Cash and medical facilities offered under the Janani Suraksha Yojana (JSY) are not sufficient incentives for pregnant women in India to take up institutional delivery services, a new study by an international group of researchers from India, Australia, and the UK, including Public Health Foundation of India (PHFI), the University of Adelaide, and Lancaster University has revealed. According to the research, the facilities are availed by less than 50 percent of those who are eligible.
The Centre launched the JSY with much fanfare in 2005 as a part of its National Rural Health Mission, or, since 2013 the National Health Mission. The scheme was designed to give impetus to the mother-and child-related Millennium Development Goals (MDGs). Till date, the goals that India had set for itself – reducing child mortality by two-thirds and cutting maternal mortality by three-quarters – remain unachieved. Notably, the MDGs expired in 2015.
JSY: A Modified Policy
The JSY was launched by modifying the 1995 National Maternity Benefit Scheme that provided cash incentives “of Rs 500 per birth, up to two live births to the pregnant women who have attained 19 years of age and belong to the Below Poverty Line (BPL) households”.
Under the scheme, the uniform cash incentive was replaced by a graded system based on socioeconomic factors. Now, in 18 high-focus states (with less than 25 percent institutional delivery rate when the JSY was launched), all pregnant women, irrespective of birth order, age and socioeconomic position, are eligible for the JSY cash incentive of Rs 1,400 per birth.
In 10 other low-focus states (with more than 25 percent institutional delivery rate), the cash incentive is Rs 700, and is limited to BPL as well as ST and SC women. There is a transport allowance and additional benefits under a sister scheme, the Janani Sishu Suraksha Karyakram.
Increased Risk of Child Mortality
What the study, published in the Social Welfare & Medicine journal in February 2017, points out is that money is not buying India assisted, institutional births and thus increasing the risk of mortality of both the mother and the newborn.
Sukumar Vellakkal of PHFI, lead author of the study, told The Quint in an e-mail interview: “Even when the government is giving free money and free medical care for pregnant women to use health facility for child birth, many people still do not use JSY scheme for child birth. For instance, in 2011-12, only 60 percent of the pregnant women in Uttar Pradesh had used health facility for child birth, and only 39 percent pregnant women had availed JSY cash incentive.”
JSY Lags in High-Focus States
The researchers found that community health workers, known as Accredited Social Health Activists or ASHAs, are the driving force of the JSY. Despite their praiseworthy efforts, the JSY seems to be lagging in many of high focus states. Is the JSY’s ‘failure’ in raking up the institutional number a unique experience?
The study’s co-author Jasmine Fledderjohann, of Lancaster University, told The Quint, “I would not say that the JSY is failing. In fact, I think our study shows that the ASHAs are doing a remarkable job. However, our study does highlight that the cash incentives alone are not sufficient to motivate the decision to deliver at a facility.”
‘Holistic Approach Needed’
She added that “attempts to address some of the supply side problems the ASHAs identified and work to combat the notion of childbirth as a natural event requiring no medical intervention may be helpful for bolstering the programme in the future.
Jasmine Fledderjohann, co-author of the study on Janani Suraksha Yojana The evidence on cash transfer programmes in other settings is mixed, but also suggests that incentives alone may not be adequate; across contexts, there is evidence that a holistic approach to healthcare delivery which addresses not only monetary costs of care, but also quality of care and opportunity costs for a stay away from home has the greatest potential.
The research, based on interviews done in 2013, unearthed several obstacles in the uptake of the JSY that cannot be done away by offering cash incentives. Some of these are:
1) Trust on local, traditional dai or midwife over the need for medical care
2) Poor quality or lack of proper infrastructure at health centres and other JSY medical facilities
3) The belief that childbirth is a natural event and it has no need for institutional delivery,
4) Delay in reimbursements
5) The lack of a ‘care-taker’ at home to look after other children.
During the interviews, the JSY non-users voiced anxiety. “I didn't want to waste four days. I didn’t want to waste four days’ wages. The advantage is only of Rs 1,000 or Rs 1,200. I didn't have a bank account. For bank account Rs 1,000 will go. Need more money in hospital. Here, just giving Rs 500 to a dai is okay. What we finally get is nothing,” the paper quotes a woman as saying.
No Shift in Family Dynamics
While the data is from 2013, there have been some changes in the country. Would the inferences have been any different had the interviews been done in more recent times? “It is difficult to say. I would be reluctant to speculate,” says Fledderjohann.
Jasmine Fledderjohann, co-author of the study on Janani Suraksha Yojana Tentatively, I would say that I’m not aware of any evidence that suggests such fundamental shifts in intra-household and family decision-making dynamics in the past four years have occurred that I would expect to see a large difference in our inferences.
Sukumar adds that “for social change, four years is a small time”, and he doesn’t think this could in anyway “affect our findings”. As for political change in the country in the form of new government since 2014, “there was no significant policy changes in the health sector to warrant considerable changes in our study inferences,” he said.
Even the people at the bottom of pyramid in India do not get moved by cash only. If the government wants to fix the problem, it needs to do much more: improve health infrastructure, fight superstition, obscurantism and pseudo-scientific beliefs through literacy drives and focus on the life of the beneficiary.
(Debkumar Mitra is a Kolkata-based freelance science writer. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for the same.)