Comment
7 Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s
Janani Suraksha Yojana, a conditional cash transfer programme to increase
births in health facilities: an impact evaluation. Lancet 2010; 375: 2009–23.
8 Commission on Social Determinants of Health. Closing the gap in a
generation: health equity through action on the social determinants of
health. Geneva: World health Organization, 2008.
9 Shiffman J. Issue attention in global health: the case of newborn survival.
Lancet 2010; 375: 2045–49.
10 Ronsmans C, Chowdhury ME, Dasgupta SK, Ahmed A, Koblinsky M. Effect of
parent’s death on child survival in rural Bangladesh: a cohort study. Lancet
2010; 375: 2024–31.
India: conditional cash transfers for in-facility deliveries
India’s conditional cash transfer scheme to promote
institutional deliveries, the Janani Suraksha Yojana
(JSY), has stimulated extraordinary attention and
curiosity by public health stakeholders worldwide
because of its scale, coverage, and budget. In just
4 years, its beneficiaries multiplied 11-fold, from
0·74 million in 2005–06 to 8·43 million in 2008–09
(thus covering nearly a third of the 26 million women
who deliver in the country annually). Budgetary
allocation for the JSY increased from a mere
US$8·5 million to $275 million in the same period.
Surely, it is time to ask the question about what health
outcomes are achieved by this massive and expensive
investment and effort. On the face of it, by promoting
a strategy of deliveries in the facilities, attended by
skilled providers, JSY should lead to a reduction of
maternal, perinatal, and neonatal mortality.1–3
In The Lancet today, Stephen Lim and colleagues4
present the first analytic study of the impact of JSY by
secondary analyses of the country wide district-level
household survey data. They document high odds for
in-facility births in the JSY users. More importantly,
the study showed a reduction of around four perinatal
and two neonatal deaths per 1000 livebirths as a result
of the JSY, 2–3 years into the programme. At this early
evolving stage of the programme, the finding of a
small beneficial effect should essentially be taken as a
pointer to JSY’s potential to reduce perinatal–neonatal
mortality, rather than its final effectiveness estimate.
The study did not show an effect on maternal
mortality (it had no power to detect a plausible
effect).
Other than the fact that JSY implementation is still
immature, the findings might also reflect a poor quality
of maternal–neonatal care in facilities, and weak
linkages. Despite substantial inputs under the National
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11 Tripathy P, Nair N, Barnet S, et al. Effect of a participatory intervention with
women’s groups on birth outcomes and maternal depression in Jharkhand
and Orissa, India: a cluster-randomised controlled trial. Lancet 2010;
375: 1182–92.
12 Smillie I. Freedom from want: the remarkable success story of BRAC, the
global grassroots organization that’s winning the fight against poverty.
Bloomfield, CT: Kumarian Press, 2009.
13 Bhutta ZA, Chopra M, Axelson H, et al. Countdown to 2015 decade
report (2000–10): taking stock of maternal, newborn, and child survival.
Lancet 2010; 375: 2032–44.
Rural Health Mission, most public sector facilities See Articles page 2009
continue to be understaffed, and do not meet the
desired functional standards.5,6 Deliveries might often
be done by unskilled support staff rather than by skilled
nurses or doctors. Best practices, such as partogram,
neonatal resuscitation, and kangaroo care, are not
followed. The system of referral to a higher level for
emergencies is inadequate. Most mothers and babies
are discharged within hours after delivery because the
hospitals lack amenities, and families want to return
home having got the cash incentive.7–9 As a result,
there is inadequate time for newborn-care counselling,
stabilisation of the post-partum mother, and detection
of danger signs in the mother and the infant. There is
an urgent need to ensure continuing postnatal care to
neonates and mothers at home, where they spend the
rest of the at-risk postnatal period.
There are other problems in the scheme too. Payments
to families and the health workers are delayed in
places,7,10 and there are instances of corruption.10 Another
The printed journal
includes an image merely
for illustration
Latha Anantharaman/Lineair/Still Pictures
1943
 Comment
serious issue is the overshadowing effect of the JSY
on other initiatives for maternal, newborn, and child
health. Because the management capacity of the health
system has not been optimally augmented for the JSY,
its large magnitude, high political visibility, and a huge
volume of transactions results in the neglect of other
vital programmes.
Today’s paper also provides excellent insights into the
state differentials of JSY coverage and disaggregated
uptake by socioeconomic strata. The study confirms the
substantial use of the JSY by poor people, as has been
shown earlier in less robust evaluations.8,9 A jump of 8%,
from 29·8% to 37·8%, in rural institutional deliveries
between 2002–04 and 2007–08 is generally attributed
to the JSY.5 However, much more needs to be done to
ensure that people who are the poorest and the most
marginalised access JSY benefits.
Notwithstanding the implementation weaknesses
and a lack of large effect, the 4 years of JSY is a
remarkable experience in public health action in India.
This period has shown that India can embark on bold
big-ticket initiatives for maternal, newborn, and
child health. With most JSY deliveries occurring in the
government facilities, it is evident that cash incentives
can stimulate demand and enhance use of the public
health system. In a span of just 1 year, for instance,
the states of Rajasthan and Madhya Pradesh showed
an increase in deliveries in government facilities by as
much as 36% and 53%, respectively.8,9
The JSY has spurred ideas about cash transfers for
other outcomes. There is a demand for conditional cash
transfers to ensure the stay of the mother–baby dyad in
a facility for at least 48 h after delivery, and for seeking
treatment of sick newborn babies and children, especially
girls whose care is often neglected. The Ministry of
Women and Child Development is contemplating a
Parents’ death and survival of their children
See Articles page 2024 For many years, maternal mortality has been considered
to be one of the leading public health problems facing
health-care systems in developing countries. Global
efforts to address this problem started with the Safe
Motherhood Initiative in 1987; the problem was
further highlighted during the 1994 International
Conference on Population and Development, and
1944
$1 billion conditional maternity-benefit scheme in
support of a package of health and nutrition practices.11
The JSY is undoubtedly a path-breaking initiative
and its full effect and implications have yet to unfold.
The challenge is to strengthen, streamline, and deepen
its implementation, and as Lim and colleagues have
emphatically advocated, to increase its equity quotient
and ensure continued independent monitoring and
evaluation.
Vinod K Paul
All India Institute of Medical Sciences, New Delhi 110029, India
vinodkpaul@gmail.com
I declare that I have no conflicts of interest.
1 Campbell OM, Graham WJ, on behalf of The Lancet Maternal Survival Series
steering group. Strategies for reducing maternal mortality: getting on with
what works. Lancet 2006; 368: 1284–99.
2 Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, for
The Lancet Neonatal Survival Steering team. Evidence-based, cost-effective
interventions: how many newborn babies can we save? Lancet 2005;
365: 977–88.
3 Bhutta ZA, Darmstadt GL, Haws RA, Yakoob MY, Lawn JE. Delivering
interventions to reduce the global burden of stillbirths: improving service
supply and community demand. BMC Pregnancy Childbirth 2009;
9 (suppl I): S7.
4 Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s
Janani Suraksha Yojana, a conditional cash transfer programme to increase
births in health facilities: an impact evaluation. Lancet 2010; 375: 2009–23.
5 International Institute for Population Sciences (IIPS), 2008. District Level
Household Survey (DLHS-3), India 2007–08. Mumbai; 2009.
6 Mohapatra B, Datta U, Gupta S, Tiwari VK, Adhish V, Nandan D. An
assessment of the functioning and impact of Janani Suraksha Yojana.
Health Pop: Perspectives Issues 2008; 31: 120–25.
7 Ministry of Health and Family Welfare, Government of India. Third common
review mission report (November 2009). New Delhi: National Rural Health
Mission, 2010. http://mohfw.nic.in/NRHM.htm (accessed May 24, 2010).
8 UNFPA and Centre for Operations Research and Training (CORT).
Assessment of ASHA and Janani Suraksha Yojana in Rajasthan. New Delhi:
2007. http://www.cortindia.com/recentpublications.html (accessed
May 20, 2010).
9 UNFPA and Centre for Operations Research and Training (CORT).
Assessment of ASHA and Janani Suraksha Yojana in Madhya Pradesh.
New Delhi: 2007. http://www.cortindia.com/recentpublications.html
(accessed May 20, 2010).
10 Malini S, Tripathi RM, Khattar P, et al. A rapid appraisal on functioning of
Janani Suraksha Yojana in South Orissa. Health Pop: Perspectives Issues 2008;
31: 126–31.
11 Aiyer S. Good intent, bad delivery. India Today May 31, 2010: 44.
most recently when reduction of maternal mortality
was identified as one of the eight Millennium
Development Goals (MDG 5).1–4 In response to these
initiatives, many countries started programmes to
reduce maternal mortality, and it seems that some of
these efforts are starting to show successes. A recent
study estimated that about 342 000 maternal deaths
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