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ORIGINAL ARTICLE
Year : 2011  |  Volume : 55  |  Issue : 2  |  Page : 115-120  

Additional cash Incentive within a conditional cash transfer scheme: A 'controlled before and during' design evaluation study from India


1 Assistant Professor, Department of Community Medicine, Gajara Raja Medical College and Associated Hospitals, Gwalior, India
2 Prof and Head, Department of Community Medicine, Gajara Raja Medical College and Associated Hospitals, Gwalior, India
3 Director, National Institute of Health and Family Welfare, New Delhi, India
4 Associate Professor, National Institute of Health and Family Welfare, New Delhi, India

Date of Web Publication22-Sep-2011

Correspondence Address:
Chandrakant Lahariya
Assistant Professor, Department of Community Medicine, Gajara Raja Medical College and Associated Hospitals, Gwalior - 474 009
India
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Source of Support: National Institute of Health and Family Welfare and UN Population Fund, Conflict of Interest: None


DOI: 10.4103/0019-557X.85245

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   Abstract 

Background : Conditional Cash Transfer (CCT) schemes have shown largely favorable changes in the health seeking behavior. This evaluation study assesses the process and performance of an Additional Cash Incentive (ACI) scheme within an ongoing CCT scheme in India, and document lessons. Material and Methods: A controlled before and during design study was conducted in Madhya Pradesh state of India, from August 2007 to March 2008, with increased in institutional deliveries as a primary outcome. In depth interviews, focus group discussions and household surveys were done for data collection. Results: Lack of awareness about ACI scheme amongst general population and beneficiaries, cumbersome cash disbursement procedure, intricate eligibility criteria, extensive paper work, and insufficient focus on community involvement were the major implementation challenges. There were anecdotal reports of political interference and possible scope for corruption. At the end of implementation period, overall rate of institutional deliveries had increased in both target and control populations; however, the differences were not statistically significant. No cause and effect association could be proven by this study. Conclusions: Poor planning and coordination, and lack of public awareness about the scheme resulted in low utilization. Thus, proper IEC and training, detailed implementation plan, orientation training for implementer, sufficient budgetary allocation, and community participation should be an integral part for successful implementation of any such scheme. The lesson learned this evaluation study may be useful in any developing country setting and may be utilized for planning and implementation of any ACI scheme in future.

Keywords: Conditional cash transfer, India, Maternal survival, Millennium Development Goals, National Rural Health Mission


How to cite this article:
Lahariya C, Mishra A, Nandan D, Gautam P, Gupta S. Additional cash Incentive within a conditional cash transfer scheme: A 'controlled before and during' design evaluation study from India. Indian J Public Health 2011;55:115-20

How to cite this URL:
Lahariya C, Mishra A, Nandan D, Gautam P, Gupta S. Additional cash Incentive within a conditional cash transfer scheme: A 'controlled before and during' design evaluation study from India. Indian J Public Health [serial online] 2011 [cited 2017 Aug 17];55:115-20. Available from: http://www.ijph.in/text.asp?2011/55/2/115/85245


   Introduction Top


Maternal mortality ratio (MMR) and infant mortality rate (IMR) in India are higher than many developing countries. [1],[2] India contributes the highest numbers of global child and maternal deaths annually. [3],[4] The national government launched a conditional cash transfer (CCT) scheme named 'Janani Suraksha Yojana' in India to bring MMR and IMR down, by ensuring institutional deliveries, and providing conditional cash incentives to the beneficiaries. [4],[5],[6] Globally, in last 2 decades, CCT schemes for health improvements have been implemented and evaluated with mixed outcomes. [7],[8],[9] Within a short period of implementation, JSY reported to have increased the proportion of institutional deliveries in India. [10] In Madhya Pradesh state [11] the local authorities noticed that though JSY had increased institutional deliveries in general, these were still low amongst below poverty line (BPL) population. Therefore, state government decided to provide additional cash incentives (ACI) to BPL group (add on to what they were entitled under JSY scheme), under a scheme called 'Vijaya Raje Janani Kalyan Bima Yojana' (VRJKBY). [12] The scheme had the provisions of 1,000 cash assistance for institutional delivery in government hospital; free of cost normal delivery in accredited private hospital; discount of 1,000 on caesarean on prefixed price in private hospital; an compensation of 50,000 in case of death during delivery or causes related to pregnancy, and delivery and abortion expense up to maximum of 1,000. All these provisions were over and above the provisions under JSY.

This study was planned with the objectives to assess the process and performance of additional cash incentives (ACI) within an existing scheme of conditional cash transfer (CCT), to understand the perception of beneficiaries about the scheme and to document the experiences and lessons from this scheme. The impact of scheme was assessed as increase in the institutional deliveries in the target population.


   Material and Methods Top


Study Design: The study was planned when the intervention was already over. The expected outcome was related to intervention and the effect was not expected to spill over beyond intervention period. Considering the situation and study objectives, a controlled before and during design study was planned. The design was called before and during as the variable was evaluated for their status before the intervention (ACI) and during the intervention. This setting was found appropriate for before and during study design, by the project advisory committee.

Study area: Madhya Pradesh (M.P.) is the central Indian states with one of the highest infant and maternal mortality rates in the country. The state has a population of approximately 65 million in 2001, with 37% BPL, and 20% tribals. [11] After careful consideration to population distribution, geography and access to health care facilities, two districts Gwalior and Guna were selected for this study. Gwalior was a relatively better performing district with good health facilities, medical college hospital, district hospital, and a number of other health facilities. Guna district was equidistant from state capital Bhopal and other study district Gwalior (situated approx. 200 kilometers), and had limited health services available. The two districts had combined population of 3.5 million.

Study period was August 2007 to March 2008. Sampling was purposive, selecting 3 rural and 1 urban block (total 4 blocks) in each study district. In depth Interviews (IDIs) and focus group discussions (FGD) were conducted to collect qualitative data. For quantitative data collection, 5 Anganwadi areas in each rural block and 4 Anganwadi areas in each urban area/block were selected by systematic random sampling. Therefore, surveys were conducted in the catchment areas of 30 Anganwadi Centres (AWCs) in rural and 8 AWCs in urban area. All the households, where any birth had taken place from June 2006 to March 2008, were included in this study (this was done to collect data for 1 year prior and during the scheme implementation).

Study subjects: The subjects for qualitative component were planners, policy makers, implementers, community members and the beneficiaries and non-beneficiaries. For the quantitative component information was collected from any adult member of the selected household, preferably women in the reproductive age group.

Study tools were pre-tested, semi structured interview schedules. Teams of trained research associates, research assistants and doctors collected data for this study. The qualitative data was collected from the beneficiaries, non beneficiaries and medical officers using separate pre-tested interview schedules. The focus group discussions (FGDs) were conducted with Panchayati Raj Institution (PRI) members and Community leaders, and ANMs and AWWs. For collection of quantitative data, a survey was conducted in the study area. The information on the deliveries, which had taken place 10 months prior to the beginning of the VRJKBY (from July 2006- April 2007) and during the 10 months of the scheme implementation (June 2007- March 2008) was collected. The data was collected on BPL status and place of delivery etc. An adult member of the family, preferably a female, was interviewed to collect information on the place of delivery and poverty line status. The BPL and APL status was assessed upon the basis of family either having a BPL card or to have their name in official BPL list.

Ethical approval: Research protocol was approved by institutional ethical review committee of National Institute of Health and Family Welfare, New Delhi. The informed consent forms were prepared in both English and Hindi, and were given to the study subjects. Illiterate participants were read the consent form and procedure was explained to them.

Quality control: External experts and observation teams were present at time of trainings of data collection teams. 20% of data collection was supervised by the Principal and Co-Principal investigators at field level and by the external teams.

Data analysis: Qualitative data was analyzed using standard analysis methods in stepwise manner. Quantitative data was entered into SPSSv12.0 software, and analyzed using proportions and chi square test, as applicable. The subgroup analysis was done to observe differences between BPL and APL categories. A P-value of ≤0.05 was considered statistically significant.


   Results Top


A total of 439 IDIs and 18 FGDs were conducted to collect qualitative information. A total of 149 people participated in 18 FGDs. There were 43 ANMs (range 6-8); 40 PRI members (range 5-9) and 66 community members (range 9-17) in 6 FGDs for each category. A total of 1,729 subjects were interviewed for quantitative data [Table 1]. It was noted that a majority of beneficiary knew about JSY (which was the original CCT scheme) but not about VRJKBY (the ACI scheme). Knowledge of the beneficiaries was limited to the fact that money was distributed for delivery at government health facilities. All Medical officers in charge (MO I/C) were aware about the scheme but field level functionaries (like ANM, AWW and ASHA) had limited knowledge and awareness. Even beneficiaries of ACI scheme were not aware under what scheme, and why money was provided. None of the beneficiaries interviewed had heard of benefits, other than cash incentives provided under VRJKBY.
Table 1: Detailed breakup of IDIs and FGDs in each study district

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AWW and ANM were the main source of information besides doctors, and newspapers and television etc. Cash benefits for AWW/ANMs to contact pregnant mothers, early in pregnancy was a major motivation for them. The implementers felt that a lot of additional paper work, including verifying the documents, keeping the record, and disbursing money, was a burden for both health staff and the beneficiaries.

None of the ANM or AWW interviewed had ever seen implementation guidelines. The health staff was not fully aware about provisions under this scheme. Suggestion of an orientations training, prior to the launch of any such scheme was given by a number of health workers. Reportedly, a number of otherwise eligible pregnant mothers could not benefits under this scheme because of non availability of BPL cards (either not issued or under process). A few complaints of demand of bribe to release cash under this scheme were also recorded.

The involvement of local government bodies was seen as an ambivalent step. While some of the respondent suggested that 'Considering politics in local government bodies, the role of health and education departments should be increased." A few others opined that involvement of these bodies may lead to the corruption. On the other hands, community leaders and PRI members felt strongly about their possible beneficial role in awareness generation, and effective implementation of scheme. No involvement of NGOs or any other Self Help Groups/Community Based Organizations was reported from the study areas.

No special efforts were reported to have made for awareness generation in the community. The majority of clients got information, about the scheme, only when they reached health facilities. Occasional contacts were made by AWW; however, major emphasis was on institutional deliveries, and other provisions under VRJKBY were never communicated.

Amount disbursed to the beneficiaries ranged from 1,000-2,400 (1 US$= 50 Indian Rupee in the year 2007). There were discrepancies in amount reported to have disbursed and amount actually received by the beneficiaries. Similarly, time taken in distribution of money varied from the day of discharge to 30 days after delivery (median: One week). The beneficiaries were not told why money is being provided and for what purpose it should be used. The beneficiaries reported having money spent on the medicines and treatment of common illnesses, of both pregnant mothers and newborn. A few beneficiaries had utilized money for family purpose, repaying a debt taken for pregnancy related expenditures or saved for the future.

A lot of documentation and paper work, repeated visits to health facilities for collecting money were the reported weaknesses. One respondent said that 'Too many documents are required and the beneficiaries had to wander here and there for getting signatures.' A few others said that: 'The process was extremely difficult. Beneficiaries had to go to the councilor need to get these documents endorsed, and then only one gets the benefits' or 'We had to visit the health facilities up to 5-6 times; some of the hospital staff don't provide any assistance, rather they always find some shortcomings in the documents.' or 'The money was being distributed after a longtime.' and that 'Rich people are having BPL cards but not the real poor. Moreover, it cost about 400-500 Rupees to get a BPL card.'

The commonest causes of non utilization were lack of awareness, non-availability of BPL cards, followed by reports that though a few mothers were registered at health facility, they delivered at home during the night or when nobody was available to accompany them to the health facilities [Table 2]. Increasing the amount of money disbursed, distributing it at the time of discharge, and reducing paper work were a few suggestions for improvement in the scheme.

Policy makers and planners commented that ACI scheme could have been better planned and would have given better outcome. They also mentioned the gaps in planning and implementation of the scheme. A number of issues had also come up with the third party insurers (the insurance companies) and there were delay in settling of bills from insurance agency also. These issues were associated with identification of beneficiaries and distribution of funds.
Table 2: Reasons for non-utilization of the scheme

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The quantitative data revealed an increase in the proportion of institutional deliveries in both districts, and in APL and BPL subgroups, with higher rate of institutional deliveries amongst APL families. Even during the implementation of ACI scheme, the proportionate increase in the institutional delivery was higher amongst APL subgroup than BPL, and the differences were statistically significant. Before implementation of VRJKBY, the proportion of institutional deliveries in both the districts were higher in APL than BPL, however, these differences were not statistically significant. Interestingly, this proportion increased in APL group in ACI scheme implementation period (though, the scheme had targeted the BPL families), and difference became statistically significant. The rest of the subgroup analyses show that APL always had significantly higher proportion of institutional deliveries in comparison to BPL, both before and during the scheme implementation period [Table 3].
Table 3: Pattern of delivery in different subsections of the populations in the study areas*

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   Discussion Top


JSY is a conditional cash incentive scheme in India. There are other global examples of conditional cash incentives including graded cash incentives. [7],[13] However, the ACI scheme evaluated in this study (VRJKBY) was not a traditional graded incentive scheme as though the expected outcome from ACI scheme was same as that of CCT; the incentives were provided with different eligibility criteria and processes/mechanisms for incentives were separate.

The limited awareness about ACI scheme amongst beneficiaries and health service providers outlines the need for wider publicity and awareness campaigns. Lack of public awareness could have been one of the reasons for low uptake of scheme. Studies have reported definitive role of community participation in the uptake and utilization of government schemes [14] and this component need to be paid the due attention.

Both schemes (CCT and ACI) had provision of cash incentives and the beneficiaries, majority of them poorly literate, were not aware about the amount of money they should be getting. The beneficiaries received 1,000 to 2,400 and show that ACI within an existing CCT scheme may create confusion, and leaves scope for corruption. The money was being distributed only after the delivery; however, many respondents felt that a part of money should have been given even before the delivery to ensure proper care of the pregnant mother in ante-natal period. There has been visible change in the proportion of Institutional deliveries in both the districts (although, the effect may be due to the original JSY scheme and not due to the VRJKBY), the people in large proportion, even from low socio-economic strata were coming to the health facilities for delivery.

The quantitative data from blocks and districts show an overall increase in the number of institutional deliveries. However, study does not show that ACI scheme led to an increase in the proportion of institutional deliveries, before and during the implementation period. It can be said that implementation of the scheme in a better way could have given different outcome. It must also be remembered that the utilization of health services is also dependent upon socio-cultural behavior and availability and the distance from the health services, which were not studied in this study. In the present study, ACI scheme increased the proportion of institutional delivery in the targeted group; however, the study design did not allow to comment whether this increase was due to the ACI scheme or due to existing CCT scheme.

Globally, CCT schemes were started to address 'demand side barriers, [5],[6],[7],[15],[16] where health systems had been assumed to have relatively adequate infrastructure. The effectiveness of CCT schemes in settings with geographical inaccessibility and poor quality service (the scenario in India), identified as 'supply side obstacles' have not been proven. [15],[16] The recently published evaluation of JSY in India suggest that cash incentives helps in increasing the institutional deliveries and improving the health seeking behavior of the population in setting like India also. [17]


   Conclusions Top


The ACI scheme evaluated was designed, recognizing & realizing that underserved and marginalized people should be given extra benefits to increase their participation in health services utilization. However, it seems that poor planning and coordination, and lack of public awareness about the scheme resulted in low utilization. ACI scheme for any specific population, within an existing scheme for CCT should be started with a meticulous planning. The sufficient budgetary allocation, proper IEC and training, detailed implementation plan, orientation training for implementer, and community participation should be an integral part of the implementation efforts.


   Acknowledgement Top


This study was jointly funded by National Institute of Health and Family Welfare, New Delhi and United Nations Population Fund, New Delhi, India as part of 'Rapid Appraisal of Health Innovation' (RAHI) Project. The authors acknowledge the contribution of Neeraj Singh Gaur, Mahendra Chaukse, Shailendra Patne, S. Vivek Adhish, Jai P Shivdasani, Manoj Bansal, Sashmita Mungi, Akshat Pathak, Dhiraj Shrivastav, Monika Puri, Alka Sodhi, and Utsuk Dutta, the other members of RAHI Project collaboration at Gwalior. The quantitative data in this manuscript was not the part of the original project and was collected, with the assistance from Medical officers in the selected PHC blocks, AWW in the selected villages and, by the field volunteers of "Write Health Society for Community Health Actions", Gwalior, India.

Special thanks are due to Medical Officers In Charge (MOIC) of the study Primary Health Centres at Gwalior and Guna districts of MP. We also thank Dr Manoj Aggarwal and Dr K.S. Nair at NIHFW, New Delhi for support during this study. The authors are thankful to Secretary (Health), Govt. of Madhya Pradesh, Bhopal, The Dean, G.R. Medical College, Gwalior, The C.M.H.O.s, Medical officers and study participants in the both the districts.

 
   References Top

1.World Health Organization. Maternal Mortality in the world in 2000. Geneva: World Health Organization; 2004. p. 1-12.  Back to cited text no. 1
    
2.Government of India. Maternal Mortality in India 1997-2003: An estimate. Registrar General of Census Operations, Government of India, New Delhi. 2006. Available from: http://www.censusofindia.org. [Last accessed on 2007 Apr 17].   Back to cited text no. 2
    
3.Registrar General of India. Special bulletin on Maternal Mortality in India 2004-06. New Delhi: Sample Registration System, Registrar General of Census Operation; 2009. p. 1-4.   Back to cited text no. 3
    
4.Lahariya C, Paul VK. Burden, differentials and causes of child deaths in India. Indian J Pediatr 2010;77:1312-21.   Back to cited text no. 4
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5.Government of India. Janani Suraksha Yojana: National Rural Health Mission: Mission document. Ministry of Health and Family Welfare, Nirman Bhawan, New Delhi, 2006. Available from: http://www.mohfw.nic.in. [Last accessed on 2007 Aug 11].   Back to cited text no. 5
    
6.Lahariya C. Cash incentives for institutional deliveries: Linking with ante natal and post natal care may ensure 'continuum of care' in India. Indian J Community Med 2009;34:15-8.   Back to cited text no. 6
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7.Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: A systematic review. JAMA 2007;298:1900-10.  Back to cited text no. 7
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10.Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana: A conditional cash transfer program to increase births in health facilities: An impact evaluation. Lancet 2010;375;2009-23.   Back to cited text no. 10
    
11.Madhya Pradesh Government. Madhya Pradesh, Bhopal. 2004. Available from: http://www.mpgovt.nic.in. [Last accessed on 2007 Aug 12].   Back to cited text no. 11
    
12.Madhya Pradesh Government. Vijaya Raje Janani Kalyan Bima Yojana: Innovations under NRHM. Madhya Pradesh, Bhopal. 2006. Available from: http://www.mpgovt.nic.in. [Last accessed on 2007 Aug 05].  Back to cited text no. 12
    
13.Carrillo PE, Ponce Jarrín J. Efficient delivery of subsidies to the poor: Improving the design of a cash transfer program in Ecuador. J Dev Econ 2009;90:276-84.   Back to cited text no. 13
    
14.Vora KS, Mavalankar DV, Ramani KV, Upadhyaya M, Sharma B, Iyengar S, et al. Maternal health situation in India: A case study. J Health Popul Nutr 2009;27:184-201.  Back to cited text no. 14
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15.Government of India. National Rural Health Mission. Mission document. MOHFW, Nirman Bhawan, New Delhi. 2005. Available from: http://www.mohfw.nic.in/nrhm [Last accessed on 2007 July 19].   Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3]


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