Over the last decade, a government programme aimed at increasing institutional deliveries has changed the health-seeking behaviour of Indian women. A new study, released on Friday, has found that the maternal health programme Janani Suraksha Yojana (JSY) led to a 22 per cent increase in women delivering in government hospitals between 2004 and 2014. The scheme also is attributed for increasing the probability of a woman being hospitalised by 1.3 per cent, resulting in a 2 per cent increase in overall hospitalisation of women in India. The increase, however marginal, is a cause of celebration as women in rural India are known to delay seeking health interventions.
Launched in 2005, JSY, the world’s biggest conditional cash-transfer scheme, aimed to promote institutional delivery — instead of delivering babies at home — to improve India’s infant and maternal mortality rates. Under JSY, pregnant women choosing to deliver at the hospital and the health worker who motivated her to take the decision get cash incentives — Rs.1,400 for the woman and Rs.600 for the Accredited Social Health Activist in rural areas and Rs.1,000 and Rs.200 respectively in urban areas. The cash incentive was intended to reduce financial barriers to accessing institutional care for delivery.
The researchers have found a causal link between JSY and increase in hospitalisation, even for non-childbirth-related ailments. The study found that while fertility rates in Indian women have steadily declined (from 2004 when it was 2.88 per woman to 2.4 in 2014), JSY impacted overall hospitalisation of women in India. “JSY led to a 15 per cent increase in institutional childbirth with a commensurate decline in deliveries at home. The data also shows that there is a tremendous increase of over 22 per cent in deliveries in government hospitals. This increase is fuelled by an 8 per cent decline in childbirth at private hospitals and a 16 per cent declined in childbirth at home. Our analysis shows that the JSY hypothesis holds true and the programme led to a significant increase of 2 percent in overall public hospitalization of women in India,” states the Brookings India report.
The study, titled ‘Health and Morbidity in India: 2004-2014’, is based on analysis of the 60th and 71st round of National Sample Survey Organisation (NSSO) data. Prima facie, childbirth has increased as an ‘ailment’ causing hospitalisation in the NSSO data. Nearly 3,50,000 women — over two rounds of NSSO surveys — were studied.
Concerns that persist
“The economic significance of a 2 per cent increase is obviously little. One has to understand that JSY was not meant to increase overall hospitalisation. The scheme’s focus was only to reduce maternal and infant mortality. But now we see that women are going for childbirth and are also coming in for other ailments. The overall increase is a windfall gain. However, we have concerns about the quality of care with increasing number of caesarean sections and hospital-acquired infections,” says Shamika Ravi, senior fellow at Brookings India.
Releasing the report, K. Srinath Reddy, president of the Public Health Foundation of India, said that it is an achievement that hospitalisation for deliveries in the public sector has increased substantially. “Women who were delivering at home are now going to public hospitals because of the cash incentives. One must also keep in mind that the percentage of women reporting sick has also increased and it could be a result of other health insurance schemes like Rashtriya Swasthya Bima Yojana. While the number of patients coming to government hospitals is going up, the quality of care remains a concern. The health outcomes are not aligned with public health goals. The fact that these many women are being hospitalised also reflects the induced demand with hospitals performing unnecessary procedures. Patients are now seen as ATMs that hospitals can milk,” he added.
Another hypothesis of the study is that large-scale rollout of health insurance schemes has also contributed to the increase in probability of hospitalisation for both men and women. “Having insurance is associated with a 17 per cent increase in probability of being hospitalized in a government facility and an 8 per cent increase in the probability of hospitalization in a private hospital,” states the report by Brookings India.