Editorial: The power of cash incentives

Published in the Hindu on June 18, 2010

The Janani Suraksha Yojana, a path-breaking conditional cash transfer initiative launched in 2005 to encourage deliveries at government health care facilities, has achieved some of its goals. It was launched at a time when India accounted for 20 per cent of maternal and 31 per cent of neonatal deaths in the world. Benefits started accruing a year after the scheme came into operation — the number of deliveries in government health facilities shot up by 36 per cent in Rajasthan and 53 per cent in Madhya Pradesh. A study based on survey data put out by the government for the period between late 2007 and early 2009 has been published recently in The Lancet.  The study revealed that cash payment led to a reduction of about four perinatal deaths per 1,000 pregnancies, and two neonatal deaths per 1,000 live births. The analysis found no reduction in maternal mortality based on the district level data. The uptake of JSY did not vary much between rural and urban areas, despite rates being higher in rural areas. But other parameters, including wealth, age, and education of women, had a bearing across both high-focus and non-high-focus States. For instance, at the national level, the uptake was highest among those who had 1-5 and 6-11 years of education. Women availing of the cash incentive showed a typical pyramid profile, with those who were neither poor nor rich accessing it the most.

With a budget of Rs.1,540 crore and 9.5 million beneficiaries, JSY is the world’s largest conditional cash transfer scheme. It has demonstrated that providing an incentive of Rs.600 and Rs.700 to women in urban and rural areas in non-high-focus States, and Rs.1,000 and Rs.1,400 in the case of high-focus States can bring about an overall reduction in the perinatal and neonatal deaths. However, effective measures are required to ensure that the benefits reach the poorest and the least educated women, who are in most need of skilled birth attendance. Although women availing of the cash incentive are required to attend three antenatal care visits, adherence was not good. Earlier studies have shown that quality of care is compromised for various reasons. For instance, early discharge after delivery, as soon as the women availed of the incentives, was reported. A modified system of staggered payments may be one way of ensuring better care. Though it may strain the system further, it can help reduce the number of maternal and neonatal deaths.