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1 Introduction
This article was written with support from a Kings Partnership Grant,
Kings College, London. The evidence used was collected during a
systematic review by Murray et al (2012), which was funded by the
Australian Agency for International Development (AusAID Agreement
Number 59613) as part of the 2010 Australian Development Research
Awards. We would like to acknowledge our colleagues Debra Bick
and Tim Ensor for their role in the design and conduct of that broader
review, and the many people who provided assistance in identifying
studies for inclusion in it (see Murray et al for a list of names and
organisations).
Benjamin M Hunter (benjamin.hunter@kcl.ac.uk) and Susan F Murray (susan_
fairley.murray@kcl.ac.uk) are at Kings College, London. Ramila Bisht
(ramila.bisht@gmail.com) is at Jawaharlal Nehru University, New Delhi. Indira
Chakravarthi (indira.chakravarthi@yahoo.co.in) is at Nehru Memorial Museum
and Library, New Delhi.
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Table 1: Description of Demand-side Financing Schemes That Promote Maternal Health in India
Unconditional cash transfers
National Maternity
A single payment of Rs 500 provided by the Ministry of Health and Family Welfare until merger into the JSY in 2005. Created in
Benefit Scheme
1995 by the Ministry of Rural Development with payments originally of Rs 300.
Dr Muthulakshmi Reddy
Began in Tami Nadu in 1986 with unconditional payments of Rs 200. By 2006, women received payments of Rs 6,000.
Maternity Benefit Scheme
Conditions have since been added to this programme.
Conditional cash transfers
Indira Gandhi Matritva
Introduced in 2011 by the Ministry of Women and Child Development. Payment of Rs 4,000 in three instalments
Sahyog Yojana
(one before birth, two after), conditional upon antenatal care and vaccinations/check-ups for the child.
Dr Muthulakshmi Reddy
Payment of Rs 12,000 made by the Tamil Nadu state government, conditional on antenatal and an
Maternity Benefit Scheme
institutional delivery.
Prasuti Aaraike
Introduced in 2008 by the Karnataka state government. Payment of Rs 2,000 conditional on antenatal care and an institutional delivery.
Mamata
Introduced by the Odisha state government in 2011. The programme increases the total amount paid through IGMSY by Rs 1,000.
Short-term payments to offset costs of access
Janani Suraksha Yojana* Introduced by the Ministry of Health and Family Welfare in 2005. In low performing states women receive Rs 1,400
for institutional deliveries in rural areas and Rs 1,000 in urban areas. In high performing states women
receive Rs 700 for institutional deliveries in rural areas and Rs 600 in urban areas. Eligible women giving birth
at home with a skilled attendant receive Rs 500.
Vijaya Raje Janani Kalyan
Payment of Rs 1,000 from the Madhya Pradesh state government, conditional on giving birth in a government hospital. Closed
Bima Yojana
after one year (2006-07) due to duplication with the JSY.
Prasav Hetu Parivahan
Payment of Rs 300 from the Madhya Pradesh state government to women from the specific tribes and castes. Ran from 2004
Evam Upchar Yojana
to 2007, conditional on institutional delivery in a government hospital.
Voucher and voucher-like schemes for the purchase of maternity services
Chiranjeevi Yojana Cashless scheme introduced by the Gujarat state government in 2005. Allows eligible women to receive
antenatal, intrapartum and postnatal care in accredited private facilities.
Sambhav vouchers
Voucher scheme piloted since 2007 by state governments in Jharkand, Uttar Pradesh and Uttarakhand. Women in urban
slums receive vouchers for antenatal, intrapartum and postnatal care, family planning and other health services at accredited
private facilities.
Sewa Mandir
Voucher scheme focused on areas with large scheduled tribe populations in Rajasthan.
MAMTA scheme
Cashless scheme introduced in 2008 by the state government in Delhi. Entitles women from urban slums to antenatal,
intrapartum and postnatal care in an accredited facility.
Janani Suvidha Yojana
Vouchers for women in specific urban slums in Haryana to use private health facilities for antenatal and intrapartum care.
Implemented by the Haryana state government from 2006 to 2008.
Thayi Bhagya
State government scheme in Karnataka to provide eligible women with cashless access to private health facilities. Includes
payment of Rs 1,000 to the woman.
Janani Sahyogi Yojana
Scheme to allow eligible women to use private facilities for intrapartum care in Madhya Pradesh.
Programme details reflect the most recent identified for the scheme; * some state governments have supplemented JSY payments to increase the total amount
or have provided insecticide-treated nets to recipients, but these have not been listed separately here.
Economic & Political Weekly
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3 Review Methodology
This paper draws on evidence from India collected as part of a
systematic review of DSF in maternal health programmes in lowand middle-income countries (Murray et al 2012). That
systematic review identified studies which had an English language abstract, using 19 bibliographic databases, a series of
online sources of international grey literature, and a detailed
search of the grey literature in India. Each retrieved study was
examined against a set of predetermined inclusion criteria for
population and intervention of interest, location of study, and
date of research (January 1990-June 2012).
Thirty-three studies from India met the inclusion criteria after
quality appraisal and data extraction using tools devel-oped by
the Joanna Briggs Institute, an organisation that spe-cialises in
mixed-methods reviews. The types of study ranged from a small
selection of maternal death reviews to larger programmatic
evaluations involving surveys, semi-structured
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Only one study in the review presented unit costs for DSF,
drawing on data from a two-year Sambhav voucher pilot in
Jharkhand. The study found that the average programme
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cost per service used (including user costs) was Rs 276 for an
antenatal care visit, Rs 3,533 for an institutional delivery, and Rs
173 for a postnatal care visit (IFPS Technical Assist-ance Project
2012). The authors concluded that programme costs were lower
than market prices and that unit costs would fall further as
utilisation increased, but also noted that unit costs would begin to
rise again if voucher utilisation incre-ased by 50%.
The costs of DSF from the perspective of enrolled health
facilities was examined by a study on a MAMTA voucher-like
scheme in Delhi (Nandan et al 2010). The study used data from a
private hospital enrolled in the scheme to show that their costs
exceeded the rate of reimbursement by an average of Rs 3,919
per institutional delivery, concluding that reimburse-ment rates
were too low for providers to remain interested in the scheme.
There is some evidence that reimbursement meth-ods for voucher
schemes have led to unscrupulous activities by contracted private
facilities. Flat rates of reimbursement in the Chiranjeevi scheme
have provided an incentive for facilities to minimise costs by
reducing the quality of supplies used (Jega 2007). The scheme
provides the same level of reimbursement to providers regardless
of whether a delivery is complicated or not and there is evidence
that this has led to some providers requesting informal payments
or referring complicated cases unnecessarily Everybody takes
extra charges (from the Chiranjeevi client). Since I dont do this,
I send them (compli-cated cases) to the district hospital since I
wont be paid differ-ently (ibid: 27).
Conditional cash transfer programmes and short-term payment
schemes distribute payments to women through health facilities
or community health workers. Delays in the distribution of
payments from government agencies can dam-age the reputation
and work of health providers if they mean that women do not
receive the payments they are entitled to (Gupta 2007; Hangmi
and Kuki 2009; Public Health Resource Network et al 2010). In
some cases, community health workers accompanying women to
health facilities have been asked for informal payments on behalf
of the womens families, under-mining the position of trust that
these workers rely on to work with families (Human Rights
Watch 2009).
The only studies that considered the effect of DSF on out-ofpocket expenditure were state-level studies of the JSY. Their fi
ndings raise some concern about the schemes limita-tions in
protecting poor households from incurring costs at maternity
facilities. Between 22% and 61% of women paid more money
than they received (Uttekar et al 2007a, 2007b, 2007c; National
Health System Resource Centre 2011; Santhya et al 2011). Three
of the studies found that JSY recipients who gave birth in health
facilities made a net loss, yet JSY recipients who gave birth at
home made a net gain (Uttekar et al 2007a, 2007b, 2007c).
Further, a large multi-state study on the JSY found that while
more than 90% of the women surveyed had received Rs 1,400 in
each of the five states studied, average expenditure ranged from
Rs 299 in Madhya Pradesh to Rs 1,639 in Odisha (UN Population
Fund 2009).
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supplies at government facilities, requests for informal payments, and poor attitudes from staff (Devadasan et al 2008;
Nandan et al 2008a, 2008b, 2010; Hangmi and Kuki 2009;
Human Rights Watch 2009; Kumar et al 2009; Lodh et al 2009;
Khan et al 2010; Krishna and Ananthpur 2011; Rai et al 2011;
Santhya et al 2011). Studies on the JSY have demonstrated how
these problems have reinforced the stigma of poverty when poor
women are unable to meet nurses demands for supplies (Gupta
2007), or are disrespected at primary health centre (PHC)
facilities, and treated like beggars simply for asking for the JSY
money (Kumar et al 2009).
Finally, the exercise of choice is often mooted as one of the
advantages of voucher schemes in healthcare. However, evidence
on the MAMTA voucher scheme in Delhi indicates that even in a
densely populated urban setting it can be difficult to provide a
genuine choice of providers to poor women (Nandan et al 2010).
Not only did women have insufficient information to use the
scheme in this way, but the scheme was also not considered
lucrative enough to attract and retain large num-bers of private
providers. Therefore women simply tended to use the enrolled
provider that was nearest to their home (Nandan et al 2010).
6 Conclusions
This paper has highlighted a series of challenges for the use of
DSF to promote maternal health. These examples serve as a
reminder of the relationship between poverty and social
exclusion, and the extent to which healthcare systems may act to
reinforce the inequities in the wider society. Gender-based
discrimination remains heavily embedded in many parts of society and it is small wonder that it poses a challenge to cash
transfers and short-term payment schemes that attempt to distribute payments for women to use. Creating and strengthen-ing
roles for community facilitators, such as ASHAs, and wom-ens
organisations in DSF schemes (Uttekar et al 2008) may help to
support improved autonomy for women in this aspect of their
lives.
While the use of BPL cards for targeting in these schemes
makes financial sense, and avoids cumbersome parallel sys-tems,
exclusion from healthcare through weaknesses and mis-targeting
in the BPL card system needs to be countered. One option has
been to allow alternative forms of certification such as tribe/caste
certificates and letters of support from commu-nity leaders. An
alternative route is the removal of user fees for transport,
medicines, and other healthcare supplies, coupled with systems
of accountability that discourage requests for in-formal fees. The
relative feasibility of these two approaches has yet to be
evaluated. The recent launch of the Janani Shishu Suraksha
Karyakram can be considered a step towards the latter, though
early evidence indicates that poor women are continuing to be
asked to pay for medicines and other supplies, transport,
examinations, informal fees, and food (Mahila Swasthya Adhikar
Manch 2012).
Recent maternal health policy in India, as globally, has tended
to focus on a set of narrow targets of mortality reduction and the
uptake of specific health services. This has been an
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