SURAKSHA YOJANA, INSTITUTIONAL DELIVERIES AND MATERNAL MORTALITY: WHAT DOES THE EVIDENCE SAY?

14 JANANI SURAKSHA YOJANA, INSTITUTIONAL DELIVERIES AND MATERNAL MORTALITY: WHAT DOES THE EVIDENCE SAY? Ambrish Dongre Despite tremendous medical advances, the instances of maternal and neonatal mortality occur quite frequently, especially in developing countries. Each year, more than half-a-million women die from causes related to pregnancy and child-birth, 99 per cent of which take place in the developing countries (UNICEF 2009). Nearly 4 million newborns die within 28 days of birth, 98 per cent of which occur in the low and the middle income developing countries. Most of these maternal and neonatal deaths are a result of direct causes 80 per cent of maternal deaths are due to obstetric complications including post-partum haemorrhage, infections, eclampsia and prolonged or obstructed labour, while 86 per cent of the newborn deaths are the direct results of the three main causes severe infections, asphyxia and pre-term births. These large numbers of maternal and neonatal deaths can be avoided if skilled medical personnel are at hand, better care is provided during labour and delivery, and key drugs, equipment are available. Given that these resources are more easily available in a medical facility, delivering in a medical facility has been recognised as an important way to reduce maternal and neonatal deaths. Yet, the proportion of women who deliver in medical facilities remains abysmally low in many developing countries, including India. India is one of the worst performers as far as maternal and neonatal mortality 1 is considered. Maternal mortality in India constitutes 22 per cent of the worldwide maternal deaths. Though there has been a steady decline in maternal mortality ratio (MMR) in the last decade (see Table 14.1), it is still much higher compared to the other developing countries, such as China, Philippines, Thailand and Sri Lanka, which have MMR less than 100 (ibid.). Further, there is a wide disparity in MMR among the states in India. As per 2004 06 figures, all the states in the top panel of Table 14.1 had MMR in excess of 300. In fact, about two-thirds of maternal deaths in India are concentrated in these states. The states in the lower panel of Table 14.1 had MMR less than 200 (with the exception of Karnataka). The table also indicates that the states with a high MMR also have a relatively lower fraction of deliveries taking place in a medical institution. 2 It was against this backdrop that the National Rural Health Mission (henceforth, NRHM) was launched by the Government of India in April 2005. One of the major objectives of the NRHM has been to reduce the maternal mortality to 100 per 100,000 live births and reduce infant mortality to 30 per thousand live births by the year 2012. This ambitious target was sought to be achieved through the Janani Suraksha Yojana (translated as Safe Motherhood Scheme; henceforth JSY), introduced in 2005. 1 Maternal mortality ratio (MMR) is the number of maternal deaths per 100,000 live births. Neonatal mortality rate is the number of infants dying before reaching 29 days of age per 1,000 live births. 2 Figures for MMR of the states have been obtained from various reports and bulletins published by the Office of Registrar General of India.

Janani Suraksha Yojana, Institutional Deliveries and Maternal Mortality 179 Table 14.1 Maternal Mortality Ratio (MMR) and Proportion of Institutional Deliveries in India MMR % of institutional deliveries 2001 03 2004 06 2007 09 2010 12 2002 04 2007 08 India 301 254 212 178 40.5 47.0 Low Assam 490 480 390 328 26.8 35.1 Performing Bihar/Jharkhand 371 312 261 219 23.0 27.5 States Jharkhand 22.4 17.7 Madhya Pradesh/Chhattisgarh 379 335 269 230 28.2 46.9 Chhattisgarh 20.2 18.0 Odisha 358 303 258 235 34.4 44.1 Rajasthan 445 388 318 255 31.4 45.4 Uttar Pradesh/Uttarakhand 517 440 359 292 22.4 24.5 Uttarakhand 23.7 30.0 High Andhra Pradesh 195 154 134 110 60.9 71.8 Performing Gujarat 172 160 148 122 52.2 56.4 States Haryana 162 186 153 146 35.1 46.8 Karnataka 228 213 178 144 58.0 65.1 Kerala 110 95 81 66 97.8 99.4 Maharashtra 149 130 104 87 57.9 63.5 Punjab 178 192 172 155 48.9 63.1 Tamil Nadu 134 111 97 90 86.1 94.0 West Bengal 194 141 145 117 46.3 49.1 Other 235 206 160 136 Notes: MMR: Maternal deaths per 100,000 live births. MMR figures for the states of Bihar and Jharkhand, Madhya Pradesh and Chhattisgarh, Uttar Pradesh and Uttarakhand are not available separately. But DLHS reports percentage of institutional deliveries for each. Hence, we have reported them separately. Sources: Figures for MMR have been obtained through various documents published by the Office of the Registrar General of India. Figures for the proportion of institutional deliveries have been obtained from national reports of the District-level Household Survey (DLHS). This chapter evaluates the impact of one of the largest Conditional Cash Transfers (CCTs) in the world, JSY in India, on institutional deliveries. JSY encourages institutional deliveries through the provision of monetary incentives to women and to local community health workers. Results indicate that institutional deliveries have increased in the backward states which were the targeted regions, after the launch of the programme. Pre-existing trends in institutional deliveries or changes in availability or access to medical facilities cannot explain these results. The increase in institutional deliveries in the backward states is driven by increased deliveries in public health facilities and decline in deliveries in private health facilities. Thus, JSY has undoubtedly increased institutional deliveries. What about its effect on maternal mortality or infant mortality? Available data indicates that JSY probably did not have much effect on maternal and infant mortality. Janani Suraksha Yojana (JSY) The main objective of JSY is to decrease maternal and infant mortality by encouraging pregnant women to deliver in medical facilities. This is sought to be achieved through payment of monetary incentives to women who deliver in government or accredited private medical facilities. 3 For the purposes of the scheme (and for NRHM as well), the states in India were divided into two categories low performing and high 3 Various direct and indirect expenses which the household has to bear are regarded as one of the most important reasons why women do not go to institutions for delivery. But when asked about why the respondent woman did not go to a health facility for delivery, 34 per cent women mentioned that it was not necessary to deliver in a health facility, 24 per cent women said that they had no time to visit a health facility for delivery, and 23 per cent women cited prohibitive costs as the reason for not going to a health facility, while 17 per cent mentioned that they had better care at home. Thus, it is important to note that the costs are not the only the reason why women do not go to health facilities for delivery (IIPS 2010).

180 India Infrastructure Report 2013 14 performing. 4 The low performing states are those that had an extremely low proportion of women delivering in a medical institution in 2005, at the start of NRHM and consequently, had a higher MMR. 5 Conversely, the high performing states are those that were functioning relatively better on this indicator. Initially, the eligibility criteria for women to avail of monetary incentives, and the magnitude of the incentives were uniform across both, low and high performing states. Only women above 19 years of age and belonging to below poverty line (BPL) families could avail of these benefits for the first two live births. The magnitude of incentives was also identical for the rural areas across the two categories of states (Rs 700), while women in the urban areas of only low performing states were eligible for the incentives. However, late 2006 saw a substantial relaxation in these eligibility conditions in the low performing states. Specifically, any woman, irrespective of age, wealth status, caste or the number of previous live births were to be eligible for JSY benefits, thereby making this scheme almost universal in these states. In addition to these, incentives were also increased substantially for women in the low performing states (see Table 14.2). No such changes were made in the high performing states. 6 To implement the scheme, a new cadre of community health worker Accredited Social Health Activist (ASHA) was introduced. She is supposed to be a trained female community health activist who would Table 14.2 Initial and Revised Incentives under JSY (in Rs) Initial incentives Rural Urban Low performing state 700 600 High performing state 700 Nil Revised Incentives Rural Urban Low performing state 1,400 1,000 High performing state 700 600 Source: UNFPA (2009). work as an interface between the community and the public health system. Selected from the village itself and accountable to it, ASHAs are supposed to play an important role in the context of maternal and child health. 7 As far as JSY is concerned, she is supposed to facilitate delivery in a government or an accredited private medical facility. As per the guidelines, she is to be paid Rs 600 per delivery only if she facilitates the delivery in a government facility. 8 Initially, ASHAs were appointed only in the low performing states. Later on, the scheme was extended to all the states. Over the years, the number of institutional deliveries as well as financial expenditure under the scheme has increased manifold as seen in Table 14.3. More importantly, this increase seems to be driven by the low performing states as indicated in Figures 14.1 and 14.2. Figure 14.1 shows that the proportion of JSY beneficiaries out of the total institutional deliveries has shot up dramatically in the low performing states. Figure 14.2 shows that the number of institutional deliveries has gone up in both categories of states, but more so in the low performing states. 9 In fact, the gap in the Table 14.3 Number of Beneficiaries and Expenditure on the JSY Year No. of beneficiaries Expenditure (Lakhs) (Rs crores) 2005 06 7.39 38.29 2006 07 31.58 258.22 2007 08 73.29 880.17 2008 09 90.37 1,241.33 2009 10 100.78 1,473.76 2010 11 106.96 1,618.39 2011 12 109.37 1,606.18 2012 13 80.68* 1,155.00* Note: * Physical and financial achievement for 2012 13 is till December 2012. Source: Physical and Financial Performance of JSY, PIB, MoHFW, 28 March 2013. 4 JSY is a part of NRHM. 5 Low performing states include Jammu & Kashmir, Himachal Pradesh, Uttarakhand, Uttar Pradesh, Bihar, Odisha, Jharkhand, Madhya Pradesh, Chhattisgarh, Rajasthan, Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura. 6 The scheme was extended to cover even the women in low performing states who belong to BPL households, and are above 19 years of age, and deliver at home with the assistance of a skilled person. These women are now entitled to Rs 500 as cash incentives. 7 Details are available at http://mohfw.nic.in/nrhm/asha.htm#abt. 8 Some states have divided this amount into three components Rs 250 for transport, which is given to whoever pays for the transport (may not be ASHA), Rs 200 as an incentive for ASHA (non-transferable) and Rs 150 if ASHA escorts woman to the facility/stays with her. 9 Both figures show a huge jump between 2006 07 and 2007 08 in the low performing states. This is likely to be the result of relaxation of eligibility and hike in incentive amounts in these States. More generally, studies such as CORT (2007); UNFPA (2009), UNICEF (2010), NHSRC (2011), NRHM (2012), Dongre and Kapur (2013) have also documented increase in institutional deliveries post-jsy.

Janani Suraksha Yojana, Institutional Deliveries and Maternal Mortality 181 % of JSY Beneficiaries after Institutional Delivery Figure 14.1 Percentage of JSY Beneficiaries amongst those Delivering in an Institution: Low and High Performing States 100 90 80 70 60 50 40 30 20 10 0 2.55 2005 06 21.42 3.12 10.69 2006 07 64.03 87.24 25.05 26.39 2007 08 LPS 2008 09 83.67 90.46 86.71 28.82 26.96 26.82 2009 10 2010 11 HPS Notes: NRHM (2013) provides number of institutional deliveries for year 2012 13 as well. But the number of JSY beneficiaries after institutional deliveries are available only up to 2011 12. LPS: Low Performing States, HPS: High Performing States. Sources: NRHM (2013), RTIs filed by Accountability Initiative. Number of Institutional Deliveries (in Lakh) Figure 14.2 Number of Institutional Deliveries: Low and High Performing States 90 80 70 60 50 40 30 20 10 0 64.55 38.68 2005 06 67.12 46.67 2006 07 72.91 76.25 64.12 63.82 2007 08 77.66 76.75 Notes: Low Performing Non-North-East states include Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Jammu & Kashmir, Himachal Pradesh, Odisha, and Rajasthan. High Performing States include Andhra Pradesh, Goa, Gujarat, Haryana, Karnataka, Kerala, Maharashtra, Punjab, Tamil Nadu and West Bengal. Source: NRHM (2013). 2008 09 Low Performing Non-NE states 2009 10 2011 12 80.74 84.47 78.93 82.37 2010 11 2011 12 High Performing states number of institutional deliveries between the low and the high performing states in 2005 06 had disappeared by 2009 10. The key question from policy-maker s point of view is: Can we attribute this increase to JSY? Just because institutional deliveries have gone up post-jsy does not necessarily mean that it is caused by JSY. There can be other plausible explanations. Opening up of new health facilities (in both, public and private sector) improves availability and access to health services. Alternatively, increase in institutional deliveries that we see in the post-jsy period might just be a continuation of a trend that started even before JSY. If any or both these explanations are valid then not taking it into account implies over-estimating the importance of JSY. What does the data suggest? Empirical Analysis using Survey Data 10 How can we use survey data to assess the relationship between JSY and institutional deliveries? As mentioned before, even though the scheme was introduced uniformly across the country, the subsequent modifications made it more attractive and inclusive among the low performing states. Thus, other things being equal, data should show faster increase in proportion of institutional deliveries in the low performing states compared to the highperforming ones. But this is not enough. To be able to say that JSY has led to increase in institutional deliveries, data should show two more things: (a) trends in institutional deliveries between the low performing and the high performing states in the pre-jsy period do not indicate convergence, and (b) there has been no differential increase in the low performing states in availability and access to medical facilities, compared to the high performing states. Does data support this? We have used three successive rounds of the District-level Household Survey (DLHS), specifically the rounds conducted in 1998 99, 2002 04 and 2007 08, to conduct this analysis. Note that the 1998 99 and 2002 04 rounds were conducted before JSY came into being, while the 2007 08 round was conducted after JSY was instituted. DLHS covers the entire country and is probably the largest when it comes to the sample size. 11 Data 10 Discussion in this section is based on Dongre (2012), which is available for download on http://papers.ssrn.com/sol3/papers. cfm?abstract_id=2196361. 11 DLHS sample size ensures that the sample is representative at the district level. For more details, see IIPS (2010).

182 India Infrastructure Report 2013 14 is collected through structured questionnaires, and relevant information is obtained about the sampled household, married women in the age group of 15 44 years in the sampled household, husbands of these women, and the sampled villages. 12 Among other things, the focus of the questionnaire for women is to obtain information on various aspects of maternal and child health and healthcare during pregnancy, delivery and post-delivery such as receipt of antenatal care, problems during pregnancy, receipt of iron folic acid tablets/ syrup, tetanus injections during pregnancy, place of delivery (whether home or medical facility, government or private), breastfeeding practices, immunisation and vaccinations, prevalence and awareness about diarrhea, pneumonia, etc. Combining the three DLHS rounds give us information about maternal and child health and healthcare for births that have taken place during 1 January 1995 to December 2008. This is quite important since it allows us to analyse trends in institutional deliveries in the low performing and the high performing states, both before and after the introduction of JSY. Impact on Institutional Deliveries 13 Data shows that at the baseline, 60 per cent women in the high performing states and barely 26 per cent in the low performing ones delivered in terms of medical facilities. 14 Thus, the gap between the two categories of states was quite large at 34 percentage points. Once we take into account other characteristics of a woman and a household which can influence institutional delivery, the gap comes down to 16.4 percentage points. 15 In simple words, it means that probability of a woman from low performing states delivering in a medical facility was 16.4 percentage points lower than an identical woman in the high performing states. What happened post-jsy? In the initial post-jsy period (i.e. mid-2005 to end-2006), institutional deliveries grew more rapidly in the high performing states, and as a result, the gap between the two categories of states widened marginally. But in 2007 and 2008, the institutional deliveries grew at a higher rate in the low performing states, and the gap started declining. The results suggest that the gap declined from 16.4 to 9.5 percentage points, i.e. probability of a woman from low performing states delivering in a medical facility was 9.5 percentage points lower instead of 16.4 percentage points, than an identical woman in the high performing states. 16 This is a very important result. But are these trends driven by JSY? Let us explore two main alternative explanations. a) Increased availability and access to medical facilities in the low performing states As mentioned previously, JSY is one component of the NRHM, and creation of medical facilities is another important element of this initiative. Since it is the low performing states where infrastructure gaps are more severe, more facilities would be created in the low performing states under NRHM. This implies that availability and access to medical facilities could change differentially in the low performing states. This can result in more institutional deliveries even in the absence of any monetary incentive due to improvement in availability and access to medical facilities. If we do not take into account impact of these factors, we would over-estimate the effect of JSY. To explore this possibility, village-level data obtained from DLHS-2 (2002 04) and DLHS-3 (2007 08) is used, which has information about the availability and access to various medical facilities such as Anganwadis, sub-centres, primary health centres (PHCs), community health centres (CHCs), government dispensaries, government hospitals and finally, mobile health clinics. Availability is defined as the presence of a particular type of medical facility in a village, and accessibility as the facility being accessible by road throughout the year. 12 The types of questionnaires canvassed are not uniform across the survey rounds village questionnaire was not canvassed in the 1998 99 round, while the questionnaire for husbands was canvassed only in the 2002 04 round. 13 We define a delivery as institutional delivery if it takes place in a medical facility, whether owned by public or private sector or by NGOs or charitable trusts. The public/government medical facilities include sub-centres, PHCs, CHCs, rural hospitals, district hospitals, municipal and state hospitals, etc. 14 The baseline is the proportion of institutional deliveries in the period 1999 2004. 15 We control for age of the women, number of pregnancies she had, her and her husband s education, caste and wealth in the regression analysis. 16 These results are from the all-india sample. The trends in the rural sample are similar to that of the all-india sample. The urban sample displays a slightly different pattern. See the original paper for more details.

Janani Suraksha Yojana, Institutional Deliveries and Maternal Mortality 183 The results indicate that except for anganwadis, there has been no differential change in the availability and access of any other medical facility. 17 Thus, larger increase in the proportion of institutional deliveries in the low performing states is unlikely to be driven by increased availability and access of public health facilities during the time period under consideration. 18 b) Pre-existing trends Other explanation of post-jsy trends in institutional delivery can be the possibility that the gap between the low and the high performing states started narrowing even before JSY was launched. But analysis of DLHS Rounds 1 (1998 99) and 2 (2002 04), which give information on births which have taken place during the years 1995 2004, clearly indicates that the gap in institutional deliveries between the low and the high performing states was in fact widening in the pre- JSY period. So pre-existing trends cannot explain the reduction of gap in the post-jsy period. Figure 14.3 aptly summarises the above discussion. Gap.2.15.1.05 Figure 14.3 Gap in Institutional Deliveries between the Low Performing and the High Performing States 1995 2000 2005 2010 Gap Year Lower Confidence Limit Upper Confidence Limit Notes: 2005: Launch of the scheme; 2006: modification in the scheme. Source: Author s analysis using successive rounds of DLHS. Deliveries in Public Facilities vs. Private Facilities As noted earlier, JSY incentives are available for deliveries in government facilities and only accredited private medical facilities. No benefits are available for delivery in the private medical facilities which are not accredited. ASHAs are not supposed to receive any incentives in cases of deliveries in private facilities, accredited or not. Further, the number of accredited private facilities and their geographical spread is quite limited. 19 This suggests that the JSY would reduce the proportion of deliveries in private facilities, and increase the same in government facilities. Does the data support this hypothesis? Indeed it does. The results show that the deliveries in public facilities have increased at a higher rate in 2007 and 2008, while deliveries in private facilities have declined. So the overall increase in institutional deliveries is actually a combination of increase in institutional deliveries in public medical facilities and decline in institutional deliveries in private medical facilities. 20 Is the Benefit of JSY Reaching the Disadvantaged Households? The direct and indirect costs associated with institutional deliveries are likely to be more binding for the disadvantaged households. Hence, a scheme providing monetary incentives like JSY is expected to benefit more to the relatively disadvantaged households. The eligibility criteria and incentive amounts also favour such households. For example, the magnitude of JSY incentives is higher in the rural areas compared to the urban areas in both the low performing and the high performing states. In the high performing states, only Scheduled Caste (SC)/Scheduled Tribe (ST) and BPL women are eligible for JSY benefits. Similarly, in the low performing states, women from only SC/ST and BPL households are eligible for monetary incentives even when they deliver in accredited private medical facilities, 17 The corresponding regression equations and tables of results can be found in Dongre (2012). 18 That there has been no differential increase in public health facilities in the low performing states vis-a-vis the high performing states (as of 2007/2008) itself is an alarming result to say the least. It raises more fundamental question about NRHM itself. 19 There were only 658 accredited private institutions as on 30 June 2012 across Bihar, Chhattisgarh, Himachal Pradesh, Jammu & Kashmir, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand. Bihar, Himachal Pradesh, Jammu & Kashmir and Uttar Pradesh have no accredited private medical facilities. Madhya Pradesh had 41, Odisha had 17 and Uttarakhand had only 2 accredited facilities (see National Rural Health Mission: State wise Progress as on 30 June, 2012, published on 25 September 2012). 20 In addition to describing an interesting outcome of the scheme, this result also adds to the robustness of overall findings.

184 India Infrastructure Report 2013 14 while other women are not. Hence, one would expect that the proportion of institutional deliveries would grow faster among women from the rural, SC/ST and BPL households in both the low performing and high performing states. What do the results show? Results for the low performing and the high performing states are analysed separately. In the low performing states, institutional deliveries have grown at an increasing rate among women from households with high wealth in the post-jsy period. 21 In the low performing states, institutional deliveries have grown at a faster rate among the women from the households with high wealth in the post-jsy period. As a result, gap in institutional deliveries, between women from high wealth households and women from other households, has increased. But the trend reversed post- 2006 with institutional deliveries growing at a higher rate among women from the households with low and medium wealth. So there is catching up albeit with a lag. But there is no evidence of catching up in the case of women from rural households or for women from SC/ ST households. The picture is slightly different in the case of high performing states. Institutional deliveries have grown faster for women from households with medium wealth, and to some extent for households with low wealth. Similarly, the proportion of institutional deliveries has been almost constant in the urban areas, while it has grown in the rural areas. As a result, the gap between the rural and urban households has narrowed. But no catching up has happened for women from SC/ST households, and as a consequence, the gap in institutional deliveries between the SC/ST and non-sc/st households has remained more or less constant. Thus, the evidence on whether socially disadvantaged households within low and high performing states are benefitting from the JSY is relatively mixed, and it is difficult to draw any definite conclusions. An important limitation of the analysis so far is that it describes trends only up to 2008 since DLHS-3 provides information on births up to December 2008. So, in some sense, what we see here are the short-term impacts of JSY. Have these trends continued even after 2008? Are more disadvantaged households benefitting from JSY? We cannot answer these questions simply because no new nation-wide household-level survey data on health has been made available since the release of DLHS-3 in 2010. Field-work for DLHS-4 is complete, but it does not include the 280-odd districts in the low performing states which are covered under the Annual Health Surveys (AHS). 22 So DLHS-4 is not much relevant for rigorous nation-wide evaluation of JSY. The last National Family Heath Survey (NFHS) was carried out way back in 2005 06. If the reports in the newspapers are to be believed, a revised NFHS is to be launched only in 2014. 23 It is not clear whether the structure of the revised NFHS will be comparable to the previous ones. Data from this revised NFHS is likely to be available only in 2015. Therefore, it will be difficult to know the medium (and potentially long) term effects of JSY till 2015. Effects of JSY on Maternal and Infant Mortality The million-dollar question is: Has JSY led to the decline in maternal, neonatal and infant mortality? Maternal Mortality Maternal mortality is a rare event, so capturing it through surveys requires a huge sample size and hence typical household surveys, including DLHS, cannot yield a reliable estimate of maternal mortality. In the Indian context, periodic Sample Registration System (SRS) bulletins are the time-tested source of mortality indicators. These indicators are provided at the state level, but unfortunately not for every year. The most recent period for which MMR numbers are available is 2010 12. The numbers indicate that MMR for the country has declined by 16 per cent, from 212 for the period 2007 09 to 178 for the period 2010 12. In 2007 09, only 21 In the analysis, we have used wealth index as the proxy for relative poverty of the household. DLHS-3 asks whether the household has a BPL card. But it is well-known that a significant fraction of non-poor households possess BPL cards. This makes using BPL cards to identify poor households inappropriate. 22 The DLHS and AHS are not comparable. More details about the Annual Health Survey can be found at http://censusindia.gov.in/ vital_statistics/ahsbulletins/ahs.html, accessed on 30 October 2013. 23 See http://www.livemint.com/politics/zjd4pm80nnrugpvbpcbrkk/govt-discontinues-annual-health-survey.html?facet=print, accessed on 30 October 2013.

Janani Suraksha Yojana, Institutional Deliveries and Maternal Mortality 185 Kerala had MMR below 100. As per 2010 12 figures, Maharashtra and Tamil Nadu have also managed to get MMR below 100. Except Haryana, Tamil Nadu, Odisha and Punjab, other states have recorded a double digit decline. The largest decline (19 per cent) has been recorded in Rajasthan, West Bengal and Karnataka, closely followed by Uttar Pradesh/Uttarakhand and Kerala. What does the trend in MMR over time show? Figure 14.4 shows that over time, the gap between low and high performing states has gone down, with the pace of decline increasing after 2004 06. In other words, MMR is declining faster in the low performing states, as compared to the high performing states. But the question is: Can we attribute this decline to JSY? The answer is: we cannot say. The reason is that MMR has been declining in both the low and the high performing states even before JSY was introduced. It is difficult to isolate the impact of various factors increased incomes, increased awareness, improved access and availability of medical care, and JSY, on reduction in maternal mortality. There might be some correlation, but one cannot say much about the causality. Infant Mortality We have performed a similar analysis for infant mortality as well, which is represented in Figure 14.5. The figure reveals that infant mortality rate (IMR) has been declining in both the low and the high performing states even before the implementation of JSY. Further, Figure 14.4 MMR in Low and High Performing States Maternal Mortality Ratio (MMR) 600 500 400 300 200 100 0 500 444.83 426.67 183.78 192.75 169.11 1997 98 1999 2000 2001 03 High Performing States Source: Author s analysis using SRS data. 376.33 153.56 2004 06 309.17 259.83 134.67 115.22 2007 09 2010 12 Low Performing States Infant Mortality Rate (IMR) Figure 14.5 IMR in Low and High Performing States 80 70 60 50 40 30 1999 2003 2007 2011 Notes: LPS: Low Performing States, HPS: High Performing States. Source: Author s analysis using SRS data. there is no visible acceleration in decline in IMR in the low performing states. Thus, we have an interesting situation here JSY has increased the proportion of institutional deliveries. But it does not seem to have led to a faster decline in either maternal or infant mortality. Conclusion LPS Year HPS One potential reason could be that JSY has not reached to those women who face the highest risk of death during child birth. 24 Given that these women are likely to be more socially disadvantaged, efforts should be made to make sure that they are aware of JSY. It is here that ASHAs are to play a very important role. An ASHA is not only supposed to facilitate institutional deliveries, but also act as health activist, and counsel women on birth preparedness and importance of safe delivery, among others. Another possible reason, and which is cited quite often, is the abysmal state of public health facilities in terms of infrastructure (physical and human), and quality of care. Despite expansion in medical infrastructure, there continues to be a major gap in coverage. According to the norms, an SC should cover a population between 3,000 5,000, a PHC between 20,000 30,000, while a CHC should cover between 80,000 120,000. However, 24 Our results suggest that this is indeed a possibility.

186 India Infrastructure Report 2013 14 BOX 14.1 Accredited Social Health Activist ASHA Appointment of ASHA (which literally means hope in Hindi) is an important element of NRHM. ASHA is envisaged as a link between the public health system and the local community, and a first port of call for health-related demands of the disadvantaged sections of the population. In the initial phase, ASHAs were appointed only in the low performing states. But soon the scheme was extended to the North-Eastern states, and subsequently to the tribal and hilly areas of the high performing states as well. Over time, almost all the states have appointed ASHAs. An ASHA is supposed to carry out a number of responsibilities. She is supposed to be the first port of call for any health related demands of deprived sections of the population, especially women and children. She provides information to the community on determinants of health nutrition, sanitation and hygiene, information on existing health services, and need for timely utilisation of health and family welfare services. In the context of maternal and child health, she counsels women on birth preparedness, importance of safe delivery, breastfeeding and immunisation. In the context of JSY, she arranges for an escort or accompany pregnant women to the nearest pre-identified facility, and facilitates payment postdelivery. She provides primary medical care for minor ailments such as diarrhoea, fevers and first-aid for minor injuries. She is also a depot-holder for essential provisions such as Oral Rehydration Therapy (ORS), Iron Folic Acid (IFA) tablets, chloroquine, disposable delivery kits (DDK), oral pills and condoms, to be made available to every habitation. Studies indicate that awareness among mothers about ASHA is fairly high. High proportion of women report receiving advice and help from ASHA in terms of pregnancy registration and information about JSY. A substantial fraction of women report that ASHA stayed with them during delivery. An important role played by ASHA in giving confidence and support to family is worth mentioning. What is also emerging is the key role ASHA play in ensuring that the pregnant woman gets JSY payment. But it is believed that ASHA focus too much on JSY and ignore an important aspect of their work counselling about pre- and postnatal care and ensuring that women receives it, is not getting enough attention. Studies also indicate than ASHAs have less than full knowledge of their roles and responsibilities. They face a number of issues, most important being a substantial delay in receiving their incentive payments. Sources: See Bajpai and Dholakia (2011), Dongre and Kapur (2013), NHSRC (2011), UNFPA (2009) for more details. data indicates that as on March 2012, a sub-centre caters to 5,615 people, a PHC caters to 34,641 people, while a CHC caters to 172,375 people. 25 In addition, most health facilities lack basic infrastructure. According to the Concurrent Evaluation of NRHM (2009), only 12.5 per cent of PHCs in Bihar and Chhattisgarh had a labour room with new-born care, while in Odisha, none of the PHCs sampled had such a facility. Only 18 per cent PHCs in the low performing states (excluding the North-east) had piped water supply, while barely 6 per cent of the PHCs have been upgraded as per the Indian Public Health Standards (IPHS). Human resource deficit is another major problem. Let us take the example of the CHCs, where non-availability of specialists (surgeons, paediatricians, physicians, obstetricians and gynaecologists) is quite worrisome. Data as on 31 March 2012 reveals that there was a shortfall of 76 per cent, and 51 per cent vacancy for surgeons, and 67 per cent shortfall, and 38 per cent vacancy for obstetrician/ gynaecologists at CHCs. 26 Physical infrastructure and manpower are necessary but not sufficient though. Chaudhury et al. (2006) find that on average, the PHCs have 40 per cent absence rate. Banerjee and Duflo (2004) report a similar absence rate in the health facilities in Udaipur. 27 Finally, the quality of care and treatment when health providers actually turn up is highly suspect. A rigorous and innovative body of work by Das and Hammer (2005, 2007) finds that the competence levels among MBBS doctors in the PHCs were so low that there was a 50:50 chance of a doctor prescribing harmful therapy. This is not a consequence of poor training but lack of effort. Thus, the provision of incentives needs to go handin-hand with improvement in physical and human 25 Rural Health Statistics, 2012. At an extreme, a CHC in Bihar caters to a population of 1,315,358 people. 26 Numbers are even worse when it comes for physicians at CHCs. If we take into account all specialists at CHCs, there was 70 per cent shortfall, and 44 per cent vacancy (Rural Health Statistics 2012). 27 On an average, the absence rate was found to be around 45 46 per cent in SCs and PHCs. For more details, see Banerjee and Duflo (2004).

Janani Suraksha Yojana, Institutional Deliveries and Maternal Mortality 187 infrastructure together with measures to improve quality of care if increase in proportion of institutional deliveries is to translate in fall in maternal mortality infant mortality. References Bajpai, N., and R. Dholakia. 2011. Improving the Performance of Accredited Social Health Activists in India, Working Paper No. 1 of Working Paper Series. Columbia Global Centres, South Asia, Columbia University. Banerjee, A., A. Deaton, and E. Duflo. 2004. Health Care Delivery in Rural Rajasthan. Economic and Political Weekly 39 (9): 944 49. Center for Operation Research and Training. 2007. Assessment of Asha and Janani Suraksha Yojana in Rajasthan, Jharkhand, Bihar, Uttar Pradesh, Chhattisgarh, Madhya Pradesh, Odisha, New Delhi. Chaudhury, N., J. Hammer, M. Kremer, K. Muralidharan, and Rogers F. Halsey. 2006. Missing in Action: Teacher and Health Worker Absence in Developing Countries. Journal of Economic Perspectives 20 (1), Winter 2006: 91 116. Das, J., and J. Hammer. 2007. Money for Nothing: The Dire Straits of Medical Practice in Delhi, India. Journal of Development Economics 83 (1): 1 36.. 2005. Which Doctor? Combining Vignettes and Item Response to Measure Clinical Competence. Journal of Development Economics 78: 348 383. Dongre, A. 2012. Can Conditional Cash Transfers impact Institutional Deliveries? Evidence from Janani Suraksha Yojana, Working Paper, http://papers.ssrn.com/sol3/ papers.cfm?abstract_id=2196361, accessed on 30 October 2013. Dongre, A., and A. Kapur. 2013. How is Janani Suraksha Yojana Performing in Backward Districts of India? Economic and Political Weekly 48 (42): 53 59. IIPS (International Institute of Population Sciences). 2010. District-level Household and Facility Survey (DLHS-3), 2007 08: India. Mumbai: IIPS. NHSRC (National Health System Resource Centre). 2011. Programme Evaluation of the Janani Suraksha Yojana, New Delhi: NHSRC and NRHM. NRHM (National Rural Health Mission). 2013. State Wise Progress as on 30.06.2013. Delhi: Ministry of Health & Family Welfare, Government of India.. 2012. State Wise Progress as on 30.06.2012. Delhi: MoHFW (Ministry of Health and Family Welfare), Government of India.. 2009. Four Years of NRHM 2005 2009: Making a Difference Everywhere. MoHFW (Ministry of Health & Family Welfare), Government of India, http://nrhm.gov. in/publications/four-years-of-nrhm-2005-2009.html, accessed on 30 October 2013. Statistics Division. 2013. Rural Health Statistics in India 2012. New Delhi: Ministry of Health and Family Welfare, Government of India. UNICEF. 2010. Coverage Evaluation Survey 2009: All India Report. New Delhi: UNICEF.. 2009. The State of the World s Children 2009: Maternal and Newborn Health. New York: UNICEF. United Nations Population Fund India. 2009. Concurrent Assessment of Janani Suraksha Yojana ( JSY) in Selected States: Bihar, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh. New Delhi: United Nations Population Fund India.