|Year : 2013 | Volume
| Issue : 1 | Page : 8-12
Utilization of financial assistance under Janani Suraksha Yojna in Rural North India
Jagbir Singh Malik, Meenakshi Kalhan, Anita Punia, Binod Kumar Behera
Department of Community Medicine, Pt. B.D. Sharma, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
|Date of Web Publication||29-Aug-2013|
Binod Kumar Behera
Department of Community Medicine II, Postgraduate Institute of Medical Sciences, Rohtak, Haryana - 124 001
Source of Support: None, Conflict of Interest: None
Context: Janani Suraksha Yojna (JSY), a conditional cash transfer scheme aims to encourage women to deliver their babies in medical facilities. Aims: To study the utilization of financial assistance under JSY. Settings: Rural areas of Haryana. Study Design: Cross-sectional study. Participants: Mothers who delivered within last 12 months (January to December 2010) and were entitled for benefits under JSY. Subjects and Methods: This cross-sectional study was conducted in two districts of Haryana. One district each was selected randomly from amongst high and low performing districts, depending upon rate of institutional deliveries. A total of 48 sub-centers were selected by multistage random sampling. Out of the 1476 enlisted JSY beneficiaries, 1386 mothers were interviewed by house-to-house visits, after getting informed consent. Data were collected on a pre-designed, pre-tested, semi-structured questionnaire, and analyzed using the SPSS (version 17.0). Results: About 14% ( n = 189) mothers had not received the financial assistance until the time of interview. Only 7.6% mothers got the financial assistance within 1 month after delivery. In nearly half (48.8%) study subjects, financial assistance was delayed beyond 3 months after delivery. More than half (52.7%) got the JSY assistance in cash and 34.8% by check. The incentive was not properly utilized as it was given to the family pool (70.2%) or put in savings account (5%). Only in about one-fifth of mothers, it was used for mother's care (I7.8%) and child care (5.8%). Conclusion: JSY is an ambitious scheme serving as a safe motherhood intervention under the National Rural Health Mission. It has been reasonably successful in promoting institutional deliveries, but the discrepancy in payment of funds was found in home deliveries as well as institutional deliveries. Therefore, the program managers should make the monitoring system for disbursement of funds more effective.
Keywords: Financial assistance, institutional deliveries, Janani Suraksha Yojna
|How to cite this article:|
Malik JS, Kalhan M, Punia A, Behera BK. Utilization of financial assistance under Janani Suraksha Yojna in Rural North India. Niger J Basic Clin Sci 2013;10:8-12
|How to cite this URL:|
Malik JS, Kalhan M, Punia A, Behera BK. Utilization of financial assistance under Janani Suraksha Yojna in Rural North India. Niger J Basic Clin Sci [serial online] 2013 [cited 2019 Oct 18];10:8-12. Available from: http://www.njbcs.net/text.asp?2013/10/1/8/117232
| Introduction|| |
The National Rural Health Mission (NRHM) is the Government of India's flagship program for rural health. Janani Suraksha Yojna (JSY), conditional cash transfer (CCT) scheme that aims to encourage women to deliver their babies in medical facilities. It was proposed by way of modifying the then existing National Maternity Benefit Scheme (NMBS). The main objective of this scheme is to reduce maternal and neo-natal mortality by the promoting institutional deliveries.
Every year, more than 500,000 women die from causes related to pregnancy and child-birth. More than 99% of these deaths take place in developing countries.  India alone has 22% of the global total.  Delivering a baby in a medical facility, under the supervision of a skilled medical professional can lead to a significant reduction in maternal and neo-natal mortality. Providing cash incentives was thought of as a faster way of encouraging women to come to the medical facilities for deliveries, thereby reducing maternal and infant mortality. 
As per JSY's guidelines, after delivery in a government or accredited private health facility, eligible women would receive cash incentive. In ten high-focus states or low performing states (LPS) with low institutional birth coverage, all women irrespective of socio-economic status and parity are eligible for the cash incentive. The cash incentive is higher in these LPS than in the high performing states (HPS) i.e. 1000 Indian Rupees (US$ 20) in urban areas and 1400 Indian Rupees (US $28) in rural areas. In the HPS, women are eligible for the cash benefit only for their first two live births, and only if they belong to below-poverty-line (BPL) category or if they are from a scheduled caste or tribe at a rate of 600 Indian Rupees (US $12) in urban areas and 700 Indian Rupees (US $14) in rural areas. JSY also continued to provide a small amount of financial assistance 500 (US $10) for births at home for pregnant women (aged 19 years and older) living BPL, and for the first two births as was given under NMBS. 
JSY is the largest CCT program in the world in terms of the number of beneficiaries.  The budget allocation in the 2009-2010 financial year was 15·4 billion rupees ($342 million) covering about 9·5 million (36%) of 26 million women giving birth in India in the same year.
The State of Haryana is one of the HPS and the scheme has been in operation for over 5 years. Moreover, no evaluation study has been conducted in the state. It was found appropriate to assess the performance of this scheme in terms of financial assistance received by the beneficiaries, which in turn may be helpful in strengthening the program implementation.
| Subjects and Methods|| |
This cross-sectional study was undertaken in two districts of Haryana after obtaining ethical clearance from the Institutional Ethics Committee of Pt. B.D. Sharma Post Graduate Institution of Medical Sciences. As per district level household survey-3 report, all the districts of India were classified into 3 categories based upon percentage of institutional deliveries as follows: Low performing (less than 45%), moderately performing (45-60%), and High performing (more than 60%). District Rewari and Panipat were randomly selected from high and low performing districts respectively. From each community health center of the districts, two primary health centers (PHC) were selected randomly. From each PHC, two sub centers were selected randomly a total of 48 sub centers were selected. List of mothers who delivered during last 1 year (January to December 2010) was obtained from the multipurpose health worker Female (MPHW F) and only those entitled under JSY scheme were contacted by the investigators during house-to-house visits. Eligible beneficiaries under JSY were interviewed on a pre-designed, pre-tested, semi-structured questionnaire. Data were entered in Microsoft Excel spreadsheet and was analyzed using the Statistical Package for Social Sciences (SPSS) version 17.
| Results|| |
A total of 1386 mothers were interviewed by the investigators. Majority of the study subjects were in the age group of 20-25 years i.e., 1079 (77.8%) followed by 279 (20.1%) from age group 26-30 years as shown in [Table 1]. Study subjects 1104 (79.6%) belonged to scheduled caste followed by backward caste 239 (17.2%) and general caste 43 (3.1%). Around one-fourth of the study subjects were illiterate while two-third were educated up to high school. Only 36 (2.6%) were graduate and above. Majority of the study subjects were house-wives 1284 (92.6%) followed by laborers as shown in [Table 1].
Out of 1376 deliveries, 1253 (90.4%) were institutional. To reach health facility 503 (40.1%) study subjects used free ambulance services (free 102 service), followed by hired vehicle 371 (29.6%) as shown in [Table 2]. More than two-third (70.9%) of the study subjects did not spend a penny on transportation, whereas 6.5% spent less than 100 Indian Rupees (US $2), 6.5% between 100 and 500 Indian Rupees (US $2-10) and 3.4% more than Rs. 500 Indian Rupees (US $10). Mean distance travelled to reach health-care facility was 6.59 ± 9.46 km. Mean expenditure on travel was 65.96 Indian Rupees (US $ 1.31) (range: 0-2000 Indian Rupees (US $0-400). Majority of the mothers incurred no expenditure on health-care (on medicines, investigations, etc.) after reaching the health-care facility. Mean expenditure incurred on medicines, investigations or payment of dues hospitals etc., in health facility was 798.40 Indian Rupees (US $15.96) (range: 0-60000 Indian Rupees [US $0-12000).
Almost all study subjects (99.9%) had heard about JSY scheme. MPHW F was the main source of information regarding JSY scheme among 1273 (91.8%) study subjects, followed by accredited social health activities (ASHA) (49.3%) and others (1.9%). Among the study subjects, 890 (64.2%) were helped by MPHW F in receiving the JSY assistance, followed by 546 (39.4%) mothers by ASHA worker.
The JSY financial assistance was not received by 189 (13.6%) beneficiaries. In 48.8% of the study subjects, financial assistance was delayed beyond 3 months after delivery. In about one-fourth of the study subjects, it was delayed for 1-3 months. Only 105 (7.6%) mothers got the financial assistance within 1 month as shown in [Table 3]. JSY assistance in cash was received by 52.7% mothers and 34.8% as check. In 70.2% of the subjects, the incentive was not properly utilized as it was put in the family pool or in savings account (5%). Only I7.8% mothers used the incentive for their own care and 5.8% for child care.
Until the time of the interview, 10.5% and 14.0% of the mothers, who delivered at home and at institutions respectively, had not received any financial assistance [Figure 1]. Among mothers, who delivered at home, 108 (81.2%) received the recommended amount of 500 Indian Rupees (US $10), whereas 25% of GC and 12.4% of SC category did not receive any financial assistance. [Table 4] shows that 5.1% from GC, 12.8% BC, and 15.4% SC did not receive any financial assistance under JSY for institutional deliveries 19.5% of mothers from SC category received the recommended amount of Rs. 2200.
|Table 4: Caste wise distribution of financial incentive received in home and institutional deliveries |
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| Discussion|| |
The utilization of maternal health-care services remains low throughout most South Asian countries despite continued efforts to strengthen the infrastructure, drug supply, and human resource capabilities. These measures are not sufficient to address the access barriers faced by the poor. Demand-side financing initiatives are specifically intended to reduce cost related access barriers for vulnerable groups by giving them purchasing power to use a designated service. The concept involves funneling government or donor funds directly to a needy. There are various approaches, one of them being a CCT. A traditional CCT bestows a financial incentive directly to the beneficiary if the recipient complies with a certain set of prerequisites. JSY, a CCT under NRHM in India has been launched with the motive to improve institutional delivery and enhance maternal and child care, particularly targeting the lower socio-economic strata and SC/ST mothers.
During the present study, 14% (n = 189) mothers did not receive the financial assistance and only 7.6% mothers got the financial assistance within 1 month after delivery. This depict the benefits under JSY are not provided to all the beneficiaries. In their study in Orissa, Mohapatra et al.  reported that around 11% did not receive the money at all and was delayed in more than one-third mothers. United Nation Population Fund (UNFPA) study also revealed delay in payment of funds in some LPS states. 
Similarly, reports from other demand-side financing programs in Nepal.  and Bangladesh  revealed that the facilitation of the cash benefit or voucher funds was problematic due to lack of funds and poor procedural implementation of the scheme. In contrast to our findings, a study by Sidney et al. in Ujjain district  found that all women who participated in the JSY program received the cash benefit, i.e., 57% at the actual time of discharge and a further 28% within 2 weeks of delivery implying a relatively well-functioning program process in that area. The success of a cash transfer program relies on the intended beneficiary receiving the incentive in a timely manner; otherwise the program falls into disrepute.
In our study, more than half got the JSY assistance in cash and 34.8% by check. In contrast, Mohapatra et al.  reported payment made through checks in 67% mothers. In a study from eight districts of Rajasthan, payment was made through checks in about 94% subjects, mainly bearer checks.  The disbursement of financial assistance should be made through checks (account payee preferably), but as the majority of beneficiaries do not have bank accounts in their name, cash/bearer checks are being used, which might not benefit the user.
Khan et al.  in a study in rural Uttar Pradesh observed that in women who delivered in public health facilities, 18% did not receive any incentive money, 79% had received the full incentive money of Rs. 1400 and 4% received less than the recommended amount. In present study, discrepancy in payment of funds was found as 82.1% of GC while 86.5% BC mothers received the recommended amount of Rs. 700 for institutional deliveries whereas only one-fifth of SC mothers received the recommended amount of Rs. 2200. However, mothers who delivered at home, 108 (81.2%) received the stipulated amount. Similarly, in the UNFPA study it was observed that more than 90% of the mothers who delivered in an institution received the stipulated payment. 
The key person who provided assistance in delivery of JSY incentives was MPHW F in 890 (64.2%) mothers while ASHA worker helped 546 (39.4%) mothers in receiving the payment. This emphasizes the need for active participation of the ASHA workers. However, low incentives for ASHA workers in the HPS may be a reason for their poor participation. As in the present study, about 90% deliveries were institutional; this reflects an improvement in the institutional deliveries, which can be attributed to the JST funding. Panja et al.  also reported that cash incentive under JSY in the antenatal period had a positive association on institutional deliveries. As only 40.1% of the study subjects used the free 102 ambulance services for reaching the place of delivery, it shows poor utilization of the free ambulance services. These GPS fitted ambulances have been in operation since April 2009 basically serving the mothers to reach the health-care facilities during pregnancy or post-partum period. Though, this service is being provided free of cost, but people tend to use hired vehicle or their personal vehicle for this purpose due to the urgency. Mean distance travelled to reach health-care facility was 6.59 ± 9.46 km. The Mean expenditure on travel was Rs. 65.96 (range: Rs. 0-2000). Majority of the mothers had no expenditure on health-care (on medicines, investigations, etc.) after reaching the health-care facility. Mean expenditure incurred on medicines, investigations etc., in health facility was Rs. 798.40 (range: 0-60000). This indicates that almost free maternal care is being delivered in most of the places in Haryana.
The little evidence from the assessment of the effects of CCTs in few countries ,,,,, suggests that although these programs have led to increased health-service use, whether they have led to improvements in health outcomes and whether their effects are generalizable across different settings are not known Lim et al.  reported that the implementation of JSY in 2007-08 was highly variable from state-to state. However, present study revealed that there is a significant effect on improvement of antenatal care and institutional deliveries with implementation of JSY.
| Conclusion and Recommendations|| |
The present study found that although JSY has been reasonably successful in promoting institutional deliveries, yet discrepancy in payment of funds was found in home deliveries as well as institutional deliveries. The financial assistance received by mothers was not utilized for the care of the mother and child in the majority of cases. So the program managers should make the monitoring system for disbursement of funds more effective .
It is recommended that proper guidelines and timeline should be prepared by State Health Department for JSY fund distribution. There is need to increase awareness regarding the scheme by using local media. Independent monitoring and evaluations are important to measure the effect of JSY as financial and political commitment to the program intensifies.
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[Table 1], [Table 2], [Table 3], [Table 4]