Over the last couple months of my fellowship, I have had the exciting opportunity to reconnect and team up with a friend and former colleague to explore our common interest in maternal health—this time, in India.
In 2009, Sarah Blake and I worked together at the Maternal Health Task Force in New York City. Since then, Sarah went on to work as a consultant with several non-profit organizations, including UNFPA and Women Deliver. I took off for India as a Clinton Fellow with the American India Foundation. As a fellow, I have been working for the past nine months on a maternal and newborn health project in Jharkhand, a state with high levels of maternal and newborn mortality and morbidity.
Over the past several weeks, we have visited hospitals, health centers, government offices, rural villages, and homes in the Seraikela block, a rural area with rugged terrain and limited infrastructure outside the industrial city of Jamshedpur, in the state of Jharkhand. We conducted a series of interviews with women, families, health workers, and government health officials. We asked questions about pregnancy, childbirth and the postpartum period. We learned about the women’s experiences with home and institutional deliveries–and the factors that influence their decision to deliver at home or in an institution. We explored the implementation of and attitudes toward Janani Suraksha Yojana, a conditional cash transfer program that aims to increase institutional deliveries across India.
Conditional cash transfers are trendy. Various governments, non-governmental organizations, and private enterprises across the globe are supporting cash transfer initiatives in efforts to improve school attendance, reduce child under-nutrition, improve maternal and newborn health, and to address other development goals.
What is a conditional cash transfer program? According to the World Bank, “conditional cash transfer programs provide cash payments to poor households that meet certain behavioral requirements, generally related to children’s health care and education”.
Janani Suraksha Yojana (JSY) is a widely discussed (mostly within the global health community but to some extent in mainstream media) and frequently praised cash transfer program. JSY was launched by the Indian government as part of the National Rural Health Mission in 2005, in an effort to reduce maternal and newborn deaths by increasing institutional deliveries.
JSY provides cash incentives to women who deliver in government health institutions as well as accredited private health centers. The program also provides a cash incentive to the health worker who supports the woman throughout her pregnancy and accompanies her to the facility. (For details and FAQs on JSY, click here.)
Maternal and newborn death rates have gradually been declining across India (and the world), but the problem has yet to be resolved. Both maternal and newborn deaths in India continue to make up an extremely large percentage of the overall global burden. According to a study published in the Lancet last year, 20% of global maternal deaths and 31% of global newborn deaths in 2005 occurred in India.
JSY is a big program (the biggest of its kind in the world) that aims to deal with a big problem. The lessons that are drawn from it have the potential to influence global health policy in a big way. The 2010 evaluation of JSY published in the Lancet suggested that the program is having a significant impact on perinatal and neonatal health, but the paper asserted that the verdict was still out in terms of any impact on maternal mortality.
The lesson that has emerged from JSY for newborn health is that giving women money increases institutional deliveries and reduces perinatal and neonatal mortality. It is likely that the same message will emerge in terms of reducing maternal mortality—and there is a good chance that this approach will be picked up in national health programs in numerous other countries that also have high levels of maternal and newborn mortality.
Our concern is that JSY is far more complex than providing women with money—and reducing maternal mortality is far more complex than increasing institutional delivery.
Given the scope, cost, and potential of JSY; it is incredibly important that we ask questions about the nuances of JSY—the role of money as an incentive for women, families and health workers; the readiness of institutions; the challenges with transportation; the human rights implications of the program; and a variety of other related factors.
Over the next several weeks, Sarah and I will share our experiences and insights from our time with the women, families, health workers, and government health officials of the Seraikela block of Jharkhand, a focus state for JSY. We will highlight stories from the people most impacted by and involved in Janani Suraksha Yojana. (Click here to read Radha’s story.)
We believe that we have scratched the surface of some interesting issues related to JSY, but our time in Seraikela certainly left us with more questions than answers, and we will be sharing those questions in upcoming posts.