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Janani Suraksha Yojana (JSY) is perhaps the largest conditional cash transfer program in the world which was launched by the MOH&FW, Government of India in 2005 with the goal to reduce maternal and infant mortality through accelerating institutional delivery and other continuum of services at government health services, particularly among the poor and marginalized groups. Since the introduction of the JSY program, a major increase has been taken place in institutional deliveries, presently (2009) it is ranging between 37 percent in Bihar to around 80 percent in Madhya. Some improvement has been reported in 3 ANC checkups and post natal checkup within 7 days of deliveries.
The Population Council, with financial support from Bill & Melinda Gates Foundation, carried out two large surveys, one in Uttar Pradesh (2009) and the other in Bihar (2011) to understand how JSY has succeeded in providing continuum of health services to pregnant women and newborn children, and the extent to which it is able to meet the increased demand for services.
Here we are sharing some key observations from Uttar Pradesh survey in which 4472 women spreads over 250 villages covering 12 districts and representing all regions of UP. The study showed some important improvement both in the knowledge base and actual behavior. For example, ASHA (the community worker) through her motivational efforts has succeeded in imparting importance of institutional delivery “we get good care in hospitals and both the mother and child will be safe–they follow hygienic practices.” An analysis of expenses for institutional delivery shows that JSY payment (Rs1400) to women for services was almost the same (Rs1290) what they actually spent. So while JSY payment helped in subsidizing cost of delivery at institution, it is the safety of women and children that appears to be the key motivator for institutional delivery. Many poor women who despite of knowing that institutional delivery will be safer and could not have effort to do it because of cost consideration, now are doing it.
The time series data of NFHS3 and DLHS-3 show that the gap in the proportion of women going to institutional delivery between family with higher standard of living index (SLI) and families with low SLI is narrowing which was indeed the objective of the JSY. The study also indicates that JSY has helped in increasing the proportion of women who are undergoing three or more antenatal check-up substantially, which is working as the gateway to many other important health behaviors like institutional delivery, delay in giving a bath to the newborn, and initiation of early breast feeding.
While all these are good news, there are many disturbing observations too. As women delivering at a private facility do not get any JSY payment, the trend of using a private facility has taken a nose dive (the share declined from 63 percent to 37 percent). As a result the workload at public facilities has increased significantly and share of institutional delivery at public facilities has gone up (37 to 63 percent). Comparing available public facilities and expected demand of delivery services shows that unless a healthy balance (50:50) between public-private is maintained, public facilities cannot meet the demand of additional deliveries without compromising quality of services.
Further, because of poor infrastructure most of the women after delivery come back home within 12 hours and thus miss a major opportunity for postnatal check ups within 24 hours. As result, postpartum care for mothers and newborns has remained very low (around 14 percent). In absence of other authentic data it is very difficult to tell, despite of some improvement in health behavior, whether JSY is achieving its goal of reducing maternal mortality and neonatal death.