ACHIEVING MATERNAL HEALTH THROUGH JANANI SURAKSHA YOJANA UNDER NRHM: A QUALITATIVE STUDY OF CONDITIONAL CASH TRANSFER SCHEME IN PUNJAB, NORTH INDIA

Vijayetta Sharma* and Prof. Pawan K. Kamra** * Research Scholar, Department of Public Administration, Panjab University, Chandigarh and Academic Associate, Indian School of Business, Mohali, India. ** Professor (Retd.), Department of Public Administration, USOL, Panjab University, Chandigarh. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 05 March 2020 Final Accepted: 07 April 2020 Published: May 2020 Maternal health has emerged as a subject matter of great significance in the age of women empowerment, inclusive growth and is a priority intervention under National Rural Health Mission (NRHM).Under the ambit of NRHM, Janani Suraksha Yojana (JSY) is one of the largest programme in the world which provides conditional cash transfer for institutional deliveries, provides skilled assistance during birth, raises the level of awareness of rural women on maternal health practices, thereby putting a serious effort to reduce the cases of mortality. The study encompasses 232 women from the state of Punjab, India selected on the basis of probability proportionate to size sampling to analyse the proportion of beneficiaries who received the cash incentives, amount of cash incentives disbursed, and difficulties faced by them during the provision of cash incentives. The qualitative observations from the field has been inured to understand the underlying causes of deviations on these grounds. Results exhibited a strong case for alignment for the above categories with the deviation on outcome maximum of the extent of 19% for the provision of cash incentives, around 22% for the provision of correct amount and 27% for the difficulties faced the by beneficiaries. The government policy and action should encompass creation of a digital database for the JSY network, which encapsulates the health centres or institutions, beneficiaries’ details, community health workers, their tieup with the institutions and a matrix relation between all the stakeholders in health, to achieve improvement in the outcomes and better policy monitoring with respect to the cash incentives provision aspects and other areas of service facilitation.


ISSN: 2320-5407
Int. J. Adv. Res. 8(05), 01-08 2 and children (United Nations, 2010). The gravity of the situation can be understood from the premise that despite the introduction of various interventions, a pregnant woman or newborn dies somewhere in the world every 11 seconds and most of these deaths accrue on account of preventable causes (WHO, 2019 b).
It has been widely acclaimed that the conundrum of poor access to maternal healthcare in the rural areas of any country makes them prone to unexpected morbidity and high incidence of mortality. Improvement in maternal health is an undeniable pre-requisite for advancement of women. However, the women residing in rural communities remain vulnerable and underserved due to low access and utilization of maternal healthcare (Nuamah et al., 2019). Further, healthcare seeking behaviour of women significantly affect the utilization of services (Kifle et.al., 2017). Better health care utilization rates has been reflected in south Indian women as they have greater autonomy as compared to north Indian (Fortney, 1988). Conditional cash transfer (CCT) programmes have shown an upsurge in health service utilization among the deprived sections of society but very less has been documented on the effects of these programmes on maternal and newborn health (Glassman et.al, 2013). The staggering statistics and underutilization of maternal health services in rural areas points towards the need of urgent maternal care interventions, which would urge the governments of various countries and international institutions to think and device novel strategies to bring the women, especially in rural areas in the network of health systems, so that they can be protected, monitored, and counselled for better health outcomes.
Government of India, under its much lauded intervention i.e. National Rural Health Mission (NRHM) has endeavoured to protect women during the difficult phases of their life via bringing them into its ambit novel approach called Janani Suraksha Yojana (JSY) in 2005 which proceeds the National Maternity Benefits Scheme (NMBS). Janani Suraksha Yojana is one of the largest programme in the world which provides conditional cash transfer for institutional deliveries, provides skilled assistance during birth, raises the level of awareness of rural women on maternal health practices, thereby putting a dent on the cases of mortality. The underlying strategy of JSY is to provide cash incentives for institutional delivery to the beneficiaries in order to bring them to the health system network, thereby reducing the cases of mortality and ensure an augmented state of maternal health(Janani Suraksha Yojana, 2005).

Objectives of the Study:-
1. To evaluate the proportion of beneficiaries who received cash incentives under JSY to promote maternal health. 2. To assess the amount of cash incentives received as part of provisions of JSY. 3. To understand the difficulties faced by JSY beneficiaries in receiving cash incentives.

Study Design:
The study comprised of two districts from the state of Punjab, India; one high performing i.e. district Ropar and one low performing i.e. district Mohali, for the purpose of the study (NRHM, 2017). The state of Punjab is a high performing state in India, as per the performance index devised by National Rural Health Mission (NRHM), an umbrella programme that encompasses wide range of initiatives including JSY.
A sample of 116 Janani Suraksha Yojana (JSY) beneficiaries has been selected from each district based on probability proportionate to size sampling. While collecting data for the sample, equal representation has been ensured from each block of the districts. The data has been collected through a structured interview schedule supplemented by qualitative observations to know the responses for cash incentives received by beneficiaries. Chi-square test of association has been applied to check the association between various queries on cash incentives and districts. Results have been discussed for the number of JSY beneficiaries who received cash incentives, amount of cash incentive received by them and the difficulties faced in receiving the cash incentives. Qualitative observation with respect to different options have been noted and brought to light, which served as a tool to draw a broad assessment of cash transfers under JSY. Table 1 gives the number of beneficiaries who received the cash assistance under JSY scheme. Computed from primary data, p-value ≤ 0.01 is highly significant to denote* * some beneficiaries who did not receive the cash assistance for some births were counted under 'No' category.

Number of JSY beneficiaries who received the cash incentives:
The data in Table 1 shows that 96.55% beneficiaries from district Ropar and 81.03% beneficiaries from district Mohali received the cash incentives under JSY. There were few beneficiaries from both districts who did not receive the cash incentives, some beneficiaries did not receive the cash incentive for some births. The causes for non-disbursal or nonreceipt of incentives by the beneficiaries have been extracted from the field and are enlisted below.

Case of no cash incentives:
One beneficiary who did not receive any cash incentive, post repeated visits to many people and places, remorsefully proclaimed; "The ASHA told me that she has filled the papers for cash payment and gave them to ANM, while enquiring the ANM after quite a long time span of 20 days, she proclaimed that she did forward them to doctor and there is no payment. Later, mother-in-law enquired the doctor who replied that no form has been given to her with the beneficiary's name. We moved to and fro for the small incentive amount, but it was not redeemed." There is a case of a beneficiary who did not receive the cash incentive for her first birth for delivery at home, did not receive it for later births with delivery secured at institution and she also did not think it worthwhile to go to health centre to enquire about the incentives for the later 2 childbirths. She disclosed; "I did not receive the cash incentive for home delivery in the year 2008, as the nurse in PHC spurned during the ANC visit that if I choose to deliver my baby at home, no incentive would be given. We went to CHC for delivery for the next two births on advice of ASHA, in the year 2011 and 2015. Nevertheless, I also did not receive the cash assistance for the later births. We did not go to the health centre for asking for money as it is their obligation." Another beneficiary revealed an alluring case of no incentives after she opted for delivery at CHC and did not receive the cash assistance. She responded in a callous tone; "I got operated for sterlization after childbirth, so it was told to me at the village sub-centre that I will not get cash incentive as under no clause of the scheme sterlization after delivery with incentives is mentioned, so not received any incentives".
Citing the negligence of ASHA being new to the scheme, one beneficiary proclaimed; "ASHA did not know about the cash incentive as she was new at that time and no amount for disbursal was provided to her. She also did not approach later for rendering her due task of left-over cases of incentives." Family mishap, death in family was another reason for not enquiring the non-payment of incentives. Another interesting revelation fetched for non-payment of incentives is that beneficiaries were told that scheme is over and there is no money in the accounts, which smells misperception or gaffe on part of health stakeholders. Many times, the beneficiaries were told that funds have not come yet which escalated their visits for enquiry at the sub-centre or PHC. Delivery at private hospital or health centre near maternal home and non-approval by sarpanch were cited as other reasons for non-disbursal of cash incentives to some beneficiaries. There have been cases who received the cash benefits for their first child but not for the subsequent births due to non-availability of funds. Some beneficiaries who had child delivery at PHC, CHC did not receive the cash incentives, no distinct plausible reason was offered by them upon enquiring. However, no case of non-disbursal of cash incentives has been noticed for those who delivered at sub-district or district hospital. It was further witnessed that among the varied reasons tendered by the beneficiaries, most of the beneficiaries who did not receive the cash incentive did not enquire about the disbursal timeline, reasons for non-payment etc. A few beneficiaries approached the higher-level health authorities to know the payment delays in cash incentives.
The foregone discussion elicits the following reasons for non-disbursal of cash incentive to the beneficiaries. 1. Non-availability of timely funds in account. 2. Delayed funds received by the PHC.
3. Miscommunication, no information or misguidance. 4. Home delivery or delivery at private hospital. 5. Institutional or home delivery while to maternal home. 6. Obstruction from panchayat. 7. No cash incentives for women undergoing sterlization. 8. Negligence by ASHA.
The extensive discussions have helped to evolve the following reasons for no enquiry for 'delayed' or 'no payment' of incentives: 1. Death in the family. 2. Lethargic attitude. 3. Collective acceptance to what is being offered and not asking for why and how. 4. Small amount of incentivesvisiting and enquiring would waste money with no evidence of receiving cash amount. 5. Belief set-"Indecent to ask if not given something", as it is not their obligation.
However, most of the beneficiaries who received cash incentive as envisaged by the mission were glad for the support tendered to them by the government and exhibited a sigh of relief, excitement and joy in their responses. Table 1 unveils that a vast majority of beneficiaries received the cash incentives under the JSY scheme. Greater number of beneficiaries from district Ropar received the cash incentives than district Mohali. The chi-square result (χ2= 8.041, p-value = 0.0045) was found to be highly significant which revealed that there is an association in proportion of responses among beneficiaries belonging to district Ropar and district Mohali with the receipt of cash incentives. Hence, it can be stated that a greater proportion of beneficiaries received cash incentives under JSY to promote maternal health.
After quantifying for the cash incentive for number or proportion, the 'amount received' as part of cash incentive is worthwhile to be examined to validate the 'correct amount of incentives received' by beneficiaries and determine the number for lesser incentives received.

Amount of cash incentives received by JSY beneficiaries:
The Janani Suraksha Yojana prescribes an amount of Rs 700 to be disbursed to the beneficiary for institutional delivery in high performing states and Rs.1400 in low performing states (Janani Suraksha Yojana, 2005). The state of Punjab falls under the category of high performing states. Therefore, a cash incentive of Rs. 700 is applicable to all the districts without bias of further classification of districts on performance parameter. Table 2 provides the amount of cash incentives received by beneficiaries under JSY. Source: Computed from primary data, p-value ≤ 0.01 is highly significant to denote* *as the beneficiaries availed the scheme more than once 5 The data highlights that maximum number of respondents i.e. around 88% from district Ropar and around 80% beneficiaries from district Mohali received an amount of Rs. 700. Some beneficiaries received a lesser amount than as prescribed under the JSY norms. The following worthy observations are imperative to be glanced in this regard: A beneficiary who unknowingly received lesser amount and did not enquire about the amount of money to be received under the mission, stated; "I received cash amount of Rs. 500 later in the same year as I did not have any bank account. The money also got lost in the way when I was returning home from PHC." Another beneficiary who gave birth to twins and received incentives for a single registration revealed; "I got a composite amount of Rs.700 for twins, one time only. The ANM did not know the amount to be paid in case of two babies as there were two deliveries with a time span of 10 minutes." Yet, another lady who re-enrolled to another scheme revealed;

"I initially registered to JSY by ASHA but thereafter on the launch of new scheme we also made card for it and also got amount as part of another scheme i.e. Mata Kaushalya Yojana in the year 2012."
Some more reasons propped up during intensive discussion for receipt of lesser amount of incentives. A beneficiary did not receive the money as she delivered baby at another PHC near her maternal home in the year 2014. Some beneficiaries who received Rs 500 in hand as cash incentive in the initial years of the scheme revealed upon enquiring that they accepted it passively. A few beneficiaries stated that they received cash incentive amount of Rs. 600 in their bank account.
The foregone discussion brings forth the following causes for lower incentive amount: 1. No information on amount of incentives to be received. 2. Money attested directly to bank account. 3. Incentives were given late, so the offered amount was inertly accepted. 4. One-time incentive for twins' deliveries.
An interesting revelation is that a beneficiary enrolled to one more scheme and received incentives for it as well, which indicate a cursor at more such cases in the population. Further, it was observed that most of the beneficiaries who received the correct amount of incentives also showed their reliance on ASHA via whom the amount was disbursed and did not know the exact amount. A few beneficiaries emphatically remarked that they were sure about the provisions of the scheme and know the exact amounts to be paid to them, to ASHA or any other benefits of the scheme.
A close encounter with the causation of lesser incentives, helped to draw the following inferences: 1. Lack of information on incentive money. 2. Cash incentive disbursed late was accepted for whatever amount bestowed.
A look at the difference between the number or correct proportion and amount of cash incentives is decoded in Table  3. It may, therefore, be stated that a fewer but valuable of 5.17% beneficiaries from district Ropar and 3.45% beneficiaries from district Mohali did receive the cash incentive but to lesser proportions; which could only be partially counted for number. However, most of the beneficiaries received the intended incentive amount as may be seen from Table1 and Table2. Eventually, it can be inferred that most of the beneficiaries received the correct amount of cash 6 incentive as envisaged in the mission document. Greater number of beneficiaries from district Ropar received the cash incentives than district Mohali.The chi-square result (χ2= 11.77, p-value = 0.0082) was found to be highly significant which revealed that there is association in proportion of responses among beneficiaries belonging to district Ropar and district Mohali with the amount of cash incentives. Hence, it can be stated that most of the beneficiaries received the correct amount of cash incentives under JSY.
The correct amount received further draws analogy for the effortless receipt of incentives without any bias or obstruction. Hence the difficulties faced to gather the incentives were evaluated further.
Difficulty faced in receiving cash incentive: Table 4 highlights the number of beneficiaries who faced difficulties in receiving the cash incentives. 100.00 116 100.00 Computed from primary data, p-value ≤ 0.01 is highly significant to denote** The data brings out that around 3% beneficiaries from district Ropar and a considerable of 26.72% beneficiaries from district Mohali faced problems in receiving the cash incentive. Some intriguing cases specifying the kind of difficulties are enumerated as under: A beneficiary who circumvented quite a few times to PHC to ask for incentives reported; "I went to ask for cash incentive many times at the PHC. Most of the time, ANM was not available, many times she specified that funds have not come. I believe that ASHA has no role in this, she delivers the cash incentives to us as they come. The amount was put in the bank account quite after a long time." Yet, another beneficiary who did not have bank account grumbled; "I did not get any amount as part of scheme after delivery in 2014 as has been propagated when we joined the scheme, made 2-3 rounds to the PHC and got an amount of Rs 500, otherwise the incentives would not have been received." Other beneficiaries reported that they received incentives after making many visits to PHC with the duration varying from 1 month to 4 months and in the next year. Some beneficiaries who received the incentives late did not have the bank account. It has also been observed that the beneficiaries who received the incentives late, got lesser amount. However, on the contrary, a beneficiary peculiarly augured that they accepted the lesser amount as they did not want to wait for the funds to come and pay more visits.
Hence it may be stated that most of the beneficiaries faced difficulties with respect to travel inconvenience i.e. multiple visits for incentive enquiry due the procedural delays and incomplete incentive disbursal formalities at their end. The discussion hitherto unbundles the following causes for difficulties faced in receiving cash incentives: 1. Delayed Funds which induced the beneficiaries to make repeated visits for enquiry. 2. Non availability of bank account with the beneficiaries.
A look at the effortless receipt of incentive in correct amount is gathered in Table 5. Interestingly, many beneficiaries who received the correct amount of incentives did not face difficulties in receiving it. It can be drawn from table 5 that 90.52% beneficiaries from district Ropar and 54.31% beneficiaries from district Mohali received the correct amount effortlessly. However, there have been beneficiaries who received the correct amount but faced difficulties in receiving it. The proportion is greater in Mohali as may be seen from table 4 and table  5. The beneficiaries who received the cash incentives effortlessly at their home from ASHA, from PHC or in their bank account have good rapport or allegiance with ASHA or exhibited a good social affinity and further as a result of administrative cogency which augurs for smooth delivery of incentives. It was further noticed that the beneficiaries who received the cash incentive effortlessly did not exhibit any specific emotion of relief from hardships, or thankfulness to that regard. However, the beneficiaries who faced difficulties felt disdained and expressed appalling and remorseful expressions. Therefore, it can be inferred that most of the beneficiaries did not face difficulties in receiving the cash incentives. Greater number of beneficiaries from district Mohali than district Ropar faced problems in receiving cash incentives.The chi-square result (χ2= 40.092, p-value = 0.0001) was found to be highly significant which revealed that there is association in proportion of responses among beneficiaries belonging to district Ropar and district Mohali with the difficulties faced in receipt of cash incentives.Hence, it can be stated that most of the beneficiaries did not face the difficulties in receiving the cash incentives.

Conclusion:-
Provision of cash incentives for the facilitation and promotion of the maternal health schemes hold wide significance in achieving the surge in institutional deliveries as envisaged by Janani Suraksha Yojana.The cash incentives serve as a viable ground for attracting the intended beneficiaries to the scheme, serving the wider goal of the government to protect their lives by bringing them into the health service network. Hence, it becomes utmost priority of the scheme to divulge the cash incentives appropriately, in correct amount and without any difficulty to the beneficiaries to earn credibly commitments, which have been ideally found to be optimal as per the study. There have been deviations maximum to the extent of 19% for the provision of cash incentives, around 22% for the provision of correct amount and 27% for the difficulties faced the by beneficiaries. The difference has also been developed for the number and correct amount, and amount and effort less delivery to further have the filtered responses. The variation in outcomes in the study, assessed by the qualitative responses furnished by the respondents in the field, which may vary depending upon the fields setting or locale, calls for serious policy measures by the government to remove the diversions.
In order to ensure that all the beneficiaries receive the cash incentive appropriately, in correct amount and without any difficulty, it is essential that the government move to the online monitoring of the scheme. A digital database of the JSY network, is need of the hour which encompasses the health centres or institutions, beneficiaries' details, community health workers, their tie-up with the institutions and a matrix relation between all the stakeholders in health. The use of m-health technology is highly desirable where the beneficiary should receive all the information in the 'JSY mobile App' with respect to the upcoming service, incentive details, past record of services with date, and to provide rating for each of the services. The community health workers should have a similar App with the different set of options regarding their role; number of beneficiaries with them, details of the upcoming date of each service, information from the health centre and to furnish rating of the services. Similarly, the third kiosk is of the ANM at the health centre. The online database should be maintained at the level of each PHC, which pools information to the district, further to the state and national database. The maintenance of this database which reaches each beneficiary and furnishes appropriate, timely and correct information would eliminate the identified flaws from the scheme implementation and reduce difficulties with the beneficiaries. The rating mechanism would prove to an ideal tool to identify and target the areas with poor services based on the responses from the primary user of the service. The government policy and action should be rooted towards adequate maintenance and utilization of the database in terms of reviewing the progress on quarterly basis.