|Year : 2011 | Volume
| Issue : 4 | Page : 252-259
Determinants of utilization of services under MMJSSA scheme in Jharkhand 'Client Perspective': A qualitative study in a low performing state of India
Sanjay K Rai1, Rajib Dasgupta2, MK Das3, Sarita Singh4, Reema Devi5, NK Arora6
1 Associate Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Associate Professor, Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
3 Director Projects, The INCLEN Trust International, New Delhi, India
4 Research Officer, The INCLEN Trust International, New Delhi, India
5 Program Consultant, The INCLEN Trust International, New Delhi, India
6 Executive Director, The INCLEN Trust International, New Delhi, India
|Date of Web Publication||30-Jan-2012|
N K Arora
Executive Director, The INCLEN Trust, International F1/5, Okhla Industrial Area, New Delhi - 20
| Abstract|| |
Preventing maternal death associated with pregnancy and child birth is one of the greatest challenges for India. Approximately 55,000 women die in India due to pregnancy- and childbirth- related conditions each year. Increasing the coverage of maternal and newborn interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. With a view to accelerate the reduction in maternal and neonatal mortality through institutional deliveries, Government of India initiated a scheme in 2005 called Janani Suraksha Yojna (JSY) under its National Rural Health Mission (NRHM). In Jharkhand the scheme is called the Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA). This paper focuses on community perspectives, for indentifying key areas that require improvement for proper implementation of the MMJSSA in Jharkhand. Qualitative research method was used to collect data through in-depth interviews (IDIs) and focus group discussions (FGDs) in six districts of Jharkhand- Gumla, West Singhbhum, Koderma, Deoghar, Garhwa, and Ranchi. Total 300 IDIs (24 IDIs each from mother given birth at home and institution respectively; two IDIs each with members of Village Health and Sanitation Committees (VHSC) / Rogi Kalyan Samitis (RKS) from each district) and 24 FGDs (four FGDs were conducted from pools of husbands, mothers-in-law and fathers-in-law in each district) were conducted. Although people indicated willingness for institutional deliveries (generally perceived to be safe deliveries), several barriers emerged as critical obstacles. These included poor infrastructure, lack of quality of care, difficulties while availing incentives, corruption in disbursement of incentives, behavior of the healthcare personnel and lack of information about MMJSSA. Poor (and expensive) transport facilities and difficult terrain made geographical access difficult. The level of utilization of maternal healthcare among women in Jharkhand is low. There was an overwhelming demand for energizing sub-centers (including for deliveries) in order to increase access to maternal and child health services. Having second ANMs will go a long way in achieving this end. The MMJSSA scheme will thus have to re-invent itself within the overall framework of the NRHM.
Keywords: Community perspective MMJSSA, Determinants MMJSSA, Jharkhand MMJSSA, JSY evaluation
|How to cite this article:|
Rai SK, Dasgupta R, Das M K, Singh S, Devi R, Arora N K. Determinants of utilization of services under MMJSSA scheme in Jharkhand 'Client Perspective': A qualitative study in a low performing state of India. Indian J Public Health 2011;55:252-9
|How to cite this URL:|
Rai SK, Dasgupta R, Das M K, Singh S, Devi R, Arora N K. Determinants of utilization of services under MMJSSA scheme in Jharkhand 'Client Perspective': A qualitative study in a low performing state of India. Indian J Public Health [serial online] 2011 [cited 2013 Dec 11];55:252-9. Available from: http://www.ijph.in/text.asp?2011/55/4/252/92400
| Introduction|| |
Reducing maternal mortality remains a major challenge to health service systems of developing nations; reflected in the Millennium Development Goal (MDG) 5. The current estimated maternal mortality ratio (MMR) in India is 212 per 100,000 live births.  This translates to about 55,000 women who die annually due to pregnancy- and childbirth-related condition in India. , The principal causes of mortality from pregnancy-related conditions include hemorrhage, pre-eclampsia and eclampsia, infection, obstructed labor and complications of unsafe abortion. Three delays, delay in deciding to seek care for an obstetric complication, delay in reaching the health facility and delay in obtaining the essential care at the health facility, contribute to poor outcomes of pregnancy in resource-constrained settings.  Utilization of health services is an outcome of intersections between service provisioning, physical and social access, and cultural and behavioral issues (Rao and Richard; Sarita and Tuominen; Kumar et al.; Rohde and Viswanathan). ,,, While improving access has been the primary strategy for increasing health service utilization in developing countries, improvements in the quality of services can further boost service utilization. Programs that maximize quality as well as access to services enhance client satisfaction, leading to greater utilization (Shelton and Davis; Levine et al.). , Access helps determine whether an individual makes contact with the provider, while quality of care influences a client's decision whether to accept and use the service or to continue using the service (Bertrand et al).  Conversely, the effects of inadequate access on utilization of services may be greater than the effects of socioeconomic factors (Sawhney; Elo) , and that as access to public health facilities improves, the effects of socioeconomic factors on utilization of services may become less important (Rosenzweig and Schultz; Govindasamy and Ramesh). ,
Promotion of maternal and child health has been one of the most important components of the Family Welfare Program of the Government of India (GoI); the National Population Policy 2000  reiterated the government's commitment to the safe motherhood program within the wider context of reproductive health. The Ministry of Health and Family Welfare (MOHFW), GoI launched Janani Suraksha Yojana (JSY) in 2005, under the National Rural Health Mission (NRHM),  as a modification to the National Maternity Benefit Scheme (NMBS). JSY focuses on reducing maternal and neonatal mortality through increased institutional deliveries. It was envisioned that increases in institutional deliveries would in turn accelerate India's progress toward reaching the maternal and child health goals and focused specific attention toward 10 low performing states including the Empowered Action Group (EAG) states (Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Rajasthan, and Orissa).
Jharkhand is remarkable as the only state registering a decline in institutional births between the last two rounds of District Level Household Survey (DLHS 2 and 3). , It also has some of the highest maternal mortality figures along with high proportions of tribal populations, undernutrition and chronic poverty. The recently released Annual Health Survey (AHS)  2010-11 has made Commissionary level maternal mortality figures available [Table 1].
The Government of Jharkhand initiated the Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA), a derivative of the JSY, in 2006. Under the scheme, a cash assistance of 1400 is given to all pregnant women who give birth in public health facilities and at accredited private institutions, and Rs 500 for all births at home.
Our study mapped the implementation process of the MMJSSA, in particular focusing on reach and utilization of services, and its determinants; planning and management; social mobilization; identification of strengths and limitations, as well as local innovations; problems faced by various stakeholders; and, quality of care. This paper focuses on community perspectives, for indentifying key areas that require improvement.
Study setting:Jharkhand is considered as a tribal state because of its high - 28% - Scheduled Tribes (ST) population. For this reason, districts of Jharkhand were stratified based on the percentage of their ST populations. They were stratified as either tribal districts (TDs), non tribal districts (NTDs) or urban areas (UA). Tribal or non-tribal status of the individual respondent was not a consideration for stratification of the districts.
For the samples to be a representation of Jharkhand, districts were selected from five regional divisions namely Kolhan, South Chotanagpur, North Chotanagpur, Palamu and Samthal Paragana. The selected districts comprised of two with high percentage of ST population (TDs; Gumla, and West Singhbhum, three with least percentage of ST population (NTDs; Koderma, Deoghar, and Garhwa), and one with highest urban population (UA; Ranchi).
Six blocks were selected using the same criteria used in selecting the districts -percentage of their ST population. For instance, from a district identified as TD a block with maximum tribal population was selected [Table 2].
|Table 2: Scheduled tribe (ST) population in the study districts (Census 2001)|
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From every block two villages were selected; one nearest to the block PHC and the other farthest from the block PHC. Using the selected villages as central starting points (epicentric village), the data collection team moved in a clockwise direction and covered surrounding villages if necessary until the desired sample size was reached.
Selection of village level respondents:This research relied on a cross-sectional design that applied tools of qualitative research methods: in-depth interviews (IDIs) and focus group discussions (FGDs). From each epi-centric village 12 mothers each who gave birth at homes and institutions were selected. The inclusion criterion was that a mother must have given a birth in last one year at home or in a health facility. 288 IDIs from both the groups (mother given birth at home and institution) were conducted. Further, two members of Village Health and Sanitation Committees (VHSC) / Rogi Kalyan Samitis (RKS) were also interviewed in each district. Thus, a total of 300 IDIs were conducted.
Respondents for four focus group discussions (FGDs) were selected from pools of husbands, mothers-in-law as well as fathers-in-law. Two FGDs consisting of husbands/fathers-in-law and two consisting of mothers-in-law were conducted in each district; thus a total of 24 FGDs were conducted from all six districts [Table 3], [Table 4], [Table 5], [Table 6] and [Table 7].
Data collection, quality assurance and analysis:All IDIs and FGDs were tape recorded to supplement missed statements during transcription and cross check data points. Data collection was done during May-June 2009. All interactions were held in locally spoken and understood language as all the research associates responsible for data collection were from the same state. On average, IDIs lasted for 40 to 60 min and each FGD, 60 to 80 min. Several quality assurance mechanisms were undertaken for validity and reliability of the data: supervision of interviews; tape recording of interviews; and, cross-checking of transcripts, data entry and translations. Data was analyzed manually by Central Coordinating Team Members (trained and experienced in handling large-scale qualitative data) by adopting free listing of responses, domain identification and coding of responses. Results from the analysis were summarized and cross tabulated by categories of stakeholders. Qualifiers (few=<1+; some =1+; half=2+; majority=3+; most=4+ and almost all = 5+) were used for semi-quantitative expression of the data.
Ethical approval: The study was approved by Institutional Ethical Review Board of All India Institutes of Medical Sciences (AIIMS), New Delhi and INCLEN Trust.
| Antenatal Care|| |
About half the mothers given birth at both homes and institutions had three Antenatal Care (ANC) checkups including TT injections and IFA tablets. They were counseled and advised on diet and general care. About half of the mothers were mobilized by health workers.
Preparations for birthing during the antenatal period were specifically probed. Majority of mothers who gave birth at institutions planned in advance regarding the place of delivery and arranged for money in advance. Half of the mothers planned for transportation, clothes, soap, razor blade and other items. Very few among them had planned for birthing at home, but due to exigencies shifted to the hospital. Some of the mothers were motivated for institutional delivery during ANC by the Sahiya, ANM or AWW. Lack of resources emerged as the principal reason for giving birth at home though a large proportion felt institutional deliveries were safer and would want to avail of the facilities. Majority of mothers who gave birth at home had not decided about the place of delivery and about half of them had arranged for money. Some of these mothers had planned for institutional delivery and arranged transport and money; but owing to emergencies like premature labor gave birth at night.
| Delivery at Institutions|| |
Sahiyas accompanied and arranged transport for only some of the mothers to hospitals and stayed with them. Most of the mothers reached facility within 1-2 h and used motorized transportation; very few mothers had access to ambulances. Reimbursement provided for transport was generally sufficient.
Services utilized by the mothers under the scheme gave a view regarding the quality of care. Half of them were satisfied with the quality of care, treatment and facilities provided to mother and baby. Some of the mothers were unhappy with the unavailability of a trained doctors or nurse to handle delivery, lack of drinking water, beds and cleanliness, poor infrastructure and lack of assistance at night. Their husbands who had accompanied them to the hospital were more critical in their opinions. Many reported buying medicines from private chemists and not receiving information about prescription that they were given. Very few respondents reported any diagnostics (including ultrasonography) being done at the institutions.
While most mothers reported uncomplicated deliveries, those experiencing complications reported prolonged labor, obstructed labor, severe pain, retention of placenta and breech presentation as the most frequent conditions.
Services after delivery included assistance with personal hygiene, availability of clean clothes and bed, regular visits by the doctors and provision of diet. Services rendered for babies focused on general care like cleaning, covering and keeping the baby warm, weighing, bathing and vaccination. Advice received by some of the mothers were regarding information and suggestions on rest, care of stitches and dietary intake, family planning, advice on adhering to prescribed medicines and information on financial incentive. Significantly, very few received advice on breast feeding including exclusive breast feeding while half of the mothers had not received any advice.
Most mothers were discharged within 24 h and half of them within 3 h after delivery, particularly those who had uncomplicated normal delivery. Few responses indicated request for early discharge because of lack of resources at hospital (particularly, shortage of human resources) and in general a perception of poor quality of services.
Dais conducted delivery for majority of mothers giving birth at home. Few deliveries were conducted by ANMs and the rest by family members. Significantly, in Deoghar, most births at home were reportedly conducted by doctors (it could not be verified whether they were qualified or informal practitioners) and none by dais.
| Decision Making Process|| |
Decisions to seek care were affected by past experiences and shared information, particularly among women. Safe delivery was the primary reason for opting for institutions. Very few respondents mentioned financial incentive as a key reason. Recent improvements in the health facilities and availability of emergency services were cited as reasons by some of the mothers. Most mothers had earlier experience of deliveries at home, including birth of their first child and, in general, there were no obvious reasons for choosing hospitals over home.
Government or private facilities were often chosen on the bases of perceived quality of services and infrastructure, good behavior, confidence in the health facility and financial condition of respondents. Free/ low cost of delivery were reasons for preferring government facilities. Influence of family members and social mobilization were stated to be less important causes. Almost all mothers who gave birth at hospitals reported that they would advise other mothers likewise. In better-off districts, some respondents in urban areas preferred private facilities as they were perceived to be more accessible, less expensive and providing better quality of care.
Adverse experiences of public facilities included non-availability of medicine and injections, poor attention, misbehavior of staff and higher out-of-pocket expenditure. No antenatal checkups and lack of responsiveness in disbursement of incentives were also the reported reasons. Fear of injections and surgery emerged as an important reason for not opting for institutions. Very few reported about the lack of awareness about the benefits of delivery at hospital. Poor accessibility, family influence and unexpected events were some of the reasons for giving birth at home.
| Post-Natal Care|| |
About half of the mothers who gave birth at institutions were given advice on care of the baby like proper covering, keeping the baby warm and clean, bathing after 2-3 days, oil massage, medicines as per the prescription and cord care. None of the mothers recalled being checked for bleeding and fever. Very few reported that their babies were weighed. Some of them were advised and assisted by doctors and nurses in early initiation of breast feeding, feeding frequency and exclusive breast feeding.
About half of the mothers were visited once at home, and very few twice. Sahiyas and/or ANMs played a negligible role in assisting for breast feeding. Few mothers were advised on vaccinations. Advice given to majority of mothers was mostly on general care and none on family planning. Of those visited at home, half were visited on the first day and the rest on third/fourth days after delivery, largely by Sahiya followed by ANMs and least by AWWs.
| Awareness Regarding the Scheme|| |
Most respondents were unaware of the MMJSSA/JSY scheme, by name; however, they were aware of an initiative for maternal benefits though and the majority recalled when probed specifically about monetary incentive. The few who had heard about the scheme had no knowledge of its specific provisions. ANC registration and care were overwhelmingly perceived as benefits from scheme. Other key benefits were identified as financial incentives, availability of (ICDS) rations, IFA tablets, vitamins and vaccinations.
| Financial Incentives|| |
Financial incentives were disbursed to the mothers through coupon, cash and cheque (account payee or bearer cheque). There had been a shift from coupon to cheque based payments and split payment ( 500 at the time of registration and 900 after delivery at institution) to onetime payment ( 500 and 1400 after delivery for home and institutional delivery respectively) a few month before the survey. About half of the mothers giving birth at institutions received full payment, generally within a week of delivery. There were fewer complaints about payment of the first installment (for ANC). Difficulties experienced in accessing the incentive included repeated visits, demand for various documents, rent-seeking behavior (bribe or incomplete payment) of staff and bank-related procedures. There was general agreement that the process of issuing coupons had minimized corrupt practices.
Financial incentives were widely believed to have led to an increase of institutional deliveries though some mothers disagreed; making the point that safety of delivery was the primary motive and not the incentive.
The purpose of the financial incentives as perceived by the most of the mothers and family members was to improve nutritional status and health of the mother by consuming good food, buying medicines, transportation costs and for other purposes like clothing. The incentive was reported to be spent mostly on food and medicine, and meeting the travel costs.
Majority of those travelling to institutions spent less than 250 on transportation and more than 500 on medicine. Half of them paid an average of 250 to hospital staff. Most mothers giving birth at institutions spent more than 1000 as out-of-pocket expenditure; much less was spent by mothers giving birth at home.
ANC registration was largely being done for most mothers. Critical components like checking blood pressure, advice on danger signs and birth planning were often missed. Despite high levels of registration, most mothers did not turn up for institutional deliveries. The finding that utilization of antenatal services is higher than use of skilled assistance during delivery is consistent with the results of studies conducted in many developing countries. ,, Poor accessibility, family influence and unexpected events were some of the reasons perceived by some of the institutional delivered mothers and home delivered mothers for home delivery. Sahiyas, a critical actor, played a minimal role in accompanying, assisting and arranging transport for mothers to institutions; their motivational role was conspicuous by absence.
Three mandatory post-natal visits were not being followed; most mothers reported one. Services and advices were poor; none of the respondent mothers were checked for bleeding or fever, and very few babies were weighed. PNC thus continues to be an urgent area of improvement.
Awareness regarding the benefits provided under the scheme was minimal. There is a need to understand why people use health services, their psychological state, belief, emotional appeal, seriousness and accordingly design social mobilization campaigns. Accessing the incentive was cumbersome; rent-seeking behavior of functionaries emerged as one of the major themes. This also reflected in an impact evaluation of India's JSY.  There were numerous instances of partial payment of the promised amount and grievance redressal mechanisms were weak; doing away with coupons may not have been a wise step. Out-of-pocket expenditure on an institutional delivery clearly exceeded the incentive amount ( 1400), and could be up to double this amount. Unequivocally, financial incentives were perceived to be a relatively weak pull factor; the emphasis and demand being on quality of care. Poor infrastructure, rude behavior of staff and purchase of medicines emerged as critical quality issues. With recent increases in institutional delivery, government hospitals were stretched beyond their capacities and that could have further aggravated quality issues. Women who preferred birthing at home did so on the basis of adverse community experiences regarding access and quality of care, as well as their socio-cultural beliefs.
We found compelling evidence that despite willingness for institutional deliveries (generally perceived to be safe deliveries), several barriers emerged as critical obstacles. These included poor infrastructure, lack of quality of care, difficulties while availing incentives (read: corruption), behavior of the healthcare personnel and lack of information about MMJSSA. Poor (and expensive) transport facilities and difficult terrain made geographical access difficult. These have to be seen in the context of chronic poverty and shortage of younger males (due to large-scale migration), in many cases the prospective fathers. The level of utilization of maternal healthcare among women in Jharkhand is thus understandably low. There was an overwhelming demand for energizing sub-centers (including for deliveries) in order to serve the mother and community in a more meaningful way. Having the full complement of second ANMs will go a long way in achieving this end. The MMJSSA scheme will thus have to re-invent itself within the overall framework of the NRHM.
| Acknowledgement|| |
The study was conducted and coordinated by Indian Clinical Epidemiology Network, (IndiaCLEN) and International Clinical Epidemiology Network (INCLEN) Executive Office, New Delhi. We thank Department of Health and National Rural Health Mission, Jharkhand and all stakeholders who agreed to share their perception and views about the program. We would also like to thank MCH STAR -USAID for funding the Study. We are greatly indebted to the support and encouragement extended by the partners, Population Foundation of India and Rajendra Institute of Medical Sciences, Ranchi, Jharkhand. The authors are solely responsible for the views expressed herein.
We thank the other contributors for this study: Dr Lalitendu Jagatdeb of PFI, New Delhi, Dr A.K. Sharma, Dr Vivek Kashyap, Dr A. K. Chaudhary of RIMS, Ranchi, Jharkhand, Dr K Suresh of INCLEN, Dr Kalyan K Ganguly of ICMR, New Delhi, Dr Vivek Adhish of NIHFW, New Delhi, Dr Puneeta Mahajan of SGM, New Delhi, Dr Kiran Goswami of AIIMS, Dr Sudha Salhan of Safdarjung Hospital, New Delhi, Dr Arti Maria of RML Hospital, New Delhi and Dr. Sanjay Chaturvedi of UCMS, New Delhi.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]