India’s Janai Suraksha Yojana: A Conditional Cash Transfer Program for Maternal and Child Health

| October 19, 2011 | 0 Comments

By Cameron Johnstone
Maternal & Child Health Columnist

Mumbai mother holding her child. Photo courtesy of Wen-Yan King.

Should governments provide cash incentives to low-income populations for using available public health services? In 2005, the Indian Ministry of Health and Family Welfare introduced a Conditional Cash Transfer (CCT) program called Janai Suraksha Yojana (JSY) that does exactly this. Eligible pregnant women who deliver their babies in a government or accredited private health facility receive 600 Indian rupees ($13) in urban areas and 700 rupees ($15) in rural areas.[1] Evidence from JSY suggests CCT programs can have a significant impact, but also present practical and ethical concerns.

The program now supports over 9.5 million births a year with a budget of $342 million. A 2010 study published in The Lancet concluded that JSY had significantly increased in-facility births and was associated with a modest reduction in perinatal and neonatal deaths.[1] India’s infant mortality rate has dropped from 55 per 1,000 births in 2005 to its current 48 in 2010, although other factors such as rising income may have contributed to this reduction.[2] Given this success, India is understandably experimenting with further CCT programs.[3]

However, the same Lancet study also found significant problems with the implementation of JSY. The authors observed a substantial variation in the percent of women receiving payments between Indian states – from as high as 42 percent to as low as seven percent. Women with some education had higher odds of receiving JSY payments than those with none, and, in some states, wealthier mothers were more likely to receive payments.[1]

In a conversation with the HCGHR, Dr. Daniel Wikler, a professor at the Harvard School of Public Health, noted that the families most in need tend to be the hardest to reach with CCT interventions. Dr Wikler states that “When payments are concentrated among the middle range of beneficiaries, the poorest and most isolated benefit less. In this way, you might even say the intervention increases health disparities.”[4] 

The inability of some Indian states to fully participate in JSY may be attributable to disparities in public health infrastructure between regions in India. Despite the availability of public facilities, nearly 80 percent of the total expenditure on health in 2005 was out-of-pocket private payments. One possible reason for this is the high level of absenteeism in subsidized public medical facilities: a 2003 survey found facilities were closed on average 56 percent of the time.[5] Although in 2005 India implemented the National Rural Health Mission with the goal of increasing public spending on health from under one percent to three percent of GDP, Indian healthcare is still largely private.[5] This raises the question: should resources spent on demand-management programs like JSY be better spent improving the supply of public healthcare itself?

Finally, conditional cash transfer programs like JSY also present ethical questions. When asked if CCT programs were paternalistic, Dr. Wikler said, “Most of the time when people use paternalistic they mean some kind of coercion is involved, which, arguably, there isn’t in this case.” But he went on to explain that CCT programs require caution due to the power of those making the payments to influence disadvantaged people’s decisions. Dr. Wikler raises the question, “Who am I to say what’s best for you?” He recommends focusing on the evidence underlying the intervention, stating, “intention on the part of the donor is not enough.”[4]

JSY demonstrates that CCT programs have the potential to expand in India and to other developing regions. However, as with the most global health work, operational and ethical challenges accompany the implementation of such programs.

 


[1] Lim, Stephen, et al. “India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.” The Lancet 375 (2010): 2009-2023.

[2] United Nations. Department of Economic and Social Affairs: United Nations Statistics Division. “Millennium Development Goals Indicators: The official United Nations site for the MDG Indicators.” New York City: UN, 2011.

[3] Prabhu, K. Seeta. “Can Conditional Cash Transfers Work in Rural India?” The Wall Street Journal. July 2009.

[4] Wikler, Daniel. Phone INTERVIEW. 15 Oct 2011

[5] Banerjee, Abhijit V., et al. “Putting a band-aid on a corpse: incentives for nurses in the Indian public healthcare system.” Journal of the European Economic Association 6 (2008): 487-500.

[6] Reddy, K. Srinath, et al. “Toward achievement of universal healthcare in India by 2020: a call to action.” The Lancet 377 (2011): 760-768.

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