ArticlesIndia's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation
Introduction
The state of maternal, newborn, and child health in India is of global importance; in 2005, more than 78 000 (20%) of 387 200 maternal deaths,1 and more than 1 million (31%) of 3·4 million neonatal deaths occurred in India.2 These estimates represent a steady but gradual improvement in India over the previous 15 years. The maternal mortality ratio declined from about 520 per 100 000 livebirths in 1990 to nearly 290 per 100 000 in 2005;1 and the neonatal mortality rate decreased from 54 per 1000 livebirths in 1990 to 38 per 1000 in 2005.2 Despite this progress, the numbers of maternal and neonatal deaths remained high. The national averages also masked remarkable inequalities in maternal and child health, with the number of child deaths ranging from 16 per 1000 livebirths in the socially advanced Kerala state to 96 per 1000 livebirths in poor states such as Uttar Pradesh.3
In April, 2005, in response to the slow and varied progress in improvement of maternal and neonatal health, the Government of India launched Janani Suraksha Yojana (JSY; translated as safe motherhood scheme)—a national conditional cash transfer scheme—to incentivise women of low socioeconomic status to give birth in a health facility. The ultimate goal of the programme is to reduce the number of maternal and neonatal deaths,4 and the scheme was based on the previous national maternity benefit scheme.5
According to JSY's guidelines,4, 6 after delivery in a government or accredited private health facility, eligible women would receive 600 Indian rupees (US$13·3) in urban areas and 700 rupees ($15·6) in rural areas. In ten high-focus states (Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir) with low in-facility birth coverage, all women irrespective of socioeconomic status and parity are eligible for the cash benefit. The cash incentive is higher in these states than in the other states: 1000 rupees ($22·2) in urban areas and 1400 rupees ($31·1) in rural areas. In the non-high-focus states, women were eligible for the cash benefit only for their first two livebirths, and only if they had a government-issued below-the-poverty-line card or if they were from a scheduled (low) caste or tribe. Like the national maternity benefit scheme, JSY also continues to provide a small amount of financial assistance—500 rupees ($11)—for births at home for pregnant women (aged 19 years and older) living below the poverty line, and for the first two births.4, 7
JSY is being implemented through community-level health workers (such as accredited social health activists [ASHAs]), who identify pregnant women and help them to get to a health facility. ASHAs receive payments of 200 rupees ($4·4) in urban areas and 600 rupees ($13·3) in rural areas per in-facility delivery assisted by them in high-focus states.4 According to JSY's guidelines, ASHAs or other health workers associated with the scheme should provide or help women to receive at least three antenatal care visits, arrange immunisation of the newborn baby, do a postnatal checkup, and counsel for initiation and continuation of breastfeeding.
JSY is the largest conditional cash transfer programme in the world in terms of the number of beneficiaries, and represents a major Indian health programme. Data from the programme suggest substantial scale-up in the past few years in terms of the number of beneficiaries, and a budget allocation of 15·4 billion rupees ($342 million) in the 2009–10 financial year. This funding is expected to provide cash transfers to about 9·5 million (36%) of 26 million women giving birth in India during this year. Other conditional cash transfer programmes have been implemented to incentivise the use of health services in low-income and-middle-income countries—Latin America, Bangladesh, Indonesia, Nepal, and Malawi.8, 9, 10, 11, 12 The little evidence from the assessment of the effects of conditional cash transfers in Mexico,13, 14, 15, 16 Colombia,8 Nicaragua,17 and Malawi18 suggests that although these programmes have led to increased health-service use,19 whether they have led to improvements in health outcomes and whether their effects are generalisable across different settings are not known.20
These issues, the importance of India to global maternal and neonatal health, and the magnitude of the continued investment in JSY, draw attention to the important role of the assessment of JSY to our understanding of the contribution of the programme to improvements in maternal and neonatal health in India. Previous assessments of JSY have been descriptive,21 or have been assessments of the process in selected states.6, 7 In this study, we use data from two rounds of the India district-level household surveys (DLHS) to provide an evaluation of the effect of JSY. Specifically, we document the level of implementation of JSY at the district level; investigate whether JSY is reaching its intended beneficiaries; and assess whether the receipt of financial assistance from JSY is associated with increases in antenatal care, the proportion of births in health facilities and with a skilled attendant present, and reductions in the numbers of perinatal, neonatal, and maternal deaths.
Section snippets
Data
We used data from two rounds of the India DLHS, which are health interview surveys covering family planning, maternal and child health, reproductive health of ever-married women and adolescent girls, and use of maternal and child health-care services at the district level for India. These surveys are done by the International Institute for Population Sciences in Mumbai with funding from the Ministry of Health and Family Welfare, Government of India. DLHS data are made available in the public
Results
Figure 1 shows substantial variation in the district-level uptake of JSY (measured as the proportion of births among all women in the 12 months before DLHS-3 who received financial assistance from JSY), from less than 5% of women receiving financial assistance from JSY in 141 districts to more than or equal to 30% in 128 districts. Variation in the uptake of JSY in the states was much higher than between districts within the same state (figure 1). Some high-focus states showed a high uptake of
Discussion
Our preliminary evidence shows that the expansion of JSY has led to substantial increases in coverage of antenatal and intrapartum care, and has probably contributed to reductions in the numbers of perinatal and neonatal deaths. We were not able to detect an effect on the number of maternal deaths, but this analysis was only powered to detect a very large reduction in the maternal mortality ratio.
Variation in the extent of implementation was substantial in high-focus and non-high-focus states
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