Cash on Delivery? Putting JSY’s Payments in Context

By: Sarah Blake,

The following originally appeared on Maternal Mortality Daily. It is reposted here with permission

This post is the second in a series on maternal health in the Seraikela block of Jharkhand, India.

Janani Suraksha Yojana, or JSY, is a conditional cash transfer program first instituted by the government of India under the National Rural Health Mission in 2005. A 2010 review published in The Lancet in 2010 characterized JSY as “a conditional cash transfer scheme, to incentivize women to give birth in a health facility,” and “the largest conditional cash transfer scheme in terms of number of beneficiaries” JSY is driven by two important assumptions that are shared by many development practitioners and policy makers around the world:

1. Conditional cash transfers can be effective in reducing poverty and promoting gender equity. As with other national conditional cash transfer programs, the cash that is entailed in JSY is part of an effort to overcome barriers to service use – such as awareness and cost; and to give money directly to poor women who otherwise may have little access or control over cash.
2. Increasing institutional delivery will lead to a decline in maternal and newborn deaths. Therefore, according to the government’s guidelines for JSY, “the scheme’s success is determined by the increase in institutional delivery among poor families.”

While the program aims to reach poor women across India, it is not applied the same everywhere and, by design, invests the most in the states where institutional delivery is lowest, including Jharkhand. As one of the focus states for JSY, women in Jharkhand have access to greater amounts of money than in other states, and must fulfill fewer conditions to attain it. This means that, while there are restrictions on age, number of previous children and income level in many states, any woman in Jharkhand who gives birth is entitled to the full incentive if they give birth in a facility, whether public or private and government-accredited; and to a smaller amount (for “nutrition assistance”) if they give birth at home.

Among the government officials and health workers we talked to, there seemed to be a broad consensus on the fact that the program is having an effect on what women do. According to one government official, before JSY, “The government institutions were seeing zero deliveries. In four years of JSY implementation, this number jumped to 39 percent.” On a visit to one of the primary health centers, which are staffed by auxiliary nurse midwives, who are trained to perform normal deliveries, a group of ANMs showed us the labor room – which is equipped with three birthing tables, but now, they told us, is often so crowded that laboring women end up using the countertops in that room and the neighboring office instead. However, despite this consensus on the impact of JSY, we came across only one person – a doctor at the main hospital where women from Seraikela are referred for complicated deliveries – who declared “they just come for the money. Without the money, they wouldn’t be here.”

While the cash that women are entitled to under JSY is perhaps the most visible component of the program, it may not always be the most important factor in women’s decision-making – or even the most significant payment.

Sahiyas are also entitled to a payment of 600Rs (around $13) for each woman they assist. Though the implementation guidelines for JSY require that sahiyas’ work be assessed based on the number of women they accompany to the health center, their payment relies on fulfilling many more conditions – some of which they may complete successfully, but may not persuade women to deliver in public facilities. Sahiyas are responsible for completing duties well beyond the trip to the health center: they are responsible for identifying and registering pregnant women who are eligible for the scheme, and ensuring that they have the documents they need to access funds, preparing a “micro-birth plan” detailing the expected delivery date, place and possible referral institutions, to accompanying women to health facilities and providing follow-up care and arranging immunizations in the weeks after a baby is born. The JSY scheme relies on community health workers, known as Accredited Social Health Activists (ASHAs) throughout India, and known in Jharkhand as sahiyas, who are paid for the assistance they provide to women and babies. The women we asked about the cash incentive told us that they had received 1650 Rs (around $40) in exchange for delivering in the health facility, an amount which includes both the incentive and additional funds to cover transportation costs.

The role of the sahiya that is defined in the government’s guidelines seems clearly designed to motivate sahiyas to persuade women to use government health facilities. After all, when this happens, everyone gets paid. And, indeed, the scheme often seems to work this way. In Sini, a village located 20 minutes by car (a mode of transportation not always accessible to the people who live there) from a primary health center, and perhaps an hour and a half from the main hospital, a sahiya named Sudha told us simply, “Everyone goes to the institutions now—not because of the money, but because they are afraid of complications.” As we walked around her village, talking to women who had given birth recently, this seemed to be the case. In fact, as we sat with a group of the village’s women, one introduced a newcomer to the group as a woman who had given birth at home a few years ago – “back before we knew about the risks.” The things we learned in Sini suggested that both the sahiyas and the women they serve are following the script written by the government: the sahiya raises awareness, touched with a little bit of fear, and the women absorb the information, and proceed to delivery in the government facilities. At the end of the day, everyone gets paid, and institutional delivery increases.

If our interviews ended there, we would have walked away with an idea that JSY is working according to the guidelines, even if this is slightly different from how it is frequently discussed.

In another village, which was located around half an hour from the nearest private hospital, we found a very different story. Sita, who had given birth to her daughter a month earlier, told us that she had originally planned to deliver at home, as she had her son, who is now four. But, after being in labor for more than a day, she started to worry, “If I stay here, if something will happen, then what will I do?” At that point, she called her mother, who arrived in a borrowed car from her own village, half an hour a away, and took her, her husband and sister-in-law to the private hospital, which she had heard was better – and closer – than any public facilities. Her daughter was born a few hours later, with no complications, and the two were discharged the next day. The village’s sahiya, Radha, who was looking on as we interviewed Sita, explained that she had not gone with the family because she had broken her arm – and because there was no room in the car. As she beamed with pride at Sita, “one of the finest ladies in the village,” Radha told us that she had filed the paperwork for Sita’s payment a few days before. Though this meant that Sita’s payment would be late, and, in all likelihood, Radha would not get paid at all, the matter seemed almost an afterthought: the money would come, sure, because Sita was entitled to it. It was not enough to cover the cost of the private hospital, which was 2500Rs, but Sita had saved some money in case she needed to pay for hospital fees, and she now plans to set the money from JSY aside for her daughter.

Where JSY – and other cash transfer programs – are often presented along the narrow lines of cash in exchange for a pre-defined healthy behaviour – in this case, institutional delivery in a public facility, in action, things are much more complicated. It is possible that people do not always want to talk about the way that cash influences the choices they make about something so momentous as childbirth, even from the few people we talked to, it seemed pretty clear that their choices, though often health-seeking, did not necessarily conform to the conditions defined by JSY–and were not necessarily strongly motivated by cash. There seemed to be no shortage of knowledge about the risks that go with having a baby, or of the ability for some health institutions to provide some help, whether for a normal delivery or as for Sita, a place to go when things seemed to be going wrong.

The more we talked to sahiyas and new mothers, the more questions followed. For a program that is so reliant on community health workers, discussions of JSY rarely address the ways in which different sahiyas may influence women and what factors are influencing them.

Does it matter that some sahiyas live in communities where the private facilities have better reputations, even if they are more expensive and there is no financial incentive for the sahiya? Is it possible that the payments sahiyas receive throughout the year ultimately influence women’s choices more than the one payment that the women receive on giving birth?

If we follow the government guidelines for assessing sahiyas, it is clear that the sahiyas in Sini are more successful, but if we also consider Sita’s ability to make and act on a plan to seek care in a nearby facility in an emergency, we are left with a different possible definition of success. It might be worth asking how JSY might allow for a broader view of what women want and need. This seems especially important in a community like Seraikela where some health facilities are reasonably accessible, but where private facilities may be too expensive and public facilities are not yet equipped to meet the demands that would come with 100 percent institutional delivery, the current goal of JSY.

Note: All names used in this post are pseudonyms.

Tata Steel Rural Development Society, the host organization for Kate’s fellowship, provided us with transportation and interpreter services. Many thanks to Shabnam Khaled for her help with translation.