|Year : 2017 | Volume
| Issue : 2 | Page : 104-109
Utilization of janani suraksha yojana by eligible pregnant women in rural South India: A qualitative study
Biswamitra Sahu1, Anita Nath1, R Anil Kumar2
1 Indian Institute of Public Health, Public Health Foundation of India, Bengaluru, Karnataka, India
2 District Hospital Campus (HQH), Bellary, Karnataka, India
|Date of Web Publication||30-May-2017|
Indian Institute of Public Health, Public Health Foundation of India, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Context: In India, the Janani Suraksha Yojana (JSY) scheme, translated as “safe motherhood scheme,” has been implemented to tackle this financial insecurity by giving cash incentives to women who give birth in public health facilities and accredited private health facilities. Although there is a reported increase in the number of institutional deliveries, there has not been much improvement in maternal or neonatal mortality rates.
Objective: To explore the utilization of and barriers toward the use of JSY scheme by eligible rural pregnant women.
Design: Qualitative research method in the form of in-depth interview was used for data collection and analysis.
Methodology: The study was conducted in seven villages of Bellary district in Karnataka, South India. In depth interview was conducted for the study participants included twenty women who had delivered over the last 1 year and were selected by purposive sampling from antenatal registers which were available from the primary and community health centers in the district.
Results: About 80% had delivered at public sector health facilities. To pay for the financial deficit to meet the pregnancy-related expenses, a large number of participants expressed to have raised money from loans, mortgage of land and house, and selling of jewelry and livestock. Many narrated their experiences with the poor quality of care at the public sector health centers. Several participants faced problems ranging from those related to opening a bank account to cumbersome procedures and logistical issues for money encashment.
Conclusion: The incentive which is given under JSY does not seem adequate as, despite its availability, the family still needs to incur lofty medical expenditure. Furthermore, lack of quality care at public health facilities results in excessive out of pocket expenditure incurred at private health centers. The encashment procedure is also fraught with cumbersome procedures once again leads to loss of work time and additional economic losses.
Keywords: Barrier, institutional delivery, Janani Suraksha Yojana, out of pocket expenditure, private health facility, public health facility, quality of care, utilization
|How to cite this article:|
Sahu B, Nath A, Kumar R A. Utilization of janani suraksha yojana by eligible pregnant women in rural South India: A qualitative study. Indian J Health Sci Biomed Res 2017;10:104-9
|How to cite this URL:|
Sahu B, Nath A, Kumar R A. Utilization of janani suraksha yojana by eligible pregnant women in rural South India: A qualitative study. Indian J Health Sci Biomed Res [serial online] 2017 [cited 2017 Dec 12];10:104-9. Available from: http://www.ijournalhs.org/text.asp?2017/10/2/104/207266
| Introduction|| |
India accounts for almost 20% of the global burden of maternal deaths., Even though India has registered a decline in the maternal mortality, many maternal lives are lost as a result of financial insecurity. In India, the Janani Suraksha Yojana (JSY) scheme, translated as “safe motherhood scheme,” has been implemented to tackle this financial insecurity by giving cash incentives to women who give birth in government facilities at all the three-tier levels of health care and accredited private health facilities. Under the JSY program, the states are categorized as “low performing” or “high performing,” varying the cash amount to provide greater incentives in low-performing states. Specifically, women in low-performing states are given Rs. 1400 in rural areas and Rs. 1000 in urban areas and those in high-performing states are offered Rs. 700 in rural areas and Rs. 600 in urban areas.
Several quantitative impact evaluations of the program have been done which have shown improved rates of institutional delivery.,,,, However, there appears to have been no improvement in the neonatal mortality rate or maternal mortality rate., Qualitative studies are needed to explore and comprehend the reasons behind this scenario. One of the important reasons as elicited from earlier qualitative studies is the poor quality of care as health providers tend to focus upon the economic benefits that they derive from this scheme. A qualitative approach enables a researcher to “see” a lot more and also broadens the field of vision. Moreover, it serves to give the study participants “voice,” both literally as well as metaphorically, which makes them feel valued. Thus, in the present study, we used qualitative methods with the objective to explore the utilization of and barriers toward the use of the JSY scheme by its beneficiaries.
Evaluation of the disadvantaged North districts of Karnataka (which is a high-performing state) has revealed that JSY is not successfully reaching the goal of reducing the maternal and infant mortality. This study was conducted in Bellary district of North Karnataka, India. The district of Bellary registers fewer institutional deliveries than the districts in the south part of the state, hence conducting the study in this district would be of greater relevance.
| Methodology|| |
The study was conducted among participants residing in seven villages in Bellary district of Karnataka, India.
A total of twenty women who were beneficiaries of JSY and who had delivered over the last 1 year before the commencement of study were enrolled in the study. The participants were purposively selected based on the above-mentioned inclusion criteria of having delivered in last 1 year.
Qualitative research method in the form of in-depth interview (IDI) was used for data collection and analysis. The address and contact details of the study participants were obtained from the antenatal care registers available from seven primary health centers and one community health center in the district. The interviews were conducted in the participant's home after taking prior appointment of their availability. Conducting interviews at their respective home ensured that they answered questions in a setting that was comfortable to them. Privacy was ensured during the interview. An attempt was made to recruit participants from different socioeconomic strata to ensure that the participants hailed from diverse contexts. Details regarding expenditure that had been incurred during delivery vis-à -vis incentives which were received were collected using a structured questionnaire. An IDI guide was used to elicit open-ended response of their experience during pregnancy and delivery. The IDI guide was first developed in English and later translated to the local language “Kannada.” To test the appropriateness of the questions, the IDI guide was pretested. Interviews were recorded using voice recorder. The voice files after the interviews were first transcribed in Kannada and then translated into English.
Voluntary written consent of the participants was obtained following her agreement to participate in the research after she had been informed about the study details. Permission to use a voice recorder was taken. Ethics approval was obtained from the Institutional Ethics Committee of the Indian Institute of Public Health, Hyderabad (IIPHH/TRCIEC/005/2013). The anonymity of the participants was maintained by taking out all identifying information from the transcripts before initiating analysis.
The quantitative data were analyzed using simple descriptive statistics. Analysis of qualitative data was done using qualitative data analysis technique of grounded theory 20. Transcripts were coded by labeling and categorizing (open coding) concepts, connecting categories and subcategories (axial coding), and integrating main categories (selective coding) to develop the induced theoretical frameworks.
| Results|| |
Sociodemographic profile of the beneficiaries
Majority (65%) of the women were in the age group of 21–25 years. Most (40%) of them had completed primary schooling. As many as 75% of them were homemakers [Table 1].
Place and type of delivery
Most (80%) of the participants had delivered at a government hospital with the remaining 20% having delivered in private health facilities.
Financial constraints encountered in case of institutional deliveries
To pay for the financial deficit resulting from pregnancy-related expenses, the participants expressed to have raised money from loans, mortgage of land and house, and selling of jewelry and livestock.
As many as 70% of the participants had incurred a deficit of Rs. 1000–5000 for meeting the expenses of institutional delivery. Again, 15% of them had incurred a deficit of Rs. 10,000–20,000 while about 10% of the participants stated to have spent more than Rs. 20,000.
One participant describes the financial ordeal that her maternal family had to undergo to pay for her institutional delivery as it is customary for the married woman to deliver at mother's home.
“Till the 5th month of my pregnancy, I was in my husband's house, so he paid for it. Next I came to my parents' house where my brother paid for the same even though they had financial problems. He had hardly Rs. 100–200 with him, so every time I visited the clinic, he used to take loan and give me. He took loan from the local moneylender in our village to pay for the delivery expenses.”
(Age: 24 years, Caste: Scheduled Caste, Education: Fifth grade)
It is customary for the maternal family to spend on rituals during their daughter's pregnancy and delivery. A participant describes how the expenses that were incurred during her delivery created financial liability for her mother who has to work in the agricultural fields of the moneylender:
“My mother arranged Rs. 2000 for blood transfusion, which she borrowed from the moneylender in the village. She will repay back the money by working in the fields. Although my husband had money, my mother had to take loan.”
(Age: 20 years, Caste: Kuruba, Education: tenth grade)
The mother of a participant from a marginalized caste had to mortgage land to raise funds for her delivery.
“My mother had two acres of land in her name which she pledged locally to get the money for my antenatal checkups. My father gave money for delivery expenses. He does a coolie work (manual laborer) and doesn't have a land of his own. He borrowed from his younger brother. He will repay the loan by contributing from his earned wages”.
(Age: 25 years, Caste: Scheduled Caste, Education: Fourth grade)
Experiences of delivering in public sector facilities
A participant narrates her experience at a government hospital due to lack of medical infrastructure wherein she was advised to go to a private hospital. Due to poor management at the government hospital, she finally had a still birth at the private hospital where she had been referred as a result of which she has lost faith in the public health sector facilities.
“During my first delivery, my blood pressure was high due to which I visited the government-run hospital where the doctor told me that 'you have come very late and you have a serious condition and here (at this public hospital) we don't have proper facility, so you go to a private hospital that I am suggesting.' Taking his advice, we went to the government run hospital and I was operated upon but the fetus was dead. Such an experience has scared me and I did not go to a public hospital for my second child.”
(Age: 29 years, Caste: Lingayat, Education: Graduate)
A lack of specialized health personnel and that of medical diagnostic equipment has emerged as one of the main reasons for referral to a private hospital (again suggested by a government doctor) in the experience of another participant as narrated below,
“The doctor examined me and told that I needed a scan and a specialist's opinion. He referred me to a private doctor at …………. We asked the doctor the reason behind this. He told us there is no concerned specialist at the General Hospital. So, we went to a private clinic.”
(Age: 23 years, caste: Lingayat, Education: Fourth grade)
A similar reason is cited by another participant who did not visit a government hospital because of lack of specialist at government hospital. This has been reflected in her answers below,
“I came to know through my friends that the doctor at this hospital could not perform cesarean operation and that there is no concerned specialist in that hospital.”
(Age: 24 years, Caste: Pinjar, Education: tenth grade)
Programmatic barriers toward receiving cash benefits from the scheme
To avail the benefits of the incentive of JSY, the participants have experienced several problems ranging from those related to opening a bank account to cumbersome procedures and logistical issues for money encashment and bribe. The JSY incentive is given to the beneficiary by issuing account payee cheque. However, many a times, the beneficiaries do not open a bank account on time and do it only after delivery. There is also irregularity in the disbursement of incentives. Hence, the cheques are not released as per the JSY guidelines. One participant describes her experience of late receipt of cheque and financial constraints for opening a bank account, a prerequisite for encashing cheque, because of which she has still not encashed the cheque.
“After three days of my delivery, I was given a cheque of Rs. 600. Sister (nurse) told me that there were no funds so I got it late. I have not encashed the money. I went to the bank; they told that I should open an account. For opening an account, I have to deposit Rs. 1000. I didn't have so much money so I came back. I have yet decided what to do about this. The process of getting this incentive is not good; I can't afford to spend money to open the bank account.”
(Age: 19 years, caste: Kuruba, Education: Seventh grade)
The cumbersome nature of opening a bank account and the nonflexibility of banks with regard to opening an account for the beneficiaries has caused a lot of distress for the following participant:
“I went to the bank at Place X. They told me that I have to open a bank account and then only would they give me the money. But I had to pay Rs. 1000 for opening this bank account. I came back and told the doctor at place Y about this. He told that there is an order from the government stating that the bank account should be opened without deposit. Again I went and asked both the banks at Place X and Place Y, both refused to open an account without Rs. 1000. The bank people are not helpful so I will wait and see, as I don't have money now.”
(Age: 23 years, caste: Gowda, Education: Fourth grade)
Again, the beneficiaries are spending money to travel to the bank which is often located miles away from their native village. The money that is spent on such travel eats away from the incentive amount, thus not being of much use for the beneficiaries. While disbursing the incentives, the woman who has recently delivered is expected to go to the bank to encash her incentive cheque. In her absence, the bank does not accept the cheque. She is not in an adequate physical state to travel to the bank for encashing cheque; this causes physical, psychological, and emotional distress for the woman. It shows insensitivity on the part of the bank to expect a woman to visit the bank for disbursement despite the knowledge of her physical state. Again, the tertiary hospital maintains account in the Banks (such as State Bank of Mysore) which has core banking facility. Hence, they issue cheques which can be encashed at the same bank at the district and taluka level. However, the beneficiaries from remote villages have to travel far to the taluka or district level and open account in the bank with core banking facility. One participant describes this experience as follows:
“They gave me cheque of Rs. 600. I went to the bank at Place X along with my father; the officials told that I should open a bank account and then only would they give me the money. After so much of documentation, I opened a bank account. To get a cash of worth Rs. 600, I had to spend around Rs. 250/- for the documentation. I am left with the remaining Rs. 350 with me. Account now.”
(Age: 20 years, Caste: Kuruba, Education: Illiterate)
| Discussion|| |
While the JSY scheme with over 7.1 million individual beneficiaries has created demand for institutional delivery, the question we are seeking to answer is: has the scheme really helped to reduce maternal morbidities, deaths, and financial burden for the poor and underprivileged as envisioned. Findings from our study indicate that the increase in demand for institutional delivery is not supported by the supply of good quality health care due to inadequate health infrastructure and shortage of specialized staff. Similarly, results from a study done in Madhya Pradesh, which is a low-performing state, display a 42.6% increase in institutional deliveries after JSY implementation, yet a large number of high-risk pregnancies were referred to the tertiary care level, and high number of maternal deaths among poor rural women were reported. Poor quality of care in the public sector facilities has been frequently encountered in other studies as well. In another study which was conducted in three districts of Madhya Pradesh province, it was seen that birth attendants in the JSY facilities at the primary and secondary level had low competence at mean emergency obstetric care (EmOC) provision. A qualitative study which was carried out also in Madhya Pradesh on the intrapartum care received during normal deliveries observed that the delivery rooms were not conducive to safe, women-friendly care provision, and coordination between providers was poor. Some participants in our study reported to have been referred for cesarean section to private health centers due to nonavailability of a qualified obstetrician. An analysis shows that the proportion of cesarean sections in public facilities is lower than the minimum recommended (5%) in all socioeconomic groups which point toward a gross unavailability of free EmOC during the JSY program. One of our study respondents had a still birth due to negligence on the part of the doctor at a government hospital. Nonadherence to Indian guidelines for managing various obstetric conditions has been widely reported., Therefore, the quality of care in health facilities, especially below the district level, is not competent enough to deal with intensive obstetric care, which is why JSY is yet not able to achieve its expected outcomes.
Since the health system is not strong enough to meet that demand, this has resulted in referral from government to private hospitals for routine antenatal investigation and specialist opinion. The poor are struggling to pay for the services at private hospitals, most of which are not accredited by JSY. Further, the financial burden gets compounded in case of cesarean deliveries. This puts a lot of financial pressure on the poor and vulnerable who are going in debt due to heavy out-of-pocket expenditure (OOPE). The participants in our study expressed to have raised money from loans, mortgage of land and house, and selling of jewelry and livestock. Study revelations from two household surveys done in Orissa show that many households approached pregnancy as a family event and mobilized resources on behalf of the women through hardship means., Despite arranging for financial resources, most of the respondents in our study had incurred a heavy financial deficit up to a maximum of Rs. 20,000 for meeting the expenses of institutional delivery. Even a secondary analysis of data from the District Level Household Survey-3, 2007–2008, demonstrates that OOPE for women having institutional deliveries remained high, with considerable variation between states and union territories. For a normal delivery in a public and private institution, mean OOPE was Rs. 1624 and Rs. 4458, and for a cesarean section, it was Rs. 5935 and Rs. 14,276, respectively. Similarly, a mixed-method study done in Orissa revealed that the JSY incentive provided partial financial risk protection as it could cover only 25.5% of the maternal health-care cost of the beneficiaries in rural areas and 14.3% in urban areas.
The encashment procedure under this scheme is tedious and time-consuming. The respondents in our study expressed that long travels to the bank incurred heavy expenditure which usually outdid the cash benefits that were received from the scheme. Similar findings were derived from a qualitative study done in Uttar Pradesh wherein husbands (mostly daily wagers) had to miss a day of work to accompany their wives and infants to retrieve the payment.
| Conclusion and Recommendations|| |
The study highlights the importance of JSY in promoting institutional deliveries. However, an understanding of the ground realities and corrective measures for overcoming barriers could help improve the program even further. Importantly, it can bring equity in addressing the health care needs of the poor and the marginalized. Strict monitoring and supervision of incentive disbursement for timeliness should be operationalized. The JSY incentive amount should be substantially increased as it is inadequate for expenditure incurred in cases of cesarean deliveries. Prompt disbursement of cash for the needy should be strengthened. Transactions should be done in nearby village banks than core banks to reduce the cost of travel.
This being a qualitative study, the results cannot be generalized to all segments of the population. Interviewing the health-care providers about their opinion and perspectives with regard to this scheme could have given a complete picture of the issue.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Montgomery AL, Ram U, Kumar R, Jha P; Million Death Study Collaborators. Maternal mortality in India: Causes and healthcare service use based on a nationally representative survey. PLoS One 2014;9:e83331.
Rai SK, Dasgupta R, Das MK, Singh S, Devi R, Arora NK. Determinants of utilization of services under MMJSSA scheme in Jharkhand 'client perspective': A qualitative study in a low performing state of India. Indian J Public Health 2011;55:252-9.
] [Full text]
Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: An impact evaluation. Lancet 2010;375:2009-23.
Ministry of Health and Family Welfare. Janani Suraksha Yojana: Features and Frequently Asked Questions and Answers. New Delhi: Government of India; 2006.
Dongre A. Effect of Monetary Incentives on Institutional Deliveries: Evidence from India. MPRA Paper, University Library of Munich, Germany; 2010.
United Nations Population Fund (UNFPA). Concurrent Assessment of Janani Suraksha Yojana (JSY) in Selected States: Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh. New Delhi: UNFPA; 2008.
Khan ME, Hazra A, Bhatnagar I. Impact of Janani Suraksha Yojana on selected family health behaviors in rural Uttar Pradesh. J Fam Welfare 2010;56:9-22.
Powell-Jackson T, Mazumdar S, Mills A. Financial incentives in health: New evidence from India's Janani Suraksha Yojana. J Health Econ 2015;43:154-69.
Das J, Hammer J. Money for nothing: The dire straits of medical practice in Delhi, India. J Dev Econ 2007;83:1-36.
Issel ML. Health Program, Planning and Evaluation: A Practical Systemic Approach for Community Health. London, UK: Jones and Bartlett; 2004.
Deshpande RV. Janani Suraksha Yojana (JSY) contributing to the reduction of maternal and infant mortality? An insight from Karnataka. Medindia 2011;57:1-9.
Ministry of Health and Family Welfare. District Level Household and Facility Survey 2007-2008. Mumbai: International Institute for Population Sciences; 2010.
Gupta SK, Pal DK, Tiwari R, Garg R, Shrivastava AK, Sarawagi R, et al.
Impact of Janani Suraksha Yojana on institutional delivery rate and maternal morbidity and mortality: An observational study in India. J Health Popul Nutr 2012;30:464-71.
Chaturvedi S, Upadhyay S, De Costa A. Competence of birth attendants at providing emergency obstetric care under India's JSY conditional cash transfer program for institutional delivery: An assessment using case vignettes in Madhya Pradesh province. BMC Pregnancy Childbirth 2014;14:174.
Chaturvedi S, De Costa A, Raven J. Does the Janani Suraksha Yojana cash transfer programme to promote facility births in India ensure skilled birth attendance? A qualitative study of intrapartum care in Madhya Pradesh. Glob Health Action 2015;8:27427.
Randive B, San Sebastian M, De Costa A, Lindholm L. Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: Results from nine states in India. Soc Sci Med 2014;123:1-6.
Stanton CK, Deepak NN, Mallapur AA, Katageri GM, Mullany LC, Koski A, et al.
Direct observation of uterotonic drug use at public health facility-based deliveries in four districts in India. Int J Gynaecol Obstet 2014;127:25-30.
Nagpal J, Sachdeva A, Sengupta Dhar R, Bhargava VL, Bhartia A. Widespread non-adherence to evidence-based maternity care guidelines: A population-based cluster randomised household survey. BJOG 2015;122:238-47.
Gopalan SS, Durairaj V. Addressing maternal healthcare through demand side financial incentives: Experience of Janani Suraksha Yojana program in India. BMC Health Serv Res 2012;12:319.
Binnendijk E, Koren R, Dror DM. Hardship financing of healthcare among rural poor in Orissa, India. BMC Health Serv Res 2012;12:23.
Modugu HR, Kumar M, Kumar A, Millett C. State and socio-demographic group variation in out-of-pocket expenditure, borrowings and Janani Suraksha Yojana (JSY) programme use for birth deliveries in India. BMC Public Health 2012;12:1048.
Coffey D. Costs and consequences of a cash transfer for hospital births in a rural district of Uttar Pradesh, India. Soc Sci Med 2014;114:89-96.