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Demand-side Financing

and Promotion of Maternal Health


What Has India Learnt?
Benjamin M Hunter, Ramila Bisht, Indira Chakravarthi, Susan F Murray
Use of demand-side financing has become increasingly

1 Introduction

common in maternal healthcare and India has been a

mortality, defi ned as death during preg-nancy or the


Maternalpost-partum
period, is commonly used to indicate levels of

leading example with large-scale programmes such as


the Janani Suraksha Yojana and Indira Gandhi Matritva
Sahyog Yojana. This paper undertakes a systematic
review of the evidence to consider how demand-side
financing has been used and whether there has been any
impact on maternal health service utilisation, maternal
health, or other outcomes. The findings suggest that a
relatively narrow focus on achieving targets has often
overburdened health facilities, while inadequate referral
systems and unethical practices present overwhelming
barriers for women with obstetric complications. The
limited evidence available also suggests that little has
been done to challenge the low status of poor women at
home and

in the health system.

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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maternal health and development.

The United Nations (UN) General Assemblys millennium


declara-tion, and subsequently the Millennium Development
Goals (MDGs), committed India, along with other signatories, to
a 75% reduction in maternal mortality between 1990 and 2015
(UN General Assembly 2001). Skilled attendance during childbirth, often equated with childbirth in health facilities, has become a core component of efforts to reduce maternal mortality.
India is considered by many to be at the forefront of using
demand-side financing (DSF) to promote skilled attendance
(Murray et al 2012). These interventions most typically cash
incentives or voucher schemes are intended to supplement
traditional supply-side financing by channelling resources
directly to service users. Or, in other words, by a transfer of
purchasing power (Pearson 2001; Ensor 2004; Witter 2011).
This paper presents findings from a mixed-methods systematic
review of the research and evaluation literature to highlight
lessons so far, the challenges of this approach, and the limitations
of what is known.
2 Policy on Maternal Healthcare
Government policy on maternal healthcare in independent India
can be divided into four periods. During the first period, which
ran for approximately 15 years, the government pro-moted an
integrated approach to maternal and child health-care and
brought together different strands of public health to achieve this
(Qadeer 2005). Policy during this period was guided by the
recommendations of the Bhore Committees re-port on health
services (Health Survey and Development Com-mittee 1946). It
was at this time that the cadre of auxiliary-nurse midwives
(ANMs) was introduced to provide community healthcare and
that the role of dais (traditional midwives), who were previously
key maternal health carers within communities, was greatly
reduced (Sadgopal 2009).
The second period began during the 1960s, as policymakers
became focused on concerns about accelerating population
growth. The department of family planning was created within
the Ministry of Health and Family Planning, and mater-nal health
services were subsumed within this new depart-ment. In the lead
up to the Emergency, any broader notion of
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maternal health became overshadowed by policies that


encouraged sterilisation using a toxic mix of cash incentives
and coercion (Banerji 1972; Visaria 1976).
A transition from family planning to family welfare programmes in the late-1970s marked the beginning of the third
period, although family planning activities continued to play a
dominant role. The programme devoted greater attention to
child mortality (as policymakers considered it a crucial determinant of fertility) though maternal healthcare continued to
be neglected by policymakers through the 1980s (Sharma
1991). Training for ANMs was reduced from 24 to 18 months in
response to pressures to quickly increase numbers (Mavalankar and Vora 2008). It was during the 1980s that maternal
mortality attracted increasing attention at an international
level, resulting in the launch of the safe motherhood initiative
by a group of UN agencies in 1987 (Rosenfield and Maine 1985;
Mahler 1987). By 1992, policymakers in India had consolidated
strategies for nutrition, immunisation, and maternal healthcare into the child survival and safe motherhood programme.
The maternal health component of the programme aimed to
improve access to essential maternity services by training
dais and ANMs to detect signs of high-risk pregnancies and by
developing referral systems for women with obstetric complications. An end of project report by the World Bank indicated

backlogs in the training of dais and weak or absent referral


systems in many areas (World Bank 1997).
The fourth period emerged following the 1994 International
Conference on Population and Development in Cairo. The Ministry of Health and Family Welfares reproductive and child
health programme was launched in 1997 as an integrated
approach to family welfare that included sexual, maternal, and
child healthcare. It provided the foundations for the national
population policy in 2000 and the national health policy in
2002 (Srinivasan et al 2007). The National Rural Health
Mission (NRHM) was launched in 2005 to accelerate progress
towards health-related MDGs, with the aim of improving the
availability of and access to quality health care in high-focus
states (Government of India 2005). Maternal health policy during this fourth period has had an increased profile, but has continued to be characterised by a medical understanding of maternal health that focuses on mortality reduction, and on improving access to clinical care at facilities through reducing the
three delays (Thaddeus and Maine 1994). Community-level
care continues to depend on ANMs, but it has been estimated
that most ANMs receive just three months of midwifery training
and that students at many training schools do not see enough
patients to develop the necessary practical experience to be
able practitioners (Mavalankar and Vora 2008).

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.
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As maternal health programmes during the fourth period have


strived towards reductions in maternal mortality, moni-toring
progress against targets has been undermined by weaknesses in
reporting systems. The most recent estimates available are for
2010 and show a national maternal mortal-ity ratio of 200
maternal deaths per 1,00,000 live births, which, while an
improvement on previous levels (of 600 in 1990 and 390 in
2000), is three to five times higher than those of the other BRIC
countries Brazil (56), Russia (34) and China (37) (World
Health Organisation et al 2012). The current rate of progress
suggests that India is unlikely to achieve its MDG target by 2015.
Estimates at the state level from the 2008 figures indicate wide
disparities within the country, ranging from 81 and 97 maternal
deaths per 1,00,000 live births in Kerala and Tamil Nadu,
respectively, to 359 in Uttar Pradesh and 390 in Assam (Office of
Registrar General India 2011).
The United Progressive Alliance governments primary
strategy to reduce maternal mortality has been the Janani
Suraksha Yojana (JSY), administered by the NRHM, in which
cash payments are offered to offset the costs of accessing
intrapartum care. A new cadre of health workers, accredited
social health activists (ASHAs), was created to facilitate NRHM
community activities. The JSY is one of the best known DSF
schemes in the maternal health field, though a range of others
have been introduced at the national and state levels (Table 1, p
66). Examples at the national level include the National
Maternity Benefit Scheme and the recently launched Indira
Gandhi Matritva Sahyog Yojana (IGMSY). Contracting and
voucher arrangements such as the Chiran-jeevi scheme in Gujarat
have also received a lot of attention. In the remainder of this
article we use fi ndings from a systematic review of research and
evaluation literature to describe the effect of Indian DSF schemes
on the utilisation of maternity services and on maternal health
and other out-comes. We also consider the evidence on the
challenges to implementation and limitations of these approaches
to improving maternal health.

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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interviews, and focus group discussions with stakeholders. The


standard of the research was variable and methods of data
collection and of analysis were often not well described.
4 The Whole Range of Demand-side Financing
The DSF schemes employed to promote maternal health in India
can be divided into four distinct modes unconditional cash
transfers (sometimes referred to as maternity benefits),
conditional cash transfers, short-term payments to offset the costs
of accessing services, and vouchers for maternity serv-ices
(Murray et al 2012). No Indian studies of a fifth mode, vouchers
for merit goods such as food or insecticide-treated bed nets,
were identified.
Use of Unconditional Cash Transfers
India is one of the few settings outside high-income countries in
which unconditional cash transfers have been used to pro-mote
maternal health. Unconditional in this context refers to benefits
that do not require proof of any specific activities to be received,
but they are conditional on being pregnant and are targeted at
poor women. The Dr Muthulakshmi Reddy Memo-rial Maternity
Assistance Scheme (DMRMMAS) was introduced in 1986 by the
Tamil Nadu state government to extend mater-nity benefits to
women in the informal sector (Public Health Resource Network
et al 2010). Unconditional payments were initially just Rs 200,
but were raised to Rs 6,000 in 2006 in recognition of the greater
support required by women to compensate for lost earnings and
their dietary needs.
The National Maternity Benefit Scheme was launched in 1995,
drawing on the aims and methods of the DMRMMAS. The
programme provided unconditional payments to women until
2005, when it was merged with the JSY and payments then
became conditional on skilled attendance at birth (either at home
or in a health facility). Despite a Supreme Court ruling in 2007 to
reinstate National Maternity Benefit Scheme payments, there has
in practice been no national programme offering unconditional
cash transfers to support rest and nutrition among poor women
since the launch of the JSY.
Unfortunately there have been very few studies on unconditional cash transfers and those that are available have been
limited in scope. The only study included in our review, on the
DMRMMAS in Tamil Nadu, highlighted issues such as
eligibility criteria that excluded vulnerable women, delays in
payments, and the lack of concurrent capacity building among
commu-nity health workers (Public Health Resource Network et
al 2010). In 2012, payments from the DMRMMAS in Tamil
Nadu were increased to Rs 12,000 and became conditional on
uptake of antenatal care and check-ups for neonates. It is unclear
if and how this will affect the programme.
Use of Conditional Cash Transfers
Conditional cash transfer schemes have only recently been
adopted in India to promote maternal health. Like uncondi-tional
cash transfers, these schemes typically aim to improve the diet of
pregnant and breastfeeding women and to
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encourage rest for several weeks up to and after childbirth.


Unlike unconditional cash transfers, women are obliged to attend antenatal care and check-ups for neonates to qualify for the
payments. The central government launched the IGMSY in 2011.
This scheme, implemented by the Ministry of Women and Child
Development, provides Rs 4,000 to poor women on the condition
that they attend antenatal care. State-level schemes such as the
Prasuti Aaraike, Mamata, and DMRMMAS have been introduced
in Karnataka, Odisha, and Tamil Nadu, respectively. Payments
range from Rs 2,000 from the Prasuti Aaraike to Rs 12,000 from
the DMRMMAS.
To date, little research has been done on conditional cash
transfers in India, reflecting the limited scale of state programmes and the short time since most were launched. A recent
qualitative study on the IGMSY highlighted supply-side problems of coverage and capacity that have not been addressed, the
insufficient amount of money provided, and eligibility crite-ria
that unfairly excluded vulnerable women (SAHAYOG 2012).
Use of Short-term Payments
These interventions have been introduced in a handful of
countries and national programmes exist in only Nepal and India.
The JSY (and its various state-specific manifestations) is the
most well-known scheme to offset maternal health service costs
in India. While many studies refer to the JSY as a conditional
cash transfer scheme, it is important to differenti-ate it from the
longer-term human development-focused con-ditional cash
transfer programmes. The JSY provides a short-term intervention
around pregnancy and birth, with retro-spective payments and
has a highly focused aim. Payments range from Rs 500 to Rs
1,400 depending on whether a woman gives birth at home or in a
health facility, and depend-ing on the state that she lives in. The
Madhya Pradesh govern-ment offered similar payments during
the mid-2000s, but these were discontinued as the JSY was rolled
out by the cen-tral government.
The JSY is the best documented DSF programme in India and
a number of high-quality studies have been conducted on it.
These fall into two categories quantitative studies that focus on
health service utilisation, health outcomes, and levels of personal
expenditure (Lim et al 2010; Powell-Jackson et al 2011; Santhya
et al 2011), and qualitative studies that focus on barriers to
implementation (Dasgupta 2007; Gupta 2007; Chaturvedi and
Randive 2009; Human Rights Watch 2009)
Use of Vouchers for Maternal Health Services
A number of state-level maternal health programmes have
incorporated private facilities for the provision of cashless
antenatal, intrapartum, and postnatal services to poor women.
Vouchers and voucher-like schemes (in which providers are
contracted to deliver services to women who possess a below the
poverty line card or caste/tribe certificate) have proved one of the
most popular DSF mechanisms in India.
The Chiranjeevi scheme in Gujarat is one of the better documented voucher-like programmes. It was introduced with the aim
of empanelling the formal private sector to provide
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maternal health services in (typically rural) areas where public


services are largely unavailable, unlike the Sambhav voucher
scheme in Uttar Pradesh, which has been introduced in urban
areas to ensure access to high-quality healthcare in the private
sector. The few high-quality studies available on the Chiranjeevi
scheme have linked it to increased rates of institutional delivery
(Bhat et al 2009), but described the emergence of unethical
practices due to regulatory weaknesses (Jega 2007).
5 Evidence on the Use of DSF Schemes
Maternal health programmes that use DSF typically aim to increase utilisation of key maternity services and reduce mater-nal
mortality. The JSY is primarily focused on improving cov-erage
of maternity care in poor populations and evidence has linked it
with increases in the use of antenatal, intrapartum, and postnatal
care. Studies using data from the second and third rounds of the
District Level Household and Facility Sur-vey (DLHS-2 and
DLHS-3) showed that the JSY increased uptake of three
antenatal care visits by 9%-11%, institutional delivery by 31%49%, and skilled attendance at delivery by 17%-39% (Lim et al
2010; Powell-Jackson et al 2011). Large household surveys
conducted in Rajasthan indicated that recipients of JSY money
were twice as likely to have three or more antenatal care visits
compared to non-recipients, three times more likely to have an
institutional delivery, twice as likely to have a skilled attendant
during childbirth, and eight times more likely to attend postnatal
care (Santhya et al 2011). Meanwhile a smaller study in Gujarat
showed that the proportion of insti-tutional deliveries was 26%
higher among women who used the Chiranjeevi Yojana
compared to those who did not (Bhat et al 2009). None of the
studies included in the review consid-ered the effects of
unconditional or conditional cash transfers on health service
utilisation.
A number of studies described critical limitations to monitoring systems for the JSY (Dasgupta 2007; Devadasan et al
2008; Nandan et al 2008a; Human Rights Watch 2009). They
reported that data has been collected on the number of institutional deliveries and the amount of money disbursed to each
woman, and not on health outcomes. Postnatal follow-up was
absent for many women described in the studies and authors
explained that there is little incentive for ANMs to report adverse outcomes in their communities. This creates an obstacle to
monitoring the impact beyond health service utilisation. None of
the studies eligible for the review presented findings showing the
equity of changes in health service utilisation or effects of DSF
modes on maternal mortality or morbidity. Lim et al (2010)
attempted to show the effect of the JSY on maternal mortality but
noted that DLHS data lacked sufficient statistical power to detect
anything other than large changes. As a conse-quence, they found
no statistically significant change in maternal mortality.

Programme Costs, Payment Systems and Costs to Users

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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Availability and Quality of Maternal Health Services


Conditional cash transfer programmes and short-term pay-ment
schemes to offset costs of access, such as the IGMSY and JSY,
require that women use formal healthcare providers for antenatal
and intrapartum care. However, at the community level in rural
areas this is undermined by gaps in antenatal care coverage and
delays to the referral of women suffering intrapartum or postpartum complications (Dasgupta 2007; Gupta 2007; Chaturvedi
and Randive 2009; Human Rights Watch 2009; Rai et al 2011).
The role of ANMs as community-level maternal healthcare
providers has been undermined by limitations to their training
and an ANM is not always posted to lower-level facilities. Where
ANMs have been posted, their midwifery activities may be
constrained by concurrent com-mitments for family planning and
child health and a large catchment area (Dasgupta 2007; Gupta
2007; Human Rights Watch 2009).
Only two of the studies included in the review attempted to
quantify the effect of using a DSF scheme on quality of care
received, and both focused on the JSY (Uttekar et al 2007d;
Santhya et al 2011). The first, based on interviews with JSY
recipients in Odisha, yielded mixed findings. On the positive
side, the average length of time spent waiting to be seen was
around 30 minutes, including registration. However, many
women were discharged early on average 22 hours after giving
birth though the government guideline is 48 hours (Uttekar et al
2007d). The second study, using survey data from before and
after the introduction of JSY in Rajasthan, showed that the JSY
increased the likelihood of receiving in-formation on danger
signs during pregnancy, of having four or more antenatal checkups, of being allowed a companion present during labour and
childbirth, and of discharge from hospital after at least 24 hours
(Santhya et al 2011). The study showed no impact on information
provided on postnatal care or neonatal health and no impact on
use of harmful practices during delivery, reported cleanliness of
facilities, and the extent of respectful behaviour by the staff. The
majority of respondents, both JSY recipients and non-recipients,
felt that their healthcare provider was clean and that the staff
members were respectful. Yet, heavy fundal pressure was applied
during the care of one-third of the women and more than 70%
received an intra-muscular oxytocin injection.
Qualitative studies indicate that in some settings the increased
utilisation of maternal health services overburdened government
and private facilities (Devadasan et al 2008; Nan-dan et al 2008b,
2010; Human Rights Watch 2009). In some areas there was a
chronic shortage of resources for emergency obstetric care such
as obstetricians, anaesthetists, and blood banks, particularly at the
lower levels (Gupta 2007; Jega 2007; Singh and Chaturvedi
2007; Nandan et al 2008a; Human Rights Watch 2009). This was
compounded by an absence of clear referral systems, leading to
multiple referrals for some women until they reached a tertiary
centre with the required skills and equipment (Dasgupta 2007;
Nandan et al 2008a, 2010; Chaturvedi and Randive 2009; Human
Rights Watch 2009; Krishna and Ananthpur 2011).
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Effects on the Social Status of Poor Women


Evidence from other settings has indicated that DSF can be used
to improve womens social status in small but important ways
(Murray et al 2012). For example, a voucher scheme in Armenia
that emphasised womens right to healthcare services increased
dignity and awareness of entitlement (Truzyan et al 2010).
Oportunidades, a conditional cash transfer programme in
Mexico, focuses primarily on child health and education
conditionalities, with some maternal healthcare requirements and
has the mother as the recipient of cash payments. It has increased
the income of poor women and thereby enhanced their capacity
for autonomy within the family (Latap and De la Rocha 2008).
However, the effects depend greatly not only on the aims of the
schemes, but also on the details of how they are organised, and
the amount of thought given to obstacles. This section
summarises qualitative evidence from Indian DSF schemes that
indicates some deep-seated barriers to entitle-ment, dignity, and
choice for poor women.
The first barriers are oversimplistic targeting mechanisms and
exclusionary eligibility criteria. Most DSF schemes use the
existing below poverty line (BPL) card system or tribe/caste
certification to determine eligibility, and this may be the most
realistic mechanism in large statewide schemes. However, there
is evidence from several studies that the use of BPL cards and
tribe/caste certificates without additional supplementary
mechanisms risks excluding women without the necessary
documents, especially migrants and some of the poorest fami-lies
(Chaturvedi and Randive 2009; Human Rights Watch 2009;
Nandan et al 2008a, 2010).
Exclusionary criteria for age and parity reflect the continued
influence of family planning in maternal health policies (Lingam
and Yelamanchili 2011), and are counterproductive to the aim of
reaching the poorest. They are more commonly em-ployed in
states with better health outcomes. Parity restric-tions typically
restrict eligibility to women with no more than one or two
previous live births. Age-based criteria, for exam-ple, that any
recipient must be aged over 19 years, are less common but have
been used in national government schemes such as the IGMSY
and JSY. In all states, JSY payments for skilled attendance
during a home birth are given only to women aged over 19 years
and with no more than one previ-ous live birth. There is no
evidence on the effect of these restrictions on maternal health,
though Lingam and Yelaman-chili (2011) noted that 63% of poor
women would be ineligible for IGMSY payments due to parity
and age restrictions.
The second set of barriers relate to the erosion of entitle-ments
once they have been claimed. Like Latin American schemes,
Indias cash transfer schemes assume the woman to be the
recipient of the cash. However, the positive impact of this
depends in part on the mechanism used for distribution. Where
cheques are used to reduce corruption, women without bank
accounts and the required documents to open them may have to
cede control of the money to family members who may not use it
for their nutrition or treatment (Chaturvedi and Ran-dive 2009;
Kumar et al 2009). Womens entitlement to free healthcare has
also been undermined by shortages in medical
Economic & Political Weekly

january 11, 2014 vol xlix no 2

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
71

SPECIAL ARTICLE

unfortunate and contradictory byproduct of the political suc-cess


of bringing maternal health to the MDG table, and the challenge
of then framing complex needs for health and well-being in
measurable smart indicators to track progress. This has been
compounded by the fragmentation of maternal health policy
between the Ministry of Health and Family Welfare, the Ministry
of Women and Child Development, and state-level policymakers.
The recent policy focus on providing maternal healthcare in
facilities, for example, has failed to integrate the role of homebased care and dais in communities. Despite the MDGs overall
concern with elimination of poverty, a fixation with institutional
deliveries has diverted attention from the need to provide a
continuum of care for poor mothers before, during, and following
pregnancy, and from their broader needs for good nutrition,
personal safety, decent work and living conditions, and adequate
rest.
The influence of MDG indicators can be seen in the shift over
the last 10 years from unconditional cash transfers concerned
with broader, indirect determinants of maternal health such as
rest and nutrition, to conditional cash transfers and short-term
payment schemes that encourage women to access for-mal
antenatal and intrapartum care. The assumption that such
measures will increase health service utilisation and translate into
improved maternal health has proved problematic, given the
challenges facing the Indian health system. The equity of changes
in utilisation remains unclear and payments condi-tional on the
use of poorly resourced public health facilities have exposed
women to underlying problems in the health system, such as gaps
in coverage, insufficient expertise and capacity in communities
and facilities, and poor attitudes towards women. The entitlement
to decent healthcare is subverted by a culture of disrespect
towards poor families in an overburdened and under-resourced
health system (Mavalankar et al 2008; Sri et al 2012).
In many settings, poor women appear to have little, if any,
choice for where to seek care and ineffective systems of
accountability mean that they cannot apply any real pressure
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