In 2005, India launched the largest conditional cash transfer program in the world with its Janani Suraksha Yojana (JSY) initiative. JSY, which roughly translates to “Safe Motherhood Scheme”, provides cash payments to pregnant women who deliver in public medical facilities, as well as the women health workers or ASHAs who accompany them. JSY was established in response to India’s persistently high rates of maternal and neonatal mortality, which account for approximately 20% and 31% of the worldwide totals. Interestingly, the cash transfer scheme targets the most vulnerable, defined as those living below the poverty line and those of specific scheduled castes or tribes.
Results have been mixed. PLOS has a great blog on the subject here. A study published in The Lancet in 2010 reported marked improvements in perinatal health outcomes, as well as an increase in the total number of institutional births. However, maternal mortality has been unaffected, and there have been no significant improvements in the quality of care received in government health facilities. Several assessments have concluded that because JSY so successfully stimulates demand for facility-based births, there must be parallel efforts to enhance the capacity of the public healthcare system to handle the new influx of patients. A rapid anthropological assessment in Maharashta found that the administrators of the program were not active enough and infrastructure inadequate tot the task. Comments on the JSY blog point to the fact that increased institutional deliveries does not, in an of itself, offer a logic for reducing deaths, say due to hemorrhage, if comprehensive emergency obstetric care is not available.
Furthermore, a UNFPA study found that the poorest women are the least likely to access JSY benefits and to deliver in health facilities. Other observers note that accessing JSY is difficult for homeless women, who cannot provide the documentation certifying that they live below the poverty line—a requirement for participation in some states.
Despite some of JSY’s successes so far, more rigorous monitoring and evaluation are vital in order to understand the full scope of the program’s impact on maternal and neonatal health. There is currently no data concerning how mothers spend their cash benefits, or whether women possess the autonomy to spend the benefits on health care. Recent evidence even suggests that some households have been plunged further into poverty due to medical costs that were not reimbursed by JSY.
Health outcomes and quality of care are more telling metrics than the mere quantity of institutional births. An excellent summary of cash transfer, financing schemes and involving the private sector was done by Dfid. Given the sheer size of this social experiment it is in fact surprising that more has not been written on the subject.
