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Study of conditional cash transfer programme Janani Suraksha Yojana for promotion of institutional births: Studies from selected provinces of India
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: To accelerate the coverage of skilled birth attendance, in 2005, the Indian government initiated a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY) that provides cash to women upon delivering in health facilities. The attempt to increase the utilization of facilities through the JSY, given the health system’s fragile state, has raised concerns about the programme’s success at achieving its intended goal of reducing maternal mortality ratio (MMR).

Aim: To understand the implementation of the CCT policy to promote institutional births in India, with a special focus on nine of India’s poorer states.

Methods: Thesis uses both quantitative and qualitative methods. The changes in coverage and inequalities in institutional births in the nine states following the initiation of JSY were analysed by comparing levels before and during the programme using state and district level data. The association between the coverage of institutional births and MMR was assessed using regression analysis (I). The change in socioeconomic inequalities in institutional births was estimated using the concentration index and concentration curve, and contributions of different factors to inequalities was computed by decomposition analysis (II). The quality of referral services was studied by conducting a survey of health facilities (n=96) and post-partum women (n=1182) in three districts of Madhya Pradesh. Conditional logistic regression was used to study the association between maternal referrals and adverse birth outcomes, while spatial data for referrals were analysed using Geographical Information Systems (III). Semi-structured interviews were conducted with government and non-government stakeholders (n=11) to explore their perceptions of the JSY, and the data were analysed using a thematic framework approach (IV).

Results: In five years, institutional births increased significantly from a pre-programme average of 20% to 49%. However, no significant association between district-level institutional birth proportions and MMR was found (I). The inequality in access to institutional delivery care, although reduced since the introduction of JSY, still persists. Differences in male literacy, availability of emergency obstetric care (EmOC) in public facilities and poverty explained 69% of the observed inequality. While MMR has decreased in all areas since the introduction of JSY, it has declined four times faster in the richest areas than in the poorest (II). Adjusted odds for adverse birth outcomes among those referred were twice than in those who were not referred (AOR 2.6, 95% CI 1.1-6.6). A spatial analysis of the inter-facility transfer time indicated that maternal deaths occurred despite good geographic access to EmOC facilities (III). While most health officials considered stimulus in the form of JSY money to be essential to promote institutional births, non-government stakeholders criticised JSY as an easy way of addressing basic developmental issues and emphasised the need for improvements to health services, instead. Supply-side constraints and poor care quality were cited as key challenges to programme success, also several implementation challenges were cited (IV).

Conclusions: Although there was a sharp increase in coverage and a decline in institutional delivery care inequalities following the introduction of JSY, the availability of critical care is still poor. CCT programmes to increase service utilization need to be essentially supported by the provision of quality health care services, in order to achieve their intended impacts on health outcomes.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2015. , 85 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1770
Keyword [en]
Maternal health, Condititonal cash transfer, Inequality, Referral, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-112844ISBN: 978-91-7601-393-9 (print)OAI: oai:DiVA.org:umu-112844DiVA: diva2:882982
Public defence
2016-01-15, Sal 135, Allmänmedicin, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2015-12-18 Created: 2015-12-16 Last updated: 2015-12-17Bibliographically approved
List of papers
1. India's conditional cash transfer programme (the JSY) to promote institutional birth: is there an association between institutional birth proportion and maternal mortality?
Open this publication in new window or tab >>India's conditional cash transfer programme (the JSY) to promote institutional birth: is there an association between institutional birth proportion and maternal mortality?
2013 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 6, e67452Article in journal (Refereed) Published
Abstract [en]

Background: India accounts for 19% of global maternal deaths, three-quarters of which come from nine states. In 2005, India launched a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY), to reduce maternal mortality ratio (MMR) through promotion of institutional births. JSY is the largest CCT in the world. In the nine states with relatively lower socioeconomic levels, JSY provides a cash incentive to all women on birthing in health institution. The cash incentive is intended to reduce financial barriers to accessing institutional care for delivery. Increased institutional births are expected to reduce MMR. Thus, JSY is expected to (a) increase institutional births and (b) reduce MMR in states with high proportions of institutional births. We examine the association between (a) service uptake, i.e., institutional birth proportions and (b) health outcome, i.e., MMR. Method: Data from Sample Registration Survey of India were analysed to describe trends in proportion of institutional births before (2005) and during (2006-2010) the implementation of the JSY. Data from Annual Health Survey (2010-2011) for all 284 districts in above-mentioned nine states were analysed to assess relationship between MMR and institutional births. Results: Proportion of institutional births increased from a pre-programme average of 20% to 49% in 5 years (p<0.05). In bivariate analysis, proportion of institutional births had a small negative correlation with district MMR (r = 20.11). The multivariate regression model did not establish significant association between institutional birth proportions and MMR [CI: -0.10, 0.68]. Conclusions: Our analysis confirmed that JSY succeeded in raising institutional births significantly. However, we were unable to detect a significant association between institutional birth proportion and MMR. This indicates that high institutional birth proportions that JSY has achieved are of themselves inadequate to reduce MMR. Other factors including improved quality of care at institutions are required for intended effect.

Place, publisher, year, edition, pages
Public Library of Science, 2013
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-79613 (URN)10.1371/journal.pone.0067452 (DOI)000321150000081 ()
Available from: 2013-10-13 Created: 2013-08-26 Last updated: 2017-12-06Bibliographically approved
2. 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
Open this publication in new window or tab >>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
2014 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 123, 1-6 p.Article in journal (Refereed) Published
Abstract [en]

Proportion of women giving birth in health institutions has increased sharply in India since the introduction of cash incentive program, Janani Suraksha Yojana (JSY) in 2005. JSY was intended to benefit disadvantaged population who had poor access to institutional care for childbirth and who bore the brunt of maternal deaths. Increase in institutional deliveries following the implementation of JSY needs to be analysed from an equity perspective. We analysed data from nine Indian states to examine the change in socioeconomic inequality in institutional deliveries five years after the implementation of JSY using the concentration curve and concentration index (CI). The CI was then decomposed in order to understand pathways through which observed inequalities occurred. Disparities in access to emergency obstetric care (EmOC) and in maternal mortality reduction among different socioeconomic groups were also assessed. Slope and relative index of inequality were used to estimate absolute and relative inequalities in maternal mortality ratio (MMR). Results shows that although inequality in access to institutional delivery care persists, it has reduced since the introduction of JSY. Nearly 70% of the present inequality was explained by differences in male literacy, EmOC availability in public facilities and poverty. EmOC in public facilities was grossly unavailable. Compared to richest division in nine states, poorest division has 135 more maternal deaths per 100,000 live births in 2010. While MMR has decreased in all areas since JSY, it has declined four times faster in richest areas compared to the poorest, resulting in increased inequalities. These findings suggest that in order for the cash incentive to succeed in reducing the inequalities in maternal health outcomes, it needs to be supported by the provision of quality health care services including EmOC. Improved targeting of disadvantaged populations for the cash incentive program could be considered.

Keyword
India, Institutional delivery, Janani Suraksha Yojana, Inequality, Maternal health, Conditional cash transfer, Maternal mortality, Decomposition analysis
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-98501 (URN)10.1016/j.socscimed.2014.10.042 (DOI)000347021800001 ()25462599 (PubMedID)
Available from: 2015-01-22 Created: 2015-01-22 Last updated: 2017-12-05Bibliographically approved
3. Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province
Open this publication in new window or tab >>Quality of Obstetric Referral Services in India's JSY Cash Transfer Programme for Institutional Births: A Study from Madhya Pradesh Province
2014 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 5, e96773Article in journal (Refereed) Published
Abstract [en]

Background:

India launched JSY cash transfer programme to increase access to emergency obstetric and neonatal care (EmONC) by incentivising in-facility births. This increased in-facility births from 30% in 2005 to 73% in 2012 however, decline in maternal mortality follows a secular trend. Dysfunctional referral services can contribute to poor programme impact on outcomes. We hence describe inter-facility referrals and study quality of referral services in JSY.

Methods and Results:

Women accessing intra natal care (n = 1182) at facilities (reporting >10 deliveries/month, n = 96) were interviewed in a 5 day cross sectional survey in 3 districts of Madhya Pradesh province. A nested matched case control study (n = 68 pairs) was performed to study association between maternal referral and adverse birth outcomes. There were 111 (9.4%) in referrals and 69 (5.8%) out referrals. Secondary level facilities sent most referrals and 40% were for conditions expected to be treated at this level. There were 36 adverse birth outcomes (intra partum and in-facility deaths). After matching for type of complication and place of delivery, conditional logistic regression model showed maternal referral at term delivery was associated with higher odds of adverse birth outcomes (OR-2.6, 95% CI: 1.0-6.6 p = 0.04). Maternal death record review (April 10-March 12) was conducted at the CEmOC facility in one district. Spatial analysis of transfer time from sending to the receiving CEmOC facility among in-facility maternal deaths was conducted in ArcGIS10 applying two hours (equated to 100 Km) as desired transfer time. There were 124 maternal deaths, 55 of which were among mothers referred in. Buffer analysis revealed 98% mothers were referred from <2 hours. Median time between arrival and death was 6.75 hours.

Conclusions:

High odds of adverse birth outcomes associated with maternal referral and high maternal deaths despite spatial access to referral care indicate poor quality of referral services.

National Category
Public Health, Global Health, Social Medicine and Epidemiology Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-91286 (URN)10.1371/journal.pone.0096773 (DOI)000338213300071 ()24810416 (PubMedID)
Available from: 2014-07-28 Created: 2014-07-28 Last updated: 2017-12-05Bibliographically approved
4. India's JSY cash transfer programme to reduce maternal mortality: Stakeholder perceptions of its appropriateness, achievements and challenges
Open this publication in new window or tab >>India's JSY cash transfer programme to reduce maternal mortality: Stakeholder perceptions of its appropriateness, achievements and challenges
(English)Article in journal (Refereed) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-112843 (URN)
Available from: 2015-12-16 Created: 2015-12-16 Last updated: 2015-12-17

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