Costs and consequences of a cash transfer for hospital births in a rural district of Uttar Pradesh, India

Abstract

The Janani Suraksha Yojana, India’s “safe motherhood program,” is a conditional cash transfer to encourage women to give birth in health facilities. Despite the program’s apparent success in increasing facility-based births, quantitative evaluations have not found corresponding improvements in health outcomes. This study analyses original qualitative data collected between January, 2012 and November, 2013 in a rural district in Uttar Pradesh to address the question of why the program has not improved health outcomes. It finds that health service providers are focused on capturing economic rents associated with the program, and provide an extremely poor quality care. Further, the program does not ultimately provide beneficiaries a large net monetary transfer at the time of birth. Based on a detailed accounting of the monetary costs of hospital and home deliveries, this study finds that the value of the transfer to beneficiaries is small due to costs associated with hospital births. Finally, this study also documents important emotional and psychological costs to women of delivering in the hospital. These findings suggest the need for a substantial rethinking of the program, paying careful attention to incentivizing health outcomes.

The association between neonatal death and facility birth in regions of India

“…The lack of an association between neonatal death and facility birth coheres with prior qualitative research which suggests that the quality of maternal and newborn care in health facilities in this region is extremely poor (Jeffery and Jeffery 2010;Coffey 2014). It also coheres with the results of Semrau et al (2017), a randomized controlled trial of the "Better Birth" coaching program which aimed to improve the quality of maternal and newborn care in health facilities in 24 districts of Uttar Pradesh.…”

Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes?

“…Perceptions of the quality of care and behaviour of providers were important for utilisation of health services, and therefore the implementation of DSF schemes. Prospective users were discouraged by reputations that facilities had long waiting times [ 81 , 85 ], were poorly equipped and unclean [ 39 , 49 , 58 , 61 , 63 , 65 , 71 , 80 , 85 , 92 ], or were places where one encountered disrespectful and abusive care [ 33 , 44 , 49 , 50 , 52 , 54 , 56 , 61 , 63 , 81 , 86 , 94 , 101 , 105 ]. Modesty rules made some women reluctant to be treated by male doctors [ 58 ] or to visit midwives where it is considered inappropriate to let someone else see one’s genitals [ 25 ].…”

Brokerage in commercialised healthcare systems: A conceptual framework and empirical evidence from Uttar Pradesh

“…The intermediating role of community health workers is well-documented (Erasmus, 2014;Kok et al, 2017;Nading, 2013), and Standing and Chowdhury noted how, in commercialised healthcare systems, community health workers can assist healthcare users to 'negotiate pluralism and the market, to work out how to locate trusted forms of expertise ' (2008, p. 2105). Some behaviours described in this article have been similarly reported in research on community health work, including the promotion of dependency and extraction of payments (Abuya et al, 2012;Coffey, 2014), and detailed study of healthcare brokerage activities in communities would be a valuable contribution to the growing body of literature on the roles and motivations of community health workers (Kok et al, 2017;Theobald et al, 2016).…”

“…Pregnant women in Lucknow's urban slums ostensibly had a choice between free government care plus a Janani Suraksha Yojana payment of 1,000 rupees, free private healthcare using the Sambhav scheme, or fee-paying private healthcare ranging from a few hundred rupees for a traditional birth attendant to several thousand rupees for care in a private hospital. Yet in practice they had limited resources with which to inform decision-making in an exclusionary and often abusive healthcare system in which entitlements and even basic rights are frequently withheld (Coffey, 2014;Nandraj, 2015;Sudhinaraset et al, 2016).…”