Publication date: 
June 4, 2010

Innovative program in India – the country with the most births – shows early signs of success

An innovative program in India that pays women to give birth in a health facility appears to be saving newborns’ lives and lowering the number of stillbirths, according to new research from the Institute for Health Metrics and Evaluation (IHME) and the Public Health Foundation of India (PHFI).

The study, India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation, was published in The Lancet on June 4. It shows that women who took part in the national government’s Janani Suraksha Yojana (JSY) program had 4 fewer stillbirths and deaths in the first week of life for every 1,000 pregnancies and 2 fewer neonatal deaths per 1,000 live births. The program offers a cash incentive to women for giving birth in health facilities. 
“JSY is the biggest program of its kind in the world, and its success has huge implications for global health policy,” said Dr. Stephen Lim, Assistant Professor of Global Health at IHME and the study’s lead author. “About one out of every five child deaths occurs in India. Finding ways to reduce newborn deaths in India is therefore a critical part of achieving global goals on improving child survival.”
Launched in 2005, JSY is now reaching an estimated 10 million women annually in India with cash payments. This IHME-PHFI study, however, found wide variations from state to state, both in the implementation and in the effects of the program. In the period 2007-2008, some states in India saw as few as 5% of all pregnant women participating in the program, while in other states, as many as 44% participated. The largest increases in the proportion of women delivering in a health facility happened in the same states where more women participated in JSY. Cash payments from JSY were also associated with a significantly higher proportion of women receiving prenatal care.
At the same time, the researchers found that the program may not be consistently reaching its biggest target. The poorest and least educated women appeared to be participating in JSY to a slightly lesser extent than women with moderate levels of education and income.
“The program aims to help the poorest and most disadvantaged women, and clearly, more work needs to be done to make sure that those women are reached to a larger extent,” said Dr. Lalit Dandona, Distinguished Research Professor at PHFI in New Delhi and Professor of Global Health at IHME. Dandona co-authored the paper and led the research effort in India. “Further investigation is needed into the barriers that prevent these women from accessing the JSY benefits.”
As the program continues, the researchers proposed that the government expand its evaluation of the program. The data were insufficient to determine whether JSY was lowering maternal deaths.
“The JSY program appears to be having a positive impact at this early stage,” said Dr. Emmanuela Gakidou, Associate Professor of Global Health at IHME and the paper’s senior author. “The trick will be to improve the way the program is being evaluated to make sure it is achieving what was intended, in particular the goal of reducing the number of women dying during pregnancy or childbirth.”
Questions remain regarding the quality of care that women receive, as workloads have increased with more women giving birth in facilities as a result of the JSY program.  
“This study demonstrates the benefits of the JSY program, but the infrastructure and availability of qualified personnel in primary- and secondary-level health care facilities in India must be improved,” said Dr. K. Srinath Reddy, Professor and President of PHFI.  “This will allow gains from increasing the number of women delivering in facilities to be enhanced.”