Janani Suraksha Yojana - India’s safe motherhood programme – provides poor women with a financial incentive for delivering births at health centres and seeking antenatal and postnatal care. This column finds that the programme has had limited success. While women with no formal education and those from rural areas have benefitted disproportionately, the programme has failed to reach the poorest women.
With more than 9.2 million beneficiaries, and a budget of nearly Rs. 15 billion ($242 mn approx.), India’s safe motherhood programme - Janani Suraksha Yojana (JSY) - is one of the largest conditional cash transfer programmes in the world1. Established in 2005 as a key component of the National Rural Health Mission (NRHM)2, the JSY aims to reduce maternal and neonatal mortality by addressing issues with both demand and supply of maternal healthcare services. Under the programme, poor women receive cash compensation for institutional deliveries and for accessing antenatal and postnatal care. Also, Accredited Social Health Activists (ASHAs)3 are given cash incentives for connecting poor pregnant women to such healthcare services4.
Who is eligible to receive benefits under Janani Suraksha Yojana?
At the time of programme’s inception, the government categorised states as either Low Performing (LP)5 or High Performing (HP) based on their institutional delivery rate (proportion of births delivered at health facilities). According to the initial rules issued in April 2005, women that were 19 years of age or older, and from Below Poverty Line (BPL) families, were eligible for JSY cash benefits. Benefits were limited to the first two live births6 . Revised rules, issued in November 2006, specified that all pregnant women in LP states, irrespective of age, poverty status or number of births, will be eligible for benefits under the JSY if they deliver in accredited facilities. In HP states, only BPL and Scheduled Caste and Scheduled Tribe (SC/ ST) households will be eligible for cash assistance.
Beneficiaries in LP states received higher transfers than those in HP states. The average transfer in LP states is currently Rs. 1,200, and the average transfer in HP states is Rs. 650. The compensation also varied across rural and urban areas.
ASHAs receive financial compensation in two installments: cash assistance of up to Rs. 850 for transportation, lodging, food etc. paid as a one-time payment at the health centre at the time of delivery, and another transfer of Rs. 200 at the first postnatal visit.
Evaluating programme impact
The programme was neither rolled out simultaneously in all districts, nor was it purposefully phased, making, precise estimation of its impact difficult. Lim et al. (2010) report that the scheme lead to a 43.5 to 49.2 percentage point increase in hospital deliveries, a 36.2 to 39.3 percentage point increase in skilled birth attendance and a 10.9 point increase in antenatal care. However, their methodology may overestimate the programme’s effect on the targeted population. This is because they compare women who did and did not receive JSY cash transfers. Women only receive the transfer if they deliver at a health facility and hence, this group may not be representative of the targeted population.
Dongre (2012) finds that the JSY led to a marginal increase in the gap between LP and HP states in terms of institutional deliveries, within 18 months of its launch. However, from 2007 onwards, the gap began to decline, with LP states witnessing much larger increases in institutional deliveries. Pre-JSY trends show that convergence between LP and HP states (that may have taken place even without the programme) cannot be an explanation for these results.
In a recent paper, we exploit the programme’s eligibility criteria in order to measure differences in the rate of hospital deliveries between targeted and non-targeted groups, and thereby estimate the impact of the programme on the targeted group (Joshi and Sivaram 2014
. We use data from two rounds (2002 and 2008) of the District Level Household Survey (DLHS), a nationally representative dataset that has information on maternal and child health, family planning and other reproductive health services, and key interventions of the NRHM. We define eligibility in exact accordance with the programme’s guidelines. Since the eligibility criteria in LP states were relaxed in November 2006, we examine impact in two phases:
• Phase 1: April 2005 - October 2006
• Phase 2: November 2006 onwards
Since response to the JSY may vary across individuals and households, we account for a variety of individual, household and village characteristics.
Overall, we find that the programme only had modest effects on those eligible to receive compensation under its guidelines in both phases. Relative to the broader population, groups specifically targeted by the scheme experienced a 3 percentage point increase in medically supervised births and no increase in antenatal or postnatal care.
We also explore the programme´s impact on poor, less educated and rural women. We define the poor as those who belonging to the bottom quintile of the wealth distribution using our own asset index. Among the group of eligible women, illiterate women are approximately 8 percentage points more likely to receive antenatal care, 6 percentage points more likely to deliver in a hospital and 12 percentage points more likely to receive postnatal care after the launch of the scheme. Women living in rural areas are 4-7 percentage points more likely to report improved access to medical care in all three indicators. Women in the poorest quintile however, do not benefit from all aspects of the programme: they are 2 percentage points more likely to give birth in a hospital, but experience no other benefits. These results suggest that the targeting aspect of the JSY may have been effective for some vulnerable women; it still fails to cover the poorest women.
Why didn’t the programme have a bigger effect?
Why has the JSY not had a greater effect, particularly on the utilisation of antenatal and postnatal care? One of the reasons is simply faulty programme design. The structure of incentives is excessively focused on institutional delivery and places little value on the quality of care. The ASHA receives a one-time payment at the time of delivery; she is given the same transfer regardless of whether she had scheduled antenatal visits prior to delivery. Moreover, the size of the transfer at the time of delivery is nearly twice that of the transfer for postnatal care. A postnatal visit requires the ASHA to track down the beneficiary, schedule a visit, and then make a trip to receive the reimbursement. The effort required to receive a postnatal cash incentive may exceed the value of the incentive itself.
The success of JSY may also be limited by its complexity. Studies of other conditional cash transfer programmes have illustrated how cumbersome processes of identification of participants, compliance monitoring and timely payments systems result in mis-targeting, leakage and delay (Ahmed 2007, Fiszbein et al. 2009). These factors may be at play in JSY as well. A study by the UNFPA in 2008
found that 81% of women were aware of the programme, but only 55% actually delivered in an institution and only 8% were accompanied by an ASHA worker.
Finally, the success of the JSY may be undermined by local conditions. The programme fails to recognise the patterns of mobility of pregnant Indian women. Traditionally, they travel to their mother´s home for delivery (Jeffrey and Jeffrey 2006, Palriwala and Uberoi 2008). While the JSY makes special allowances to issue cash transfers for women who deliver away from home, its success is entirely dependent on the local ASHA´s initiative in coordinating care with another worker in a distant location. ASHAs only receive cash transfers after accompanying women to a hospital for delivery, and may not put in effort to connect women to antenatal care if they do not expect to be compensated. Additionally, they may not be aware of each pregnant woman who travels to their town to deliver. Similarly, pregnant women may also find it difficult to seek out the help of an ASHA, accessing the services or proving their eligibility in a new location.
Our results illustrate that the impact of large-scale conditional cash transfer programmes such as JSY may vary across as well as within regions of India. They also show that the programme may not have reached the poorest women. Finally, it confirms that improving women’s access to high-quality health-care services in India may require more than just cash incentives.
- These estimates are drawn from IndiaStat.com, which collected the data from the Rajya Sabha´s records on 27 July 2010.
- The National Rural Health Mission (NRHM) was launched in 2005 to provide accessible, affordable and quality healthcare to the rural population, especially the vulnerable groups. The main goals were to improve public health as well as community participation in all aspects of health care delivery.
- ASHA is a female community health activist that is provided to every village under the NRHM. She is trained to work as an interface between the community and the public health system. She is selected from the village itself and is accountable to it.
- ASHAs are the first, and most important, point of contact for pregnant women, and are integral to the success of the JSY. They must contact each pregnant woman in their jurisdiction, and enroll them into the programme, as well as help them coordinate all medical care during their pregnancy.
- At the time of the programme’s inception, the government categorised states as Low Performing or High Performing. Low Performing states are those in which the rate of institutional deliveries has been very low in the past. These include Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Rajasthan, Bihar, Jharkhand, Orissa, Jammu and Kashmir, and Assam.
- Ahmed, A, M Adato, A Kudan, D Gilligan and R Colasan (2007), ‘Impact evaluation of the conditional cash transfer program in Turkey: Final report’, International Food Policy Research Institute, Washington, DC.
- Dongre, A (2012), ‘Can Conditional Cash Transfers Impact Institutional Deliveries? Evidence from Janani Suraksha Yojana in India’, Center for Policy Research, Working Paper, New Delhi. Available at SSRN: http://ssrn.com/abstract=2196361 or http://dx.doi.org/10.2139/ssrn.2196361
- Fiszbein, A, NR Schady and FH Ferreira (2009), ‘Conditional cash transfers: reducing present and future poverty’, World Bank Publications.
- Joshi, S and A Sivaram (2014), "Does it Pay to Deliver? An Evaluation of India’s Safe Motherhood Program", World Development, 64: 434-447.
- Jeffery, P and R Jeffery (1996), Don´t marry me to a plowman!: women´s everyday lives in rural North India, Boulder, CO: Westview Press.
- Lim, SS, L Dandona, JA Hoisington, SL James, MC Hogan and E Gakidou (2010), “India´s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation”, The Lancet, 375(9730), 2009-2023.
- Palriwala, R and P Uberoi (eds.) (2008), Marriage, migration and gender (Vol. 5), SAGE Publications Ltd.
- UNFPA India (2009), ‘Concurrent assessment of Janani Suraksha Yojana (JSY) in selected states’.