but also in the country. This paper reviews briefly the available crop residue and quantities burned, proposes a scheme to incorporate part of the residue in the field for its fertilizer value. The remaining biomass is harvested for animal feed and the excess is converted to bioenergy and biofuels. Among the developed and developing biofuels, the paper identifies biogas production from biomass for on-farm use. Pelletization is identified as an enabling technology to provide high quality feedstock for conversion to heat/power and in near future to advanced biofuels.

Equity and Accessibility of Antenatal Care Utilization in India

Aims and Objectives: In this paper, we examine the determinants at both the person and household level, and the connexion of the population to health facilities in childcare, wealth, caste, education and others are responsible for the stability found in Antenatal Care utilization. For this study, data used from the Indian National Family Health Survey (NFHS-4 2015-2016) three rounds are available. The findings of the analysis are given in three parts. First, at least 1 Injection of tetanus toxoid (TT), the Iron Folic Acid tablets (IFA), identified as four or more prenatal visits at least 100 days. Second, state profiles of NFHS-4 antenatal care usage are provided to compare patterns. Third, the impact of demand and access variables calculated from multi-level logistics.
 Methods: In India, we analyzed a group of 190, 898 women in the Nationwide Family Health Study 4. In order to measure Equity for the maximum ANC usage, concentration and index curves were employed. The multivariable logistic regression model has used to analyze the relevant variables to the usage of complete ANC.
 Results: 21% of pregnant women in India use complete ANC, which is 2.3-65.9% throughout the world. 51.6% received four or more ANC visits, 30.8% had at least 100 days of IFA and 91.1% had tetanus toxoid in one or two doses. Complete usage of the ANC in the family, caste and maternal education were unequal. The utilization of the Integrated Child Development Services (ICDS) government register, birth registration and health care coverage has related to improved chances of complete ANC utilization. Lower maternity schooling, lower-income, father intrusiveness during prenatal visits, a higher birth order, puberty and accidental pregnancy were related to lower odds of maximum ANC use.

Explaining changing patterns and inequalities in maternal healthcare services utilization in India

This study aims to examine the long‐term changing patterns of inequalities in maternal healthcare services utilization and to quantify the contribution of selected factors that explain the gap between poor and nonpoor women in the use of maternal healthcare services. This study used three rounds of the National Family Health Survey (NFHS) data conducted during 1998–1999, 2005–2006, and 2015–2016. Using Blinder–Oaxaca decomposition method (BODM), this study explores the inequalities in maternal healthcare services utilization between poor and nonpoor women and examines the relative contribution of each predictor. The findings show that the utilization of maternal healthcare services was low among poor women. Comparison of maternal healthcare services utilization results over the years reveals that inequality has been rising. The decomposition analysis shows that women's education, mass media exposure, partner's education, and women's age at birth of first child contributed an important share to the gap in maternal healthcare services utilization. The use of maternal healthcare services remains disproportionately low among poor women. Therefore, the Government of India should put extra effort to directly target these women for reducing the gap in the use of maternal healthcare services.

Modern development and potential uses of solar energy utilization in India: A review

Potential for solar energy is immense in India as it has maximum sunny days throughout the year. The fuel used in a thermal power plant is exhausting at a fast rate and is important to identify alternate source as solar power. India lying in the equator region is at 5th position in solar power generation across the globe. The power extracted from solar radiation has been on rise from the year 2017 and the government remains focused on it by making solar power as major contributor in renewable energy. This manuscript offers a summary of the present situation, status, and the forthcoming challenges of solar energy generation in India. It further emphasizes on completely diverse aspects related with solar energy, steps, and policy decision carry out by the government to satisfy the long run power demand.

Men and maternal health care utilization in India and in selected less-developed states: evidence from a large-scale survey 2015-16.

Male involvement in maternal health care utilization is an important contributor to maternal health, especially in male-dominated societies. This study aimed to understand the variations and determinants of women's antenatal care (ANC) utilization and institutional delivery in India and three socioeconomically less-developed states (Bihar, Madhya Pradesh and Uttar Pradesh) using NFHS-4 data (2015-16). Husband's knowledge of pregnancy care and delivery, having a non-violent marital relationship and a respectful attitude towards his wife, better education and wealth, higher exposure to mass media and fewer children substantially enhanced the probability of him being present at his wife's ANC visits. Furthermore, men's presence at any ANC visit was shown to be an important factor influencing institutional delivery in India as a whole, as well as in the three less-developed states. The two major hurdles in maternal and child health care utilization in India were incorrect perception of 'unnecessary' maternal health care by families and high cost as reported by husbands. Furthermore, the proportion of husbands who received knowledge from health workers on maternal and child health was too low to achieve the maternal health SDGs by 2030. The dissemination of knowledge on maternal care among husbands, and encouraging their presence during antenatal care, may help secure better maternal health outcomes in India. It is imperative that the husband-involvement agenda is strengthened in India if the SDGs for maternal care are to be achieved.

Identification of patients at high risk of fragility fractures in an Indian clinical setting using FRAX.

The Fracture Risk Assessment Tool (FRAX) appears useful to diagnose fragility fractures. The study aims to answer whether the FRAX tool has utility in India. One hundred ten cases with a history of recent fragility fractures and 84 controls with no fractures were included in the study. FRAX scores without bone mineral density (BMD), and also with it, of participants were calculated. Several cutoff FRAX scores were chosen around mean and median FRAX score of cases. The odds ratio was calculated along with sensitivity, specificity, positive predictive value, negative predictive value and Youden's index. The most ideal cutoff was chosen to construct a hypothetical model to detect individuals at high risk. The FRAX score with BMD and without BMD exhibited relatively high specificity and moderate to low sensitivity implying that FRAX scores above cutoff have diagnostic value. Cutoffs at which FRAX score without BMD exhibited high specificity (> 90%) were chosen to construct a hypothetical model. Patients with FRAX score without BMD in the intermediate range be advised dual-energy X-ray absorptiometry (DEXA) followed by recalculation of FRAX score with BMD. DEXA scan T score less than - 2.5 or FRAX score with BMD above the cutoff at which specificity was high (> 80%) were included to construct the hypothetical model. Patients with low FRAX score could be followed up. The hypothetical model was applied to the case group to analyse its detection potential. FRAX has utility in India. It cuts the cost of screening and limits the use of expensive investigation.

Education, employment, economic status and empowerment: Implications for maternal health care services utilization in India

The aim of this study is to investigate the effects of Education, Employment, Economic Status and Empowerment (introduced as the 4Es) and other explanatory socio‐demographic factors on the utilization of maternal health care services in India. This study used data from the National Family Health Survey‐4 (2015–2016). Separate logistic regression models were fitted for four or more antenatal care visits, skilled birth attendance and postnatal care to understand the effects of 4Es on the utilization of maternal health care services in India. The findings indicate positive effects of education on antenatal care, skilled birth attendance and postnatal care, the effects of higher education being even stronger in case of antenatal care. Education leads to employment, economic status and empowerment which in turn are significantly associated with the use of antenatal care and skilled birth attendance. Interestingly, in case of postnatal care, while controlling for economic status and empowerment, the effects of education vanish. Overall, education, employment, greater economic status and empowerment emerged as reliable predictors of the use of all three maternal health care services. The positive association between the 4Es and maternal health care services utilization reiterates the need for rigorous monitoring and evaluation of the existing policies and programs, coupled with efforts to change societal attitudes toward females through political advocacy and commitment which is reflected in parallel investment in girl education, job creation for poverty reduction to facilitate women empowerment.

Assessing the financial sustainability of rural grid electrification pathway: A case study of India

India has recently achieved universal electricity access. However, the financial sustainability of supplying electricity in many rural areas in India still remains a key concern. In 2018–2019, total annual loss of all the distribution utilities in India was reported to be INR 270 billion. This is a huge financial burden and remains as a sustainability challenge to provide affordable and reliable electricity supply (SDG7.1). In this paper, a generic mathematical cost model has been developed in terms of viability gap and applied the model to evaluate the financial sustainability of rural grid electrification in four Indian provinces Andhra Pradesh (AP), Madhya Pradesh (MP), Uttar Pradesh (UP), and Uttarakhand (UTKH). The viability gap is basically the difference between electricity tariff and actual delivery cost of electricity considering the life cycle analysis. The analysis showed that viability gap is negative in all four provinces indicating the fact that existing modality of electrification is financially unsustainable. The paper also revealed that the tariff revision along with annual increment in the tariff, minimizing the distribution losses and increasing the load factor could significantly reduce the viability gap. This study could be of high interest to the policy makers, power distribution companies (DISCOMs) and energy researchers.

Performance Measurement of Water Supply Services: A Cross-Country Comparison between India and the UK.

Increased emphasis on efficiency improvements has brought the benefits of internal savings and improved service deliveries of water supplies to the developed countries. However, water supply services in developing countries often exhibit large inefficiencies making it difficult to expand coverage or improve supply services. A comparative assessment of efficiencies in the developed and developing countries is therefore essential to estimate the actual lag that developing countries typically experience, and to arrive at an estimate of their efficiency improvements. This manuscript makes an effort in this direction by undertaking a cross-country benchmarking study on the level of inefficiencies prevailing in Indian urban water supply services (IUWSS) relative to the utilities in the UK-England and Wales. This manuscript uses data envelopment analysis approach to measure relative efficiencies of water supplies for a sample of 30 water utilities in India and the UK-England and Wales for the year 2015. The results indicate that there exist significant technical and scale inefficiencies in water supply operations of Indian municipalities compared with the UK-England and Wales. DEA results also show a significant scope for savings with respect to operating expenditures and non-revenue water, if Indian utilities were to adopt the best practices and managerial tools of the utilities in the UK-England and Wales. Further, it was found that IUWSS need a restructuring of their municipalities to become more efficient. This manuscript discusses the above results in the context of policy implications and suggests few mechanisms that are relevant from a developing country perspective for possible improvement in water supply services.

Analysis of Organ Utilization From Deceased Organ Donation in India

ObjectivesThis report presents an audit of utilization of various organs from deceased donors in different states of India over a 3-year period MethodsData released by the various regions on their official website was analyzed from 2015 to 2017.Regions with less than 25 donations per year were excluded while calculating utilization rates. ResultsTotal organ donation in India had increased from 570 to 843 donations from 2015 to 2017 (47.8% increase) with southern states performing exceedingly well compared with northern states. Total organs retrieved during the 3-year period were 6659 with a 54.7% increase in organ retrieval in 2017 compared with 2015 (2592 vs 1675 respectively). The net utilization rate of kidneys was 87.35%. Total liver transplants done during this period were 1894. Net liver utilization rate was 86.81% over 3 years. Total Heart transplants during this period were 641 with net utilization rate of 28.98%. An increase in utilization rates was observed from 2015 to 2017 (19.33%-34.46%). A total of 217 lung transplants were done with net utilization rate of 8.86% with an increase in yearly utilization rate from 6.5% in 2015 to 11.97% in 2017. Total pancreas transplants remained low with 48 transplants over 3 year duration with net utilization rate of 2.25% but an increase in utilization rate was observed. (0.92% in 2015 to 2.1% in 2017). ConclusionThere is a significant regional variability in organ utilization in India. Evaluating and addressing the cause of high variability can further increase the transplant activity.

Family support and community respect for community health workers and the association of these with CHW productivity and clinic health care utilization

Background This paper examines associations between family support and community respect as perceived by community health workers, and their productivity and maternal health care utilization in India. Methods We conducted cross-sectional surveys with the community health workers, known as accredited social health activists (ASHA) and her clients, women with a child aged one year or less. The data were matched and merged for dyadic analysis. ASHA productivity was defined as number of households visited, number of women accompanied to a health facility, and earnings as reported by ASHAs. It also included two variables reported by the clients - number of ASHA visits during the clients’ pregnancy and ASHA visits during postnatal period. Maternal health care utilization included client reports of 4+ antenatal care visits and facility delivery. Husband/family support in domestic work referred to sharing of household responsibilities. Support in ASHA-related work included help in reaching target households, help in taking clients to facilities, help in organizing village health and nutrition days, and help in filling out required paperwork. We used bivariate, multivariate, and hierarchical logistic regression models to test the associations. Results Husband/family support in domestic work was associated with a significantly higher number of households reached by ASHAs (regression coefficient, beta (β)=0.21, P<0.001), higher number of clients accompanied to a facility for delivery (β=0.14, P=0.04), higher odds of a client receiving an ASHA visit during pregnancy (adjusted odds ratio AOR: 1.20; 95% confidence interval (CI)=1.04-1.37), and receiving 4+ antenatal care (adjusted odds ratio (AOR)=1.20, 95% CI= 1.00-1.43). Husband/family support for ASHA-related work (eg, taking on domestic labor) was also associated with a significantly higher number of households reached by ASHAs (β=0.32, P<0.001), but no significant associations were observed for health care utilization with respect to antenatal care or facility delivery. Male community members’ respect for ASHAs was associated with a significantly higher number of households reached by ASHAs (β=0.36, P=0.02), and earnings (β=0.23, P=0.04). Conclusions The study indicates the need for family support and community respect in improving ASHAs’ productivity as well as health outcomes within the community they serve. Findings also suggest the need for more equitable distribution of domestic labour.

Long-term trend in socioeconomic inequalities and geographic variation in the utilization of antenatal care service in India between 1998 and 2015.

To investigate the temporal trend of socioeconomic and rural-urban disparities and geographical variation in the utilization of antenatal care (ANC) services in India before and throughout the Millennium Development Goals era. For this temporal analysis, secondary data from the Indian National Family Health Surveys between 1998 and 2015 (Waves 2, 3, and 4) were used. We analyzed the trend in inequality for at least one and four ANC visits to a health care professional (ANC1+ and ANC4+, respectively) by education, wealth, and residence type. Multilevel logistic regression models were used to assess the temporal trend and the relative contribution of communities and states to the overall variation in ANC1+ and ANC4+. Data on utilization of ANC services for the last birth of women aged 15-49years during the three or five years preceding the survey (depending on the survey year) were used. Educational and wealth inequality in ANC1+ and ANC4+ worsened between 1998 and 2005 and improved between 2005 and 2015 (for ANC4+, OR [95% CI]=0.22 [0.19-0.25] in Wave 2; OR [95% CI]=0.19 [0.17-0.22] in Wave 3; and OR [95% CI]=0.38 [0.36-0.40] in Wave 4 for the poorest). Rural-urban inequality showed a consistent decline (for ANC4+, OR [95% CI]=0.59 [0.54-0.64] in Wave 2; OR [95% CI]=0.63 [0.59-0.68] in Wave 3; and OR [95% CI]=0.82 [0.79-0.85] in Wave 4 for rural area). The relative contribution of the community to the total geographic variation in the utilization of ANC services increased more than four times during the study period. The use of ANC services remains disproportionately lower among women with low socioeconomic status. Efforts to directly target these women are necessary to tackle inequality in ANC utilization in India.

Access to women physicians and uptake of reproductive, maternal and child health services in India

BackgroundLow availability of women physicians in rural areas can compromise women's health care seeking, where need can be greatest. We examined the associations between availability of women physicians and maternal and child health service utilization in India. MethodsWe analyzed cross-sectional district-level data from all 256 districts in 18 states, from India's District-Level Household and Facility Survey (2012–13) and the National Family Health Survey (2015–16). Assessed measures included lady medical officers (LMOs) availability at Primary Health Centers (PHCs, which are largely rural serving), modern contraceptive use, antenatal care (ANC), skilled birth attendance (SBA), maternal postnatal care (PNC), infant PNC, and child immunization. Multilevel regression models nesting districts in states examined associations between LMO availability and health service utilization, adjusting for district-level socioeconomic status (SES) indicators (e.g., women's education, household water access), urbanicity, health insurance coverage and sampled PHCs (15 on average) within districts. FindingsOnly 72 of 256 districts (28.1%) reported >50% of PHCs with LMOs. In multivariable models, LMO availability in PHCs was associated with higher district prevalence (%) of modern contraceptive use [β=0.04 (95% CI: 0.007, 0.08)], 4+ ANC [β =0.07 (95% CI: 0.008, 0.13)], skilled birth attendance [β=0.09 (0.03, 0.14) and maternal PNC [β=0.08 (95% CI: 0.03, 0.12)], but not infant PNC or child immunization. InterpretationHigher district availability of women physicians is associated with higher maternal health care utilization but not child health care utilization. Improving gender parity in the physician workforce and rural women physician access may improve maternal health care use in India.

Socioeconomic Inequality in Healthcare Utilization in India: Is Health Insurance a Way Out?

Socioeconomic Inequality in Healthcare Utilization in India: Is Health Insurance a Way Out?

More than credit: Exploring associations between microcredit programs and maternal and reproductive health service utilization in India.

Microcredit programs are increasingly popular interventions aimed at enabling women's economic empowerment in low- and middle-income countries. Resultant improved income, and social support from co-members of microcredit programs, may lead to increased utilization of health services. But existing research is inconclusive. This study investigates the association of microcredit program awareness and participation, with maternal and postpartum reproductive health service utilization in India. We use data from a nationally representative survey, the National Family Health Survey (2015–16), and assess three indicators of maternal health service utilization: receipt of four or more antenatal check-ups, institutional delivery, and postnatal check-up among women who had a child less than 5 years of age (N = 32,880). Reproductive health service utilization is assessed via postpartum contraceptive use within 12 months of childbirth, among women who had a live birth in the 12–59 months preceding the survey (N = 24,258). We use binomial and multinomial logistic regression models to examine associations. Additionally, we use propensity score matching to account for self-selection bias. One-third of women are aware of microcredit programs in their community/village, but only 6% have ever taken a loan from these programs. Both microcredit program awareness and participation are associated with higher odds of antenatal care, postnatal check-ups, as well as use of a modern method of contraceptive within 12 months of childbirth, even after accounting for self-selection bias. Stratified analysis by household wealth show that significant associations seen in our primary analyses are significant only for the poorest women. Findings highlight the potential value of microcredit programs in improving health service utilization during and after pregnancy, particularly among poor women. Microcredit program benefits extend beyond their participants. Non-participants living close to the programs also have greater odds of maternal and reproductive health service utilization, suggesting a spillover effect of these programs at the community level.

One price doesn't fit all: An examination of heterogeneity in price elasticity of residential electricity in India

Although well-designed consumer electricity pricing can improve access, contribute to higher metering, increase penetration of energy efficient technologies, limit extent of the rebound effect, and influence viability of electricity distribution utilities in India, there has been no comprehensive, policy-relevant assessment of price elasticities of electricity demand in the country. The objective of this study is to estimate price elasticity of residential electricity consumption and disaggregate it by state, rural and urban residence, and income categories to provide evidence for electricity tariff setting in India. We combine survey data from five rounds of nationally-representative household consumption expenditure surveys covering the period 2005–2012 with administrative data on electricity deficit and improve on methods applied in previous studies by estimating price elasticities using a quadratic form to account for constraints in electricity supply. We find that while the average price elasticity at the national level is −0.39 (95% confidence interval: −0.46, −0.31), it varies significantly by state, rural and urban residence, and income categories. Our results indicate that a “one ‘price’ fits all” policy may not be an effective approach to electricity tariff setting in India and a data-driven understanding of heterogeneities in price elasticities can better inform residential electricity tariff design in the country.

Downstream electric utility restructuring and upstream generation efficiency: Productivity dynamics of Indian coal and gas based electricity generators

This paper investigates the producer-level temporal dynamics of total factor productivity and operational performance changes in coal- and gas-based generators during the 2000–20013 period of major structural reforms in the downstream utilities in India. The total factor productivity is estimated using a recently developed improvement in the Stochastic Frontier panel method that controls for time-invariant unobserved heterogeneity, and the productivity change is decomposed into components of changes in technology frontier, efficiency, scale and allocation. A unique dataset of station-level data for coal and gas plants, that represents about two-thirds of all power generation in India during this period, is constructed for the analysis. The study shows that while there is improvement in the coal generator productivity at the mean rate of 0.20% per year that converges towards a point of higher efficiency for most plants, the gas generators show a trend of stagnant efficiency and declining total factor productivity at the mean rate of −0.80% per year. Unbundling and multi-dimensional utility reform indices are significantly associated with improvement in thermal efficiency and capacity utilization for coal generators. In contrast, utility reforms shows no significant positive influence on gas generators, instead a decline in capacity utilization is observed following unbundling.

Long-Term Trend in Inequalities by Socioeconomic Status and Residence Type and Geographic Variation in the Utilization of Antenatal Care Service in India: Result from the National Family Health Survey 1998-2015

Background: India has been making long-term efforts toward increasing antenatal care (ANC) to reduce maternal and neonatal mortality and morbidity. We aimed to investigate the temporal trend of socioeconomic and rural-urban disparities and geographical variation in utilization of ANC services before and throughout the MDG era. Methods: Using a series of National Family Health Survey between 1998 and 2015 (Wave II, III, and IV), we analyzed the trend in inequality for at least one and four ANC visits to health care professional for ANC (ANCS1, ANCS4) by education, wealth, and residence type. Multilevel logistic regression models were used to assess the trend in relative contribution of various geographical levels (states and communities). Age at pregnancy, history of terminated pregnancy, marital status, religions, birth order, caste were adjusted for. Findings: Educational and economic inequality in ANCS1 and ANC4 worsened in between 1998 and 2005. However, there was a huge decrease in inequality between 2005 and 2015 that compensated for increase in inequality during preceding half period. Educational inequality narrowed down more than wealth inequality(e.g., ORs of the poorest and the least educated for ANC4 are 0.23, 0.20, and 0.38 and 0.26, 0.28 and 0.58 in wave II, III, and IV. P values for all are <0.001). Rural-urban inequality showed consistent decline during the study period without any fluctuation(e.g., ORs of the rural area for ANC4 are 0.58, 0.63,and 0.82 in wave II, III, and IV. P values for all are <0.001). Relative contribution of community to the total variation in utilization of ANC increased more than four times while contribution of states decreased. Interpretation: Despite the long history of maternal and child health care interventions in India, the inequality in utilization of ANC started to decline only after special efforts were made for disadvantaged and vulnerable populations. Strengthening community factors such as community health workers and further efforts to remove economic barriers are necessary to tackle the persisting inequality in ANC utilization in India. Funding Statement: The authors have no support of funding to report. Declaration of Interests: We declare no competing interests. Ethical Approval: NFHS data are free to download through Demographic Health Survey (DHS) data distribution system and can be used after registration. The procedures and questionnaires for standard DHS survey have been reviewed and approved by ICF Institutional Review Board(IRB). Additionally, NFHS was approved by the international Institute for Population science (IIPS) Institutional Review Board. Each respondent's informed consent for participation in the survey was obtained. The results presented in this study are based on the analysis of existing survey data which do not contain any identifying information on patients.