India has made significant progress in maternal and child health (MNCH) indicators in the last two decades. Maternal and neonatal death rates are still higher than that of economies of similar magnitude. For example, the maternal mortality ratio (per 100,000 live births) was 174 in 2015, which was higher than corresponding figures for comparable developing countries in Asia, such as Indonesia (126), and Malaysia (79) (WHO, 2015). Access to and/or demand for maternal and child health services were identified as barriers to progress in maternal and child health in many developing countries, including India. To overcome these demand-side barriers, following multiple countries (Anwar et al. 2008; Behrman and Knowles 1998; Bhatia et al. 2006; Bhatia and Gorter 2007; Van de Poel et al. 2014), the Government of India launched a Demand Side Financing (DSF) program known as ‘Janani Suraksha Yojana’ (JSY).
JSY is one of the largest DSF programs in the world. It was launched in April 2005 by the prime minister of India. The key objective of the JSY is reducing maternal and neonatal mortality by promoting institutional delivery in public or accredited private healthcare institutions. The JSY initially targeted poorer women in selected poorer states. However, JSY was extended to all states in 2007. As of January 2017, all pregnant women are eligible for JSY in 10 low performing states (LPS) where the rates of institutional delivery were below 25%. These are: Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir. All other states were high performing states (HPS), those with more than 25% institutional delivery rates. Only the poor and marginal women, such as scheduled caste and tribal women, are eligible for the program in HPS.
The overall eligibility criteria for JSY in LPS and HPS are listed in Table 1. However, in HPS, some of the criteria were amended in 2013 by removing restrictions regarding age and the number of children. As earlier (in Table 1), JSY was only open to women living below the poverty line, scheduled caste, or scheduled tribe categories. But the earlier version excluded those women who were 19 years and less and had more than the second birth. This amendment was based on the review that found women aged below 19 years and with higher numbers of children were at higher risk of maternal mortality and their children experienced higher rates of neonatal mortality. Although these restrictions were amended in May 2013, we are unable to report when they were implemented in various states. However, these changes have no impact on the present study, as our data comes from the survey happened in 2013–2014 and the times of the last births of women used in this study fall within the period from 2008 to just before the survey (that means the survey included those women who already gave their last births). So, this study uses the eligibility criteria mentioned in Table 1.
JSY is implemented through the public healthcare system. Accredited social health activist (ASHA) and grassroots level health volunteers work as an intermediary between the health system and pregnant women to implement the JSY. In both LPS and HPS, the roles of the ASHA associated with the JSY are as follows (Yojana 2006): (1) to identify the eligible pregnant woman for JSY and to report or facilitate registration for Antenatal Care (ANC); (2) to assist the pregnant woman in obtaining the necessary certificates of the eligibility for JSY; (3) to provide and/or help the pregnant woman in receiving at least three ANC check-ups, including tetanus injections and Iron Folic Acid tablets; (4) to identify a functional Government healthcare centre or an accredited private health institution for referral and delivery; (5) to counsel for institutional delivery; (6) to escort the beneficiary woman to the pre-determined health centre and stay with her until discharged; (7) to arrange to immunize the new born until the age of 14 weeks; (8) to inform of the birth or death of the child or mother to the auxiliary nurse and midwife ; (9) to arrange a postnatal visit within 7 days of delivery to track mother’s health after delivery and facilitate in obtaining care, wherever necessary; (10) to counsel for initiation of breastfeeding of the new-born within one-hour of delivery and its continuance until 3–6 months and promote family planning. ASHA receive financial incentives for undertaking the above activities under the JSY.
When the eligible pregnant woman visits a public health facility for the first time to register her entitled benefits/services – three antenatal care services including iron-folic acid and tetanus injection, institutional delivery and one postnatal care service for both mother and the new born, she receives her total entitled cash as payee cheque from that facility. If she goes first time to an accredited private health facility for those entitled benefits’ registrations, that facility gives her the third-fourth of her entitled cash at the time of that visit and the rest at the time of her discharge after delivery. Without those services’ registrations, an eligible woman will not receive her entitled cash at all. The ASHA gets her entitled money also from the facility where the JSY recipient woman gave her birth but only at the time of her discharge after delivery. As JSY directly works to increase the uptake of the above registered services, these are called intended outcomes. The program may have effects not only on intended outcomes but also on unintended outcomes such as immunization and birth rate because of a spill over effect. There are several studies (Carvalho et al. 2014; Das et al. 2011; Gopalan and Durairaj 2012; Gupta et al. 2011; Gupta et al. 2012; Khan et al. 2010; Lim et al. 2010; Powell-Jackson et al. 2015; Modugu et al. 2012), which show the effects of JSY on both intended and unintended outcomes.. However, these studies were limited to discussing the effects of JSY on some specific (intended or/and unintended) MNCH care components/services. Such treatment effect analyses are not able to provide sufficiently a broad picture regarding pathways towards reducing maternal and child mortality rates (Angrist and Pischke 2008). For this, a method that provides information about how the program is performing with regard to all (possible intended and unintended) service components is needed. The proposed approach is consistent with the current understanding that gains in reproductive, maternal, newborn, child and adolescent health can best be realised by ensuring services across the continuum of care, rather than concentrating on one element or some elements and the neglect of others.
The hypothetical/theoretical Fig. (1) illustrates the concept of the continuum of care. The horizontal axis of the figure shows four hypothetical MNCH care services, such as MNCH1-MNCH4. For the time being, we consider that these are all possible intended and unintended service components under the continuum of care required to reduce maternal and child mortality. The vertical axis of the figure shows the utilization rates (or uptakes) of those four service components with JSY and without JSY. That axis also shows the continuum of care line (parallel to the vertical line) at where the utilization rates of those service components are 100% (e.g., 1). If all mothers in an area or a country received all the components in the figure, the continuum of care line would have been obtained. Any deviation from the straight (e.g., continuum of care) line to the level of uptake of a service/component (indicated in red with JSY and green without JSY) indicates a gap in the uptake. The gap could depend on the JSY intervention or lack of it. It is hypothesized here that the JSY intervention will increase the uptake of a service and decrease the gap. The objective of this paper is to measure gaps between uptakes with and without JSY and also gaps between the continuum of care line and uptakes without JSY. These measures together will demonstrate the effect of the JSY on the MNCH continuum of care.