Janani Suraksha Yojana — the Indian way of improving maternal and child health
After a brief visit to New Delhi, I want to share some of the insights I have gleaned from maternal and child experts about the current state of maternal and child health in the vast country of India, home to about a sixth of the world’s population.
As I am sure you are aware, a few years ago (2005), the Indian Government launched a highly innovative and ambitious scheme—the Janani Suraksha Yojana scheme, which everyone refers to as JSY—to reduce maternal and newborn mortality and improve maternal and newborn health by promoting institutional delivery. Essentially, JSY is a conditional cash transfer program in which payments are given to mothers living below the poverty line and to ASHAs (Accredited Social Health Activists, female health workers who are responsible for the mother) if the mother gives birth in a public health-care facility. JSY includes delivery and post-delivery care in addition to reimbursement for any out-of-pocket expenses incurred for transport to and from the health care facility.
Much has been written about the JSY scheme and there have been some formal evaluations about its impact on maternal and neonatal mortality. However, what perhaps is most striking is how JSY has completely changed the demographics of health care in India. The Indian experts I talked to said that deliveries in health facilities have dramatically increased, by at least three times in some states, and interestingly, the proportion of public versus private health care deliveries has changed. Before JSY, for women who chose to give birth in health care facilities, about 65% of births were in the private sector and 35% in the public sector. However, as one of the aims of JSY is equity in addition to coverage, the conditional cash payments do not include the private sector. Government officials told me that since the implementation of JSY, the proportions have now flipped to 65% of births in the public sector and 35% in the private sector. This change is quite an achievement in itself.
Because of the dramatic rise in births in public health facilities, the system is understandably strained and so the focus of the Indian Government is now on the quality of health care and standards of care within health facilities (including hospitals) where the number of inpatients has greatly increased.
There is much still to do, especially in some states such as Uttar Pradesh where a large proportion of the 200 million population (about the same population as Brazil) are living below the poverty line. However, hearing more about the effects of the incredible JSY scheme from the health workers on the front line, brought home to me the importance of political will and what can happen when the government of a country is really committed to improving the health of all its people.
It is interesting to read Rhona MacDonald’s impressionistic review of the Janani Suraksha Yojana. It is true that the numbers of institutional delivery have reached dizzying and perhaps unbelievable heights. The information from secondary sources would have you believe these figures and unfortunately we do not have any devil’s advocate in the system. I have been following the roll out of JSY carefully since its inception and the situation on the ground is different.
1. There is over-reporting because it is in everybody’s interest to over report, because everybody gets paid. We came across the phenomenon of ‘born in the way’ during an official review of maternal deaths in institutions in the district of Badwani in Madhya Pradesh. It is said to be common elsewhere as well.
2. Community based surveys also show high institutional delivery – eg. the UNICEF sponsored Coverage Evaluation Survey. However some states and districts still have low institutional delivery – see NHSRC report on JSY. Even though there is information about continuing low institutional delivery/high home delivery in many places, the system completely ignores ways of strengthening home deliveries even though there is emerging literature that trained home deliveries definitely reduce neonatal mortality and probably reduce maternal mortality.
3. There is very little extra Comprehensive Emergency Obstetric Care available at the institutional level. Life saving is not possible without CEmOC. No one seems to remember this basic tent in their hurry to declare JSY a success. Preliminary analysis done by us of DLHS 3 data ( the latest data available in the public domain) shows that institutional delivery has become less safe after introduction of JSY – raised still birth and neo natal deaths, infections and post partum fever and bleeding.
4. Maternal death rates from states like Rajasthan, MP, Bihar, Orissa have actually shown an upward trend through the Annual Health Survey done in 2010 compared to earlier studies in the 2007 -09. The 2010 has a larger sample size and reports MMR at a sub-state level for the first time and both studies were done by the Registrar General of India.
5. Conceptually JSY does not address maternal deaths in the post partum period or in pregnancy. In practice provides poor and at best uneven quality of care at the point of service delivery. It is difficult to find a ‘logic’ to how it is expected to contribute to substantially safer deliveries.
JSY has led to increases in institutional delivery because of the incentive – a considerable amount for the poorest of the poor. Women are also going to institutions with the hope of better outcomes. Unfortunately community based studies show that women’s experience of institutional delivery is often one of harassment if not downright abuse. We need to address issues around quality if we want women’s faith in public institutions to persist beyond this initial rise of instititutional deliveries. We also need to make adequate provisions for making home deliveries safer with adequate provisions for CEmOC. My fear is that unsafe institutional deliveries promoted through JSY carrot may actually end up becoming the stick.
JSY is (has been) seen as an innovative conditional cash transfer mechanism to promote uptake of “safe delivery” in public hospitals. Indeed, it was launched under the National Rural Health Mission (NRHM) and the intention was JSY would increase public service utilisation of the facilities that the NRHM would seek to improve through better financing. And the numbers do show (as you illustrate) such a “good” trend.
Indeed, the quality of services has not improved much. Many women now deliver in poorly equipped (both people-wise and otherwise!) hospitals. Capacity-building of staff has not matched the hurry to ensure fund-availability for distribution. While the “innovativeness” of the financing mechanism is appreciable, the lack of systems to ensure capacity to “absorb” increased funds at district and sub-district levels result in a poor utilisation of the increasing finances.
Agreed that JSY is a good measure but unaccompanied by a responsive system, the financing mechanism alone merely increases “theoretical utlisation” and does not translate into better service (recalling