Gopalan and D BMC Health Services Research 2012, 12:319 102427 http://www.biomedcentral.com/1472-6963/12/319 RESEARCH ARTICLE Open Access Addressing maternal healthcare through demand side financial incentives: experience of Janani Suraksha Yojana program in India Saji S Gopalan1* and Durairaj Varatharajan2 Abstract Background: Demand side financing (DSF) is a widely employed strategy to enhance utilization of healthcare. The impact of DSF on health care seeking in general and that of maternal care in particular is already known. Yet, its effect on financial access to care, out-of-pocket spending (OOPS) and provider motivations is not considerably established. Without such evidence, DSFs may not be recommendable to build up any sustainable healthcare delivery approach. This study explores the above aspects on India’s Janani Suraksha Yojana (JSY) program. Methods: This study employed design and was conducted in three districts of Orissa, selected through a three-stage stratified sampling. The quantitative method was used to review the Health Management Information System (HMIS). The qualitative methods included focus groups discussions with beneficiaries (n = 19) and community intermediaries (n = 9), and interviews (n = 7) with Ministry of Health officials. HMIS data enabled to review maternal healthcare utilization. Group discussions and interviews explored the perceived impact of JSY on in-facility delivery, OOPS, healthcare costs, quality of care and performance motivation of community health workers. Results: The number of institutional deliveries, ante-and post-natal care visits increased after the introduction of JSY with an annual net growth of 18.1%, 3.6% and 5% respectively. The financial incentive provided partial financial risk-protection as it could cover only 25.5% of the maternal healthcare cost of the beneficiaries in rural areas and 14.3% in urban areas. The incentive induced fresh out-of-pocket spending for some mothers and it could not address maternal care requirements comprehensively. An activity-based community worker model was encouraging to augment maternal healthcare consumption. However, the existing level of financial incentives and systemic support were inadequate to motivate the volunteers optimally on their performance. Conclusion: Demand side financial incentive could enhance financial access to maternal healthcare. However, it did not adequately protect households from financial risks. An effective integration of JSY with similar social protection or financial risk-protection measures may protect mothers substantially from potential out-of-pocket spending. Further, this integrated approach may help upholding more awareness on maternal health rights and entitlements. It can also address maternal health beyond ‘maternal healthcare’ and ensure sustainability through pooled financial and non-financial resources. Keywords: Maternal healthcare consumption, Out-of-pocket spending, Demand side financing, Financial risk-protection, Low-and-middle income countries, India * Correspondence: sajisaraswathyg@gmail.com 1 The World Bank, 1818 H Street NW, Washington, DC 20433, USA Full list of author information is available at the end of the article © 2012 Gopalan and D; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Gopalan and D BMC Health Services Research 2012, 12:319 Page 2 of 10 http://www.biomedcentral.com/1472-6963/12/319 Background maternal health status are awaited [4]. However, the evi- Demand side financial incentive (DSF) is a form of dence on their contribution to out-of-pocket spending subsidy and it directly provides purchasing ability to (OOPS) and performance motivation of providers is scanty. consumers on certain publicly provided goods such Although, they target purchasing power provision to reduce as health and nutrition [1]. DSF introduces two key OOPS, the prime focus on achieving the specified health changes in the public financing of such goods and targets derail them from addressing OOPS largely [4]. This services [1]. First, it entitles the government to be a may ultimately concern the fulfillment of MDG 1 (i.e. pov- supplier of purchasing power to consumers instead erty reduction) in many countries, even if they are able to of being a direct service provider. Secondly, it tunes fi- achieve other health related MDGs. Further, without under- nancing as ‘output-based’ than ‘input-based’ and hence standing the intricacies of OOPS vis-à-vis DSF, healthcare links the subsidy or its objective with the beneficiary. delivery may not be appropriately organized under DSF. DSF’s importance primarily lies on its scope to integrate The optimal packaging of incentives for rational consumer various human development approaches and advance in- choices may not be reasonable without understanding the dividual and societal capabilities. Under DSF, overall scope of OOPS under DSF. Many resource constraint set- human development occurs as it addresses populations’ tings introduced DSF to enhance skilled birth attendance social, environmental and economic risks or vulnerabil- with the intermediation of community health workers [4]. ities [2]. Without ensuring their performance motivation, the In health sector, DSF has a possible role in the delivery achievement of specific community response and effective- of certain sub-optimally and inequitably consumed services ness of the financial resources employed may not be (e.g. maternal care) and betterment of unmet health feasible. behaviors [3–5]. DSF operates on the principal-agent the- The present study on Janani Suraksha Yojana (JSY) pro- ory, where the principal (government, donor or commu- gram in India explored the following; 1) JSY’s potential to nity) transfers funds to an agent (consumer) conditional on enhance women’s financial access to maternal healthcare, a defined action [6]. Primarily it caters to under- 2) its effect on household out-of-pocket spending (OOPS) served areas, populations and services [6]. Its underlying on maternal healthcare, and 3) its influence on community principle is to synergize the supply-and demand-sides health workers’ performance motivation. through additional demand generation and supply strengthening [4,7]. Thus, DSF links various supply- Methods and demand-side measures (e.g. service provision and Janani Suraksha Yojana: an overview community awareness) with differential financing JSY is a federal government funded nation-wide scheme approach [3,7]. It also harnesses the private sector offering conditional cash transfers for safe motherhood potential and promotes innovative pooling and trans- since 2005 [11,12]. JSY was initiated in the milieu of India’s fer of funds. As of now, among the various health needs, persistently alarming maternal and infant deaths [11–13]. DSF has predominantly focused on millennium develop- Paid in bank cheques after child birth, the incentive is con- ment goals (MDG) [7]. ditional upon either in-facility delivery or skilled birth at- tendance [14,15]. Women are encouraged to avail free Demand side financial incentives for maternal healthcare: ante- and post-natal care in public facilities, but no incen- What is already known? tive is linked to such care [14,15]. In many regions and countries (e.g. Latin America, India, JSY holds different conditions for low-and high-per- Nepal and Bangladesh) the earliest public sector DSF initia- forming states, a classification by Government of India tives catered to maternal and child health (MCH) [8–10]. (GOI) based on basic demographic and health indicators This MCH focus was due to such countries’ persistent need [14,15]. to meet MDGs 4 and 5. Among the variants of DSF, In low-performing states like Orissa, women of all socio- vouchers and conditional cash transfers are more wide- economic and demographic profiles are covered, irrespect- spread on MCH compared to health insurance. This is ive of the order of their child birth [14,15]. Upon in-facility because the former appear to be better streamlined to delivery, each pregnant woman receives US$ 30.10 in rural achieve specified outcomes in a given timeframe [2,3,10]. areas and US$ 21.50 in urban areas [16]. The incentive for DSF’s design, roll-out and monitoring vary across countries. home delivery is US$ 10.75. The community health worker For instance, the Indian DSF initiatives exhibit less conver- (known as Accredited Social Health Activist or ASHA) gence of maternal care with reproductive health services, receives US$ 7.50 per pregnant woman in rural areas (US$ unlike those many Latin American and African countries. 4.30 in urban areas) for coordinating ante-and post-natal DSF’s impact on intermediate outcomes such as care and escorting for in-facility delivery. An additional sum skilled birth attendance and consumer awareness are con- of (ANC and PNC) US$ 5.30 is also packaged with ASHA siderably documented, though their long-term benefits on incentives to cover transport costs of mothers. In high- Gopalan and D BMC Health Services Research 2012, 12:319 Page 3 of 10 http://www.biomedcentral.com/1472-6963/12/319 performing states, JSY addresses only socio-economically FGDs backward women and each eligible woman receives US$ Nineteen FGDs were conducted among 141 beneficia- 15.05 and 12.90 in rural and urban areas respectively [16]. ries of JSY during the six months preceding the study. The state governments manage the scheme and empanel There were nine FGDs for 78 ASHAs. Discussions with healthcare providers, including the private ones, who fulfill mothers explored their understanding of JSY and its im- certain eligibility criteria [15,17]. JSY’s annual financial allo- pact on rationalizing maternal healthcare choice, their cation increased from US$ 8.2 million to US$ 266.8 million approach towards skilled birth attendance, maternal between 2005–06 and 2008–09. The number of beneficiar- healthcare seeking, OOPS and financial risk-protection. ies increased from 0.73 million to 8Á43 million, covering a Discussions with ASHAs provided the information on third of the 26 million child births annually in India during their understanding of JSY, payment mechanisms, per- the same period. For the same period, the operational cost formance motivations, challenges on effective functioning per beneficiary had amplified from US$11.24 to US$ 31.65 of JSY and adequacy of financial risk-protection for [17]. mothers. Study setting and sampling The study was performed in Orissa, a socio-economically Key informant interviews backward state with 85% rural, 40% poor and 22% in- Seven state, district and sub-district level MoH offi- digenous population [18]. Maternal mortality ratio in cials were interviewed on the functioning of JSY, chal- Orissa is 540 per 100,000 live births (national average 301) lenges on its effective functioning and adequacy of and 39% of deliveries are institutional (national average financial risk-protection for mothers and financial in- 40.7%) [18]. The study settings were selected through a centives for ASHAs. The selected MoH officials were three-stage stratified random sampling. In the first stage, responsible for planning, implementation and moni- Orissa was selected among low-performing states. In the toring of maternal and child health programs in the state. second stage, the districts of Gajapati, Nayagarh, and Mayurbhanj were chosen representing the administrative division of the state. Finally, a half of the rural and urban Data analysis blocks from each district were included in the study, Verbal informed consent was obtained from each re- which together had 10% of Orissa’s population. spondent after describing the study objectives and the use of forthcoming information. There was no refusal Data collection or withdrawal from any of the participants approa- This study employed a ‘mixed-methods design’ and was ched for the study. Information was collected by carried out in the first half of 2010. The quantitative locally-based researchers through pre-tested and semi- method was employed to review the Health Manage- structured guides in the local language Odia. The group ment Information System (HMIS) data. The qualitative discussions and interviews lasted between 30 and methods consisted of focus group discussions (FGDs) 45 minutes. Responses were audio-recorded, transcribed with mothers (JSY beneficiaries) and ASHAs (JSY inter- verbatim and translated to English. Data collection, co- mediaries). Further, there were key-informant interviews ding and translation were supervised by two graduate with the Ministry of Health (MoH) officials (JSY and researchers. healthcare providers). The study also reviewed some re- Emerging themes among the responses were coded, ports and policy pronouncements to validate the data collated and analyzed by the first author to generate gathered from HMIS, FGDs and interviews. The benefi- higher order generalizations through NVivo software. ciaries were identified with the help of ASHAs, women’s The thematic analysis of the responses was based on six groups and other community-based entities. The categories; influence of JSY on the place of delivery; JSY ’s ASHAs were identified through the local MoH program impact on OOPs; maternal healthcare seeking; perfor- officers. mance motivations of ASHAs; determinants and out- comes of maternal healthcare cost; and the need to link Review of documents and data sources JSY with other financial risk -protection measures. The The indicators on maternal healthcare consumption data on maternal healthcare utilization from HMIS were (i.e. institutional deliveries, ANC and PNC) and out- entered into Microsoft Excel spreadsheet and its trends comes (maternal deaths) from HMIS were compared were analyzed in STATA software. Ethical approval was before (2002–2004) and during the implementation obtained from an Independent Ethics Committee in (2005–2010) of JSY in the state. The review of other Bhubaneswar. It consisted of stakeholders from the documents mentioned earlier helped to triangulate the Ministry of Health and Family Welfare, academia, civil study outcomes. society organizations and the community. Gopalan and D BMC Health Services Research 2012, 12:319 Page 4 of 10 http://www.biomedcentral.com/1472-6963/12/319 Results previous childbirth. Key background characteristics of Trend of institutional deliveries vis-à-vis JSY benefits in mothers, ASHAs and MoH officials are given in Table 2. Orissa During the JSY period (2005–2010), there has been a Influence of JSY on the place of delivery considerable improvement in maternal healthcare uti- According to the discussant mothers (93%) financial in- lization (Table 1). The number of institutional deliveries centives motivated them and their households to opt grew at 20.3% annually (255,323 to 514,792). The num- for institutional deliveries. Both ASHAs (98%) and MoH ber of pregnant women receiving ANC and PNC in- (96%) officials also acknowledged JSY’s potential to in- creased respectively at 8.4% (350,982 to 452,980) and duce institutional deliveries. One-third of the mothers 5.9% (241,980 to 313,456). During the pre-JSY period would have delivered at home in the absence of financial (2002–2004), institutional deliveries, ANC and PNC grew incentives. However, young, literate and first-time mothers at 2.2% (149,341 to159,126), 4.8% (226,489 to259,376) and would have still had in-facility delivery, particularly at 0.9% (111, 257 to 241,980) respectively. Thus, JSY’s pos- government health centers, even without the incentives. sible positive net contribution to the spread of institu- This preference was due to better facilities in accredited tional deliveries, ANC and PNC was 18.1%, 3.6% and 5.0% health centers and the current non-availability of birth respectively (without controlling for other contributing attendants in the community. Preference for institu- factors). The proportion of deliveries receiving JSY bene- tional delivery was the least among those aged above fits increased from 3.7% (26,407) in 2005–06 to 87.3% 25 years and staying far away from secondary level (587,158) in 2009–10. About 12% (70,458 out of 587,158) hospitals. While validating these revelations from the of JSY beneficiaries had domiciliary childbirth in 2010. secondary sources, we found that there is an increas- The C-section rate among the JSY beneficiaries was 3.8% ing trend for skilled birth attendance in the state (22,312). The proportionate increment in ANC and PNC [18]. Further, being far away from secondary hospitals were lesser than that of institutional deliveries during the reduce the probability of in-facility delivery [19]. JSY period (Figure 1). I went to a government hospital for delivery as ASHA Experience and perceptions on JSY didi (sister) told me about the JSY incentives. About the JSY beneficiaries [Mother, Nayagarh] Among the 141 discussant mothers, about a half did Many mothers had hospitalized delivery due to JSY not have any formal education and 59.7%, (n = 84) were [ASHA, Mayurbhanj] below the poverty line. There were 65.3% (n = 92) from I feel a drastic improvement in institutionalized delivery socially backward communities and 36.3% (n = 51) in with JSY program [Medical Officer, Mayurbhanj] 15–23 age group. Some had first time child birth (23.9%, n = 33), while 44% (n = 62) and 32% (n = 45) were second- Impact on out-of-pocket spending (OOPS) and third -time mothers respectively. Around 9% (n = 14) Many mothers (96%) were concerned about them incur- were second-time JSY beneficiaries, 10% (n = 14) had ring huge OOPS on maternal care. The average cost of domiciliary child birth and none had adverse birth out- pregnancy and delivery care in rural Orissa was about comes. There were 40% (25 out of 62) and 38% (17 out of US$ 110 (US$ 70 in urban areas). The JSY incentive was 45) of second-time and third-time mothers respectively, able to cover only 25.5% (14.3% in urban areas) of this who had institutional delivery without JSY benefits for the cost. Rural mothers had to mobilize OOPS for the rest Table 1 Key maternal healthcare indicators pre- and during JSY in Orissa Year Total No. of JSY beneficiaries Institutional At least At least Infant mortality rate Maternal mortality deliveries* deliveries one ANC one PNC (per 1000 live births) ratio(per 100000 live births) 2002-03 811,104 Not applicable 149,341(18.4) 226,489 (27.9) 111, 257 (13.7) 97 354 2003-04 789,215 Not applicable 142,825(18.9) 243,125 (30.8) 113, 242 (14.3) 83 358 2004-05 743,711 Not applicable 159,126 (21.3) 259,376 (35.1) 114,231 (15.4) 77 351 2005-06 709,829 26,407 (1.9) 255,323 (36.0) 350,982 (49.5) 241,980 (34.1) 75 348 2006-07 772,736 227,204 (29.4) 357661 (46.3) 378,902 (49.0) 265,324 (37.4) 71 341 2007-08 701,215 490,657 (70.0) 440,234 (62.8) 401,196 (57.2) 283,556 (40.4) 62 335 2008-09 711,501 506,879 (71.2) 504,823 (71.0) 412,910 (58.0) 299,891 (42.2) 57 321 2009-10 672,585 587,158 (87.3) 514,792 (76.5) 452,980 (67.3) 313,456 (46.6) 53 303 Source: Health Management Information System Government of Orissa. * Figures in parentheses are percentages to total number of deliveries. Gopalan and D BMC Health Services Research 2012, 12:319 Page 5 of 10 http://www.biomedcentral.com/1472-6963/12/319 Figure 1 Maternal healthcare trend in Orissa before and during JSY. US$ 80 (US$ 48 in urban areas). Many households I spent at least one year’s household income on approached pregnancy as a family event and mobilized pregnancy care. [Mother, Gajapati] resources on behalf of the women. Some women them- Our major constraint is that we do not have liquid selves looked for resources to finance their cost of cash with us when we need. [Mother, Nayagarh] child birth. Since the cost often exceeded the house- holds’ ability-to-pay, they covered it through some distress A comparison of OOPS demonstrates that it was higher coping measures such as unorganized loans and sale of for institutional deliveries supported by JSY than domici- hard-earned assets. Since the JSY incentive was received liary deliveries and non-JSY supported institutional deli- after the delivery, it could not prevent the need for raising veries (Figure 2). For instance, OOPS for mothers with short-term loans. After receiving the reimbursement, they domiciliary delivery was US$32 and US$29 in rural and were able to pay back at least a portion of their loans. A urban areas respectively. It was US$35 for some rural household survey in the state also observed that around mothers (US$ 29 in urban areas) for their previous institu- 25% of households mobilized resources for maternal care tionalized child birth during the last two years without through hardship means [20]. JSY support. Table 2 Background characteristics of the study participants Characteristics No of participants Mean age (range) Mean years of Social community Poverty status schooling (range) (backward/forward) (BPL/APL) Focus group discussions Mothers groups (n = 17) 141 24(15–35) 02(0–9) 92/49 84/57 ASHA’s groups (n = 11) 78 32(25–40) 08(6–9) 52/26 56/22 Key-informant interviews MoH officials 07 33(24–51) 15(14–20) 2/5 0/5 Gopalan and D BMC Health Services Research 2012, 12:319 Page 6 of 10 http://www.biomedcentral.com/1472-6963/12/319 120 Average maternalc are cost (US$) 100 80 60 40 20 0 Institutional deliveries JSY Institutional JSY domiciliary without JSY benefits deliveries (2010) deliveries (2010) (2008-2009) JSY’s Contribution (USD) OOPs (USD) Figure 2 Share of JSY and out-of-pocket expenditure (OOP) in total cost of maternal healthcare. Maternal healthcare cost - decomposition, determinants These huge transport costs occurred in order to com- and outcomes mute to an accredited facility despite the availability A decomposition of the reported cost highlights that of facilities nearby. In the absence of incentives, women around 45% (US$45.5/110 in rural and US$30/70 in would have preferred to go to those non-accredited urban areas) was incurred during the ANC period and hospitals as they had faith on the providers over there. the rest during the delivery. A few had to spend 5% of their total cost on PNC. Even though the public health- Many women have to spend on sutures, antibiotics etc. care system provided free ANC and PNC, women largely But, we are not able to do anything to overcome this. incurred OOPS in this regard. Some public providers [Medical Officer, Mayurbhanj] directed many women to purchase vitamin syrups from I spent Rs.300 (US$6.45) on a truck to go to the private pharmacies. They also prescribed vitamin syrups hospital where JSY benefits were available and it (some upon demand by mothers), each costing US$ 3–5. was more than what I have received. The reported cost of care was 12.3% higher in private [Mother, Gajapati] institutions (ANC 8.1%, delivery 4.2%) than in public institutions. The largest cost difference was observed on About 40% of the JSY incentive was given back to the diagnosis (12% to 18%) followed by consultation fee providers as ‘informal payments’, particularly in, but (11.1% to 16%). Other sources also indicated that the not limited to the public sector. Some mothers were cost of care on maternal care in Orissa was more in the concerned about ASHAs asking for incentives without private sector (Rs.3487), than that of the public sector providing sufficient support. In short, the financial in- (Rs.1494) [13]. centives could not prevent irrational prescription prac- tices, OOPS on supplies during delivery, and informal I went to the private clinic for ANC and it costed me payments. around half of my total pregnancy related expenses. [Mother, Mayurbhanj] Some providers at the primary health center behaved My ANC was in a public hospital, but I purchased as if I was accepting their mercy and they were giving vitamin syrups costing more than Rs.120 (US$2.58) me some benefits through JSY incentives. [Mother, from a medicine store upon my request. Mayurbhanj] [Mother, Gajapati] I paid more this time to the primary health center staff than my first delivery, when I did not receive JSY Another dimension of OOPS was on medicines and benefits. [Mother, Gajapati] supplies during the time of delivery in public hospi- ASHA didi told me to report that she had escorted me tals. The MoH officials were concerned about these to the hospital. But I was surprised, because she did additional expenses, though they expressed helpless- not do so. [Mother, Mayurbhanj] ness to overcome such system constraints. Some women ASHA didi asked me a share on transportation expressed the inevitability to spend on transportation reimbursement, though what I received was lesser than and it was more than what they received as incentive. my actual spending. [Mother, Nayagarh] Gopalan and D BMC Health Services Research 2012, 12:319 Page 7 of 10 http://www.biomedcentral.com/1472-6963/12/319 Effect on maternal healthcare awareness, healthcare on-the-job training, supportive supervision and systematic consumption and health seeking capacity development. The majority of women (irrespective of age and education) were not aware of the appropriate maternal healthcare I am forced to perform each activity, otherwise I will requirements. They preferred institutional delivery or skilled not get the provisioned incentives. [ASHA, Gajapati] birth attendance to comprehensive maternal healthcare. How can we be heartless when we deal with pregnant Only 23% (32 out of 141) had at least two ANC and mothers, who are our own sisters from the village? PNC visits. Among the domiciliary deliveries with JSY [ASHA Mayurbhanj] benefits, three-fourth received at least one ANC. Women I do spend from my purse on mother’s food and did not perceive maternal care or its entitlement as a right medicines at hospitals, but I often get lesser than what nor had adequate awareness on the whole objectives of I spend. [ASHA, Nayagarh] JSY. Though public institutions catered to over 75% My knowledge and performance will be improved with (95 out of 127) of the institutional deliveries, private further training on work and capacity development institutions serviced over 65% (94 out of 141) of ANC. activities. I also need regular supervision and on-the- Women did not differentiate the quality of care they job support. [ASHA, Mayurbhanj] received between the public and private hospitals as both had different merits and demerits of their own. Need to link JSY with other financial risk -protection They were more appreciative of the staff behavior and measures the status of supplies at the private hospitals. On the Women were largely concerned about OOPS on maternal contrary, they felt the infrastructure status and drug healthcare. Yet, they were happy to receive JSY incentive efficacy to be the same in both the sectors. as it reduced their financial burden to some extent. They were more appreciative of the ‘direct’ financial incentives I think JSY aims at hospitalized delivery, as it is under JSY than the ‘indirect’ financial risk- protection safer, if any complication arises during delivery. measures offered by other alternative health financing [Mother, Nayagarh] schemes. In one of the districts, the study had specifically I only prefer ante natal care as the child will not have explored about the Rashtriya Swasthya Bima Yojana any complications even if post natal care is omitted. (RSBY), a government scheme providing health insurance [Mother, Mayurbhanj] coverage for the poor [21]. Those who received both I did not have post natal care, as the chances of RSBY and JSY benefits were appreciative of their com- complications were less after delivery. bined role in reducing OOPS. Among the three options [Mother, Gajapati] such as free care, JSY alone, and a combination of JSY and I am happy that the Government at least gives us an other measures (e.g. RSBY), women preferred the third opportunity to have institutionalized delivery. So, we option. This preference was mainly due to their expe- should be obliged to adhere to the norms of JSY. rience of incurring fresh OOPS through incentives such as [Mother, Nayagarh] JSY. Further, they had also perceived that the free care option too could induce OOPS of some kind. Performance motivations of community health workers (or ASHAs) I like to receive JSY benefits as it is an incentive for us, The CHWs, on an average spent five to six days in hos- if we deliver in a hospital. [Mother, Gajapati] pitals when mothers required C-sections. Otherwise, they I want to have both JSY and any other scheme, spent 40 to 60 hours (60–80 hours in remote areas) for because JSY is a financial incentive and other each mother during the entire maternity period. Linking measures might help us to reduce instant spending remuneration with the conduct of each activity motivated from our side. [Mother, Mayurbhanj] ASHAs on their designated duties. ASHAs were satisfied I am not able to believe a situation of free care. We on mothers’ attitude towards them. However, supply-side every time have to spend on many things. People constraints such as lack of transportation and non-timely say that government hospitals are meant for poor availability of JSY cards de-motivated their performance, people, but we never get absolutely free care. besides affecting community’s confidence on them. In [Mother, Gajapati] addition to their time, ASHAs also spent money on mothers’ food and medicines limiting their actual in- ASHAs did not support integrating various incentive centive to US$ 2–4 instead of the earmarked US$ schemes (e.g. RSBY and JSY) since they were skeptical 7.50. Despite this, ASHAs were proud of their moral about the reporting and monitoring procedures. They responsibilities on supporting mothers. In order to preferred separate activity-based incentives under both serve the mothers better, they desired to receive more schemes. MoH officials appreciated combining demand- Gopalan and D BMC Health Services Research 2012, 12:319 Page 8 of 10 http://www.biomedcentral.com/1472-6963/12/319 and supply-side measures to meet the increased demand supply constraints, quality of care might be compromised brought in by demand-side boosters. However, they were and further, providers and consumers may not be moti- cynical on integrating JSY with other measures as it vated on rational behaviors [8]. There are examples from might negate the gains achieved so far on institutionaliz- Nepal demonstrating that private sector was excessively ing childbirths. They wanted to enhance ASHA’s incen- utilized as the public system faced systemic limitations [8]. tives, but were against providing ASHAs a permanent Under the JSY scheme, the synergy between the demand- employment as it could reduce their performance mo- and supply-sides is enhanced through the intermedia- tivation. They urged for enhancing mother’s financial ry or link-worker role of ASHAs. ASHAs also tried to incentives to meet the additional expenses incur during neutralize the supply constraints by externally purcha- hospitalization. sing the supplies, which were unavailable at facilities for mothers during childbirth. However, this is not a I find it difficult to understand how the reporting and sustainable solution as it might affect their perform- monitoring will be if we integrate different incentive ance motivation in the long run. Hence, supply-side schemes for mothers. [CHW, Mayurbhanj] strengthening is a necessary precondition for any I prefer to have activity-based incentives under each demand-side incentive to produce desirable results. scheme than combining the incentives. [CHW, Gajapati] Is demand side incentive an appropriate financial risk- JSY could uptake institutional delivery; an integration protection mechanism for maternal care? of different schemes might undermine the role of JSY. A DSF scheme like JSY is not designed to pool financial [Medical Officer, Gajapati] risks [24]. While inducing a specific behavior change, it It is wise to increase the financial incentives of both can trigger fresh OOPS and deepen household financial mothers and ASHAs. But, giving a permanent cadre to crisis. The financial catastrophe arises when financial ASHAs might reduce their performance motivations. access or risk-protection is not ensured otherwise for [Medical Officer, Nayagarh] those who are exposed to the first-time institutionalized care and those who do not have adequate purchasing Discussion power. It is worth noting that JSY-supported institu- Demand side financing through the JSY scheme could tional deliveries incurred more OOPS than domiciliary enhance access to and utilization of maternal healthcare child birth and non-JSY supported institutional deliver- services. JSY’s contribution was evident in increased ies. If fresh OOPS fetch substantial health benefits and skilled birth attendance, ANC, PNC, and a partial finan- are not deepening the financial crisis of the payer, cial risk-protection. The gains in institutionalization of they might be justifiable. However, in this study, we deliveries are far greater than those of ANC and PNC, do not have evidence in this regard to justify the indicating the limited role of JSY in comprehensively presence of fresh OOPS. addressing the maternal care needs. This could be due The extent of OOPS largely depends on the design to the linking of entire incentives with in-facility delivery of the incentives, conditionality, provider and consumer or skilled birth attendance than individually for each accountability and service delivery status [25]. For aspect of maternal care. instance, the use of a designated health facility was a For a sustained improvement in maternal and child JSY requirement. Though many non-designated faci- health, a comprehensive maternal care integrating its mul- lities were available nearby, women incurred conside- tiple aspects (e.g. health education, nutrition, ANC and rable OOPS to reach out to far off designated health PNC) will be required [22]. The non-encouraging trend of facilities. Further, mothers and ASHAs spent privately maternal deaths compared to infant deaths also highlights on supplies due to systemic constraints. The consu- the relevance of post-partum care, as substantial share of mer accountability also mattered as without realizing maternal deaths might occur around the post-partum the real benefits of institutionalized childbirth, mothers period [22,23]. Since DSF can motivate behavior change, preferred it over home delivery. This preference was their initiation, design, roll-out and evaluation need to owing to their realization that in-facility deliveries carried be carefully planned to induce appropriate and rational more financial incentives than home-based skilled-birth health-seeking behaviors [4]. attendance. Another concern was the lack of provider accounta- Demand creation and supply strengthening bility leading to substantial OOPS in terms of informal DSF is a way to translate healthcare needs into demand payments. One of the reasons behind this perverse for health services [5]. In the presence of adequeate behavior could be lack of adequate incentives for them capacity, creation of additional demand can ensure effec- [25]. Many Latin American and Turkish DSF initiatives tive service utilization [24].On the contrary, if there are also had reported that adequate provider incentives were Gopalan and D BMC Health Services Research 2012, 12:319 Page 9 of 10 http://www.biomedcentral.com/1472-6963/12/319 essential to ensure optimum provider accountability and service delivery improvements can enhance commu- [25].Without proper provider behavior, it will be difficult nity health awareness and service utilization. However, to inculcate necessary consumer awareness and a sense maintaining optimum performance motivation for such of entitlement. volunteers especially through adequate remuneration, Financial incentives induce a particular behavioral change supervision, capacity development and monitoring is an and improve awareness on health seeking. Having gained emerging need [36,37]. This requirement was evident in awareness, people’s compliance to the changed behavior is a fewer cases where ASHAs demanded for remuneration likely to be higher for discrete healthcare choices, especially without real performances. As pointed out by the stake- for child birth (more of a household event) [6]. Therefore, holders, their performance might be less-optimal, if given there would be fairly increased demand for skilled birth at- a permanent cadre or being asked to perform non- tendance in future. However, it should be ensured that fi- incentivized activities. A democratic revision of their nancial incentives for behavior changes are not inducing incentives may be worth maintaining their motivations. deeper OOPS and financial catastrophe. If women face sub- While fixing up incentives, the time spent on processes stantial transport costs and informal payments, it may be also needs to considered than the end activity alone. wise considering cost-effective and safe home-based deliv- eries with skilled birth attendance [26,27]. The considerable presence of home deliveries among the respondents justi- Strengths and limitations of the study fies this transportation constraints. Many home-based ma- This was one of the unique attempts to look at the ternal care models exist and JSY can promote some of financial risk-protection and financial access to health- them [27,28]. care under demand side financing. As applicable to the qualitative research methods, our study might not have Harmonization of financial assistance measures wider implications beyond the study context. Though we Many Latin American countries could demonstrat that fi- looked at the secular trend of maternal healthcare con- nancial incentives can be full-fledged and substantial to sumption, the study design did not allow us to consider comprehensively cover various health aspects under a par- the factors attributable to it other than JSY. There was ticular health goal (e.g. MDG 5) [28]. For JSY, it might be scope for recall bias while exploring the OOPs on child essential to integrate with other financial risk-protection or birth without JSY benefits. However, considering the social assistance measures as Brazil and Nicaragua had universality of the program and its extent, the findings demonstrated [29,30]. For instance, integration with health add to the rare global evidence base on DSFs. The recom- insurance might enable covering with careful planning the mendations might carry special value for the design and hospital costs fairly and improve consumer choices and implementation of DSFs in similar LMIC settings. We also provider accountability [25]. However, a federal structure validated the healthcare costs and financial catastrophe on like India with multiple ministries handling social assistance maternal care from other sources in the study settings. has to ensure a unified coordination [29]. A social assist- ance approach may enable DSF to uphold more sense of Conclusion ‘right to maternal healthcare’ than a mere tight and condi- The Indian version of the DSF incentive appears to have tional approach [31,32]. Currently, one Indian initiative enhanced financial access to and utilization of maternal namely Muthulakshmi Reddy Scheme comprehensively healthcare, particularly institutional deliveries. The pres- addresses ‘maternal care’ by incorporating nutritional ence of financial risk-protection in JSY-supported child- aspects. However, the provision of cash transfer after child- birth was partial. It did not adequately link institutional birth makes this scheme unfit to track each outcome [33].A delivery with ANC and PNC. Similarly, the knowledge provision of fixed sum or pumping money, rather than ob- transfer on maternal healthcare was limited and lopsided jective based transfer to women may not achieve the due to which fresh out-of-pocket spending was triggered expected results. This is certainly because of the house- by this incentive. An integration of JSY with similar social holds’ alternative needs, prioritization and gender power or financial risk-protection measures is likely to provide structure [34,35]. comprehensive financial risk- protection. Such an inte- grated approach would also enable addressing maternal Community health worker model for incentivized health beyond ‘maternal healthcare,’ upholding awareness maternal healthcare on maternal health entitlements and ensuring sustainabi- India brings in an encouraging model on community lity through pooled resources. health workers as grass roots level change makers for healthcare. The optimum level of compensation for such Competing interests a voluntary cadre is still debatable. We observed that The views expressed in this paper are solely those of the authors and not of the volunteers with activity-based financial incentives their organizations. Gopalan and D BMC Health Services Research 2012, 12:319 Page 10 of 10 http://www.biomedcentral.com/1472-6963/12/319 Authors’ contributions 16. Government of India: Exchange rate review cited 05 September 2010 [cited on SSG and DV conceptualized the study, designed the study tools and drafted 05September, 2010]. Mumbai: Reserve Bank of India; 2010. http://rbi.org.in/ the manuscript. SSG drafted the first version of the manuscript and analyzed home.aspx#. the data. Both authors read and approved the manuscript. 17. Lim SS, Dandona L, Hoisington JA, et al: India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health Acknowledgements facilities: an impact evaluation. Lancet 2010, We greatly appreciate the information provided by the Department of health 375:2009–2023. and family welfare, Government of Orissa and the JSY beneficiaries. We are 18. Government of India: Report National Family Health Survey-3 2006. Available also grateful to Mr Satya N Mohanty and Mr Dinabandhu Swain for from: www.nfhsindia.org/india3.htm. facilitating the study. We thank David B Evans and Riku Elovainio (World 19. C-TRAN Consulting: An analysis of health status of Orissa in specific reference Health Organization, Geneva) for their comments on an earlier version of the to equity. Bhubaneswar, India: Report to MohFW; 2009. manuscript. We thank the editorial Board and the reviewers for their relevant 20. Binnendijk E, Koren R, Dror DM: Hardship financing of healthcare among comments on the manuscript. rural poor in Orissa. India. BMC Heal Serv Res 2012, 12:23. 21. Government of India: RSBY process 2009–10. New Delhi: Ministry of Labour Author details and Employment; 2008. 1 The World Bank, 1818 H Street NW, Washington, DC 20433, USA. 22. World Health Organization: Today’s evidence tomorrow’s agenda. World 2 Department of Health Systems financing, The World Health Organization, 20 Health Report. Geneva: World Health Organization; 2009. Avenue Appia, Geneva, Switzerland. 23. 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