|Year : 2015 | Volume
| Issue : 4 | Page : 279-285
Does Janani Shishu Suraksha Karyakram ensure cost-free institutional delivery? A cross-sectional study in rural Bankura of West Bengal, India
Janmenjoy Mondal1, Dipta Kanti Mukhopadhyay2, Sujishnu Mukhopadhyay2, Apurba Sinhababu3
1 MBBS Student, Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
2 Associate Professor, Department of Community Medicine, College of Medicine and Sagar Dutta Hospital, Kolkata, West Bengal, India
3 Professor, Department of Community Medicine, IQ City Medical College, Durgapur, West Bengal, India
|Date of Web Publication||17-Nov-2015|
Dipta Kanti Mukhopadhyay
Lokepur, Near NCC Office, Bankura - 722 102, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Janani Shishu Suraksha Karyakram (JSSK) was launched in India to ensure cost-free institutional delivery. Objectives: 1) To assess the awareness of recently delivered women regarding JSSK 2) To estimate the cost of institutional delivery and its differentials. Materials and Methods: A community-based, cross-sectional study was conducted in a rural community in Bankura, West Bengal, India in 2013, among 210 women who delivered babies in the last 12 months. Information regarding sociodemographic and health service-related variables as well as item-wise costs incurred for institutional delivery were collected. Costs were expressed in Indian National Rupee (INR). A nonparametric, bivariate analysis was performed to examine the difference in median cost. Results: All components of JSSK were known to 12.9% women; the highest (77.1%) for admission and lowest (29.0%) for blood transfusion. The median (±IQR) costs of delivery in the Block level Primary Health Center (PHC), medical college, and private facilities were INR 205.0 (±825.0), 900.0 (±1013.0), and 6600.0 (±16195.0), respectively. Median cost of normal delivery in a private facility (INR 2750.0) was 3.6 times of that in a government facility (INR 765.0). Median direct cost of caesarian section (CS) in a government facility (INR 1100.0) was nearly one-fifteenth of that in a private facility (INR 16,350.0). Cash incentives under Janani Suraksha Yojana for poor and socially marginalized women could not cover the cost of CS delivery in a government facility. Conclusion: Gaps existed in the awareness of beneficiaries regarding entitlement under JSSK. Drugs and transport were two major causes of out-of-pocket (OOP) expenditure in public health facilities.
Keywords: Cost, delivery, direct, government, indirect, Janani Sishu Suraksha Karyakram (JSSK), private
|How to cite this article:|
Mondal J, Mukhopadhyay DK, Mukhopadhyay S, Sinhababu A. Does Janani Shishu Suraksha Karyakram ensure cost-free institutional delivery? A cross-sectional study in rural Bankura of West Bengal, India. Indian J Public Health 2015;59:279-85
|How to cite this URL:|
Mondal J, Mukhopadhyay DK, Mukhopadhyay S, Sinhababu A. Does Janani Shishu Suraksha Karyakram ensure cost-free institutional delivery? A cross-sectional study in rural Bankura of West Bengal, India. Indian J Public Health [serial online] 2015 [cited 2019 Aug 26];59:279-85. Available from: http://www.ijph.in/text.asp?2015/59/4/279/169655
| Introduction|| |
In 2013, about 50,000 women in India died due to pregnancy-related complications.  With a maternal mortality ratio of 117 per 100,000, West Bengal ranks fifth in the country, with the national figure being 178. 
Most of those deaths could be prevented through universalizing skilled care at birth and round-the-clock emergency obstetric care (EmOC) through the public health system. ,
Lack of liquid cash and round-the-clock availability of transport are two major stumbling blocks for institutional care for childbirth. Three financial burden also plays a crucial role in accessing health care in general and maternity care in particular in resource-constrained settings. 
A major proportion of health expenditure in India is met by households (61.8%) followed by the government (28.2%), business firms, and external flows.  Often, the health expenditure in India is catastrophic for the resource-constrained households.  Similar pictures are also noted for maternity care, especially in rural and slum areas. , Poor households often resort to borrow cash or sell assets to meet the health expenditure. ,
The household costs are broadly categorized as direct cost and indirect cost. While direct costs include users' fee, investigation charges, costs for food, drugs, transport, special attendants at the health facility and blood transfusion, the indirect costs include loss of wages, cost for the stay of the persons accompanying, and cost for the home attendants. Direct cost incurred by the end user was considered as out-of-pocket (OOP) expenditure and both the terms were used interchangeably.  To increase the institutional childbirth, a conditional cash transfer scheme named "Janani Suraksha Yojana (JSY)" was launched in 2005 for poor and socially marginalized women.  In 2011, the Government of India started Janani Shishu Suraksha Karyakram (JSSK) to ensure free-of-cost care for all childbirth and neonatal care at public health facilities.  The state of West Bengal too started implementing it since 2011. However, a study in India demonstrated that the free maternity care in the government health facility involved hidden costs such as costs for transport, drugs, and food as well as registration fees and other costs. 
In this context, the present study was conducted to assess the awareness of rural women in Bankura, West Bengal, India who delivered in the last 12 months regarding JSSK and to estimate the cost of institutional delivery in government and private health facilities and their differentials.
| Materials and Methods|| |
Study design, setting, and subjects
A community-based, cross-sectional study was conducted during July 2013-August 2013 in Bankura I Community Development Block having a population of 0.11 million in the district of Bankura, West Bengal, India among women who delivered in the last 12 months. The deliveries were conducted at home, en route, and in various institutions, both public and private. Doctors and nurses were the usual birth attendants in health institutions. The study population depends on the Primary Health Center (PHC) of that block for basic emergency obstetric care (BEmOC) and a nearby medical college and a certain number of private health facilities for comprehensive emergency obstetric care (CEmOC) as defined by the World Health Organization (WHO).  There was no other secondary care government health facility nearby.
In the paucity of published literature, assuming the prevalence of awareness as 0.5 with absolute precision of 0.1, 95% confidence level, design effect 2, and nonresponse rate of 5%, the final sample size was 202. It was rounded off to 210 with a cluster sample size of 7 in a 30 cluster study using two-stage cluster sampling. In first stage, 30 villages were selected through probability proportional to the size method. In selected villages, from a list of target women prepared for this purpose, seven women were selected randomly. If the total number of target women in any village was less than seven, those from the nearest village were included in the list.
Method of data collection
A questionnaire in local vernacular (Bengali) was prepared for collection of relevant information. The questionnaire was checked for content validity by three independent public health experts and pretested. Internal consistency (Cronbach's alpha) was found to be 0.72.
After obtaining written informed consent, sociodemographic and health service-related information of the study participants such as age, religion, caste, education, occupation, parity, number of antenatal visits, and distance of nearest delivery hub (24 × 7) were collected through a house-to-house visit. Information regarding the place of delivery, mode of transport, and item-wise monetary expenditure incurred by the household for accessing and receiving institutional care for childbirth were also collected. Investigators reviewed the relevant records and money receipts whichever were available. Awareness of participants on the availability of free transport to and from health facilities, health care, investigations, drugs and consumables, food, and blood transfusion for institutional delivery in government facilities under JSSK was assessed.
Cost of transport, food, drugs and consumables, charges for admission, stay, and investigations as well as charges for blood transfusion and special attendants at hospital were included as direct costs/out-of-pocket (OOP) expenditure of maternity care in this study.  Charges paid for staying and loss of wages of the accompanying persons as well as the charges of attendants for homemaking were considered in the present study as indirect costs.  Information on occupation and wages of accompanying persons, recruitment of special attendants at health facility, and home attendant and related costs were collected.
Data management and analysis
Data were double entered in MS excel after codification and checked for consistency. All costs were expressed in Indian National Rupee (INR). The mean, standard deviation (SD), median, and interquartile range (IQR) were used to present the attributes of the study population as well as the cost of institutional delivery in government and private health facilities. Cost differentials across the sociodemographic and health service-related variables were examined using the Mann-Whitney U (MW-U) test, when two categories were compared and the Kruskal-Wallis (KW) test when more than two categories were compared, as assumptions for parametric tests were not fulfilled in some cases.
The study obtained clearance from the Institutional Ethics Committee, Bankura Sammilani Medical College, Bankura, West Bengal, India. It followed the ethical standard for observational epidemiological study.
| Results|| |
A total of 210 married women who delivered in the last 12 months (postnatal mothers) were interviewed. Out of them, five (2.4%) delivered at home.
The mean [±standard deviation (SD)] age of the mothers was 22.2 (±3.2) years; around one-sixth (15.7%) were teenagers. The study population was dominated by Hindus (89.5%). Around one-tenth (10.5%) belong to scheduled tribes, 44.3% belonged to scheduled castes, and the rest belonged to the general caste (42.4%) or other backward classes (OBC). More than half of the study population (53.8%) had below poverty line (BPL) card. Around one-fourth of the study population (27.1%) received 10 or more years of formal education and nearly the same proportion of women was illiterate (25.7%); the average duration of schooling was 5.9 (±4.6) years. Almost nine out of ten women (91.4%) were homemakers. Around three-fourth (72.4%) were multipara and 83.8% received four or more antenatal check-ups, with the average being 5.0 (±2.2). Average distance of the nearest delivery hub (24 × 7) was 9.5 (±7.1) Kms. According to the norms, 48.1% were eligible for Janani Suraksha Yojana; 59.4% of them received INR 1,000 and another 4.0% received INR 500 as cash benefits. All except one of the JSY eligible women delivered at health institutions.
Awareness on JSSK
Among the study subjects, 77.1% were aware about provision of free admission and staying but only one-third (34.8%) knew about free drugs and consumables and 58.6% knew about free investigation at public health institutions. The availability of free food at a government health facilities was known to 59.5% of the participants while only 29.0% were aware of free blood for transfusion. Only 12.9% women were aware of all components of JSSK and three (1.4%) women could state the name of the scheme, i.e., "Janani Shishu Suraksha Karyakram." In a majority of cases, the source of information was the peripheral health workers.
Place of delivery and transport
Of the participants, 5(2.4%) had home delivery and 89.5% attended government health facility for childbirth; 84.8% delivered in a Government medical college, 8.1% in private facilities, and 4.7% in Block Primary Health Centers (BPHCs).
Matri Yaan is the dedicated vehicle for cashless transport of pregnant women to the health facility for institutional childbirth and the journey back home. Out of 205 pregnant women who sought institutional care for childbirth, 23.4% availed the both way cost-free transport to and from the health facility. Another 17.1% availed the vehicle for the one-way journey either to or from the health facility. More than half (53.2%) of the women/their families had to pay for motorized vehicle and the rest availed hired slow-moving vehicle.
Cost of institutional delivery
The average OOP expenditure for institutional delivery in a BPHC was INR 460.5 while the unit cost in a medical college and private facility was higher by 1.8 and 23.1 times, respectively. [Table 1] showed that median direct costs were INR 205.0, INR 900.0, and INR 6600.0, respectively, in those three types of facilities. In government health facilities, the major expenditure was incurred for drugs and consumables followed by transport and food. However, in a private facility the major expenditure was incurred for admission, stay, and investigations followed by drugs and consumables. Indirect costs such as costs for the stay of accompanying persons and loss of wages were the highest in case of a medical college followed by a private health facility [Table 1].
|Table 1: Item-wise distribution of cost for institutional childbirth according to the institutions (n = 205)|
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As shown in [Table 2], irrespective of the mode of delivery, in almost all item women seeking maternity care in a private health facility had more OOP expenditure than those who sought it in government facilities. In vaginal delivery, the cost differences for drugs, admission and investigations, and food and attendants at the health facility were statistically significant. In case of caesarian section, the cost difference was found to be significant in the case of drugs as well as admission and investigations. However, indirect costs were higher in government facilities in both vaginal and caesarian section (CS) deliveries.
|Table 2: Institution-wise distribution of cost for institutional childbirth according to the mode of childbirth (n = 205)|
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Janani suraksha yojana and cost coverage
In the study population, based on the criteria for age, caste, and possession of BPL card as well as precondition of three ANCs, 48.1% were eligible for JSY benefits. One-sixth of JSY eligible women who delivered in a BPHC and 39.3% who delivered in a medical college did not receive JSY benefits. In the present situation, the direct cost for institutional delivery in a Government facility of only 53.5% of JSY eligible women was covered by the cash incentives from JSY. Median additional direct cost of rest of the JSY eligible women over the cash benefits received under JSY. (INR 500.0) was INR 780.0 (±1300.0). Thus, half of those JSY eligible women had to expend INR 780.0 over the cash incentives they received. If all JSY eligible women were to receive the cash benefits, it would cover the cost of 71.3% women having deliveries in government health facilities and the median additional cost would be INR 600.0 (±2225.0), which means that INR 600.0 over JSY incentive would cover the cost of another 14.5% (half of the rest women).
As shown in [Table 3], direct cost was highest in upper ager group while indirect cost was lowest. Muslim women as well as women of the general caste and OBC had more direct expenditure but less indirect expenditure compared to their respective counterparts. Scheduled caste women had lowest direct costs and scheduled tribe women paid the least amount of money as indirect costs. Homemaker, primipara, and women with three or less antenatal check-ups incurred more direct costs. Delivery hub beyond 5% km of residence was associated with higher direct and indirect costs. Women with higher education were more likely to have more OOP expenditure and the difference was statistically significant.
|Table 3: Direct and indirect cost for institutional childbirth according to sociodemographic and health service-related variables (n = 205)|
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| Discussion|| |
In the study area, institutional delivery was a near-universal phenomenon; most of these took place in government health facilities. More reliance on public sector over private sector was a unique feature of eastern India, particularly in West Bengal.  However, this study revealed that women showed a preference for a medical college, which was geographically accessible and reliable as a place for delivery in the absence of any secondary care government health facility or district hospital. It supported the notion that the predictability and quality of maternal services in a health facility are essential for utilization. 
It is believed by the scientific community and policy makers alike that the cost of care was a very critical factor in taking decisions on care seeking and choosing the care provider. High cost was documented to be a barrier in seeking institutional care for childbirth.  Cash incentive was given to promote institutional delivery under JSY. One objective was to save socially marginalized groups from expenditure for institutional childbirth. To address this issue further, the Government of India launched JSSK to provide free-of-cost care for delivery including transport, drugs, investigation, food, and blood. The present study showed that there were gaps in awareness among the beneficiaries on the availability of those services. The gaps were more regarding the availability of free drugs, consumables, and blood transfusion. Therefore, the priority areas for intervention are awareness generation as well as service provision.
Matri Yaan scheme was started (and later incorporated in JSSK) to ensure free transport round the clock to women for institutional delivery. However, it was noted in this study that every three in five women had to resort to hired vehicles for the journey to and from the health facility and another one-sixth availed a one-way journey with Matri Yaan.
Median OOP expenditure in a BPHC for vaginal delivery was the lowest; nearly one-fifth of the cash benefits under JSY. The median OOP expenditure for delivery including both vaginal and CS in the medical college was almost four times higher than that in a block level PHC, which could still be covered by the cash benefits of JSY. The median direct cost of delivery in a private facility was nearly seven times higher than that of a medical college and the cash benefits under JSY. Bonu et al. reported a similar average cost of institutional delivery in a government facility (INR 884) but lower average cost for a delivery in private facilities (INR 5,038) for West Bengal, India.  In a study in eight high priority states in India, the average cost of delivery in public facilities was found to be INR 1,400-1,600.  A study in 12 districts of Uttar Pradesh, India also reported that the average OOP expenditure for delivery ranged from INR 1,144 to INR 1,897. 
The median direct cost of normal and CS deliveries in a private facility was nearly four times and 15 times costlier than a government facility, respectively. It was a universal finding throughout India as evident from earlier studies. ,,,,, However, all those studies were conducted before the implementation of JSSK. All earlier studies except that by Balaji et al. reported a higher cost of normal delivery or C.S. delivery in government facilities than the present study but similar or lower cost for delivery in private facilities. ,,,,, Mohanty et al. noted a gradual reduction in the cost of delivery in a government institute in India since 2004.  Different timeframes with differing price indices and very low proportion of women in this study opting for private facilities might be the reasons behind higher cost in private facilities in this study.
The aim of direct cash transfer was to assist poorest households to overcome their financial stress to access maternal care.  As evident from the present study, the OOP expenditure for C. S. delivery in a government facility could not be covered by cash benefits under JSY. The cash benefits should be enough to help poor households to meet the direct and indirect costs of health care.  As noted in the present study, JSY even combined with JSSK falls far short of that.
The direct cost in a government health facility was mostly contributed by cost of drugs followed by food. An earlier study in eight high priority states in India also reported the similar findings.  JSSK has enough provision to meet those costs. Even provision of low-cost generic drugs through fair-price shop might reduce those costs. As noted in the present study, JSSK fails to achieve its envisaged goal of cost-free delivery at government health facilities due to gaps in its implementation at facility level.
In private facilities, the maximum cost was for admission, stay, and investigation followed by drugs and consumables. Private-public collaboration and regulation of private health facilities might be a realistic approach toward cost reduction.  However, indirect costs for institutional delivery was higher in government facilities.
Women of a higher age group, Islam religion, general caste, homemakers, primipara women, those who received less than four antenatal check-ups, and whose residence was more than 5 Kms away from the delivery hub were more likely to have higher median OOP expenditure. Formal education for 5 or more years was significantly associated with higher OOP expenditure. Modugu et al. also reported that women of the general caste, richest quintile, those having higher education, and with full antenatal care (ANC) were more likely to have higher OOP expenditure.  Higher direct costs in case of primipara were also noted. , Mohanty et al. observed that in India women of the general caste, higher age, and those who were above the poverty line without any JSY benefits had higher OOP expenditure.  In case of education, occupation, and distance from the delivery hub, indirect costs also followed the same pattern as of direct costs but was reverse in case of other variables.
It was a descriptive study on a relevant, contemporary issue and it appraised the implementation status of a flagship program of the Government of India. There is paucity of data regarding this issue after the implementation of JSSK. However, a small (though adequate with the given confidence level and precision) sample size where the majority delivered in a medical college might be a limitation. Recall about expenditure in the absence of documentary evidence in some cases for a period of 12 months, although widely accepted in the Indian situation, has its own limitation. We have performed a subgroup analysis, which lacked adequate power. The study finding is to be interpreted considering these issues. A longitudinal study design with a comparison group could probably answer the research question more precisely.
The policy decision behind JSSK was to remove the economic barrier to access institutional childbirth by every pregnant woman. The present study noted gaps in awareness among beneficiaries on the provision of JSSK, particularly for drugs and consumables. The major proportion of OOP expenditure in a government health facility was also contributed by drugs and consumables. There was also a deficit in the accessibility of free vehicles for transport. It underscores the need for replanning to address issues such as transport and drugs, which caused maximum expenditure. The gap between OOP expenditure and cash received under JSY by poor families can be reduced by a marginal increase in entitlement or by addressing the deficiency in service provision under JSSK, which is another policy implication.
The authors gratefully acknowledge the financial support from the Indian Council of Medical Research (ICMR) to the first author under the short-term studentship (STS) project.
Financial support and sponsorship
Financial support was given to the first author from the Indian Council of Medical Research through the STS project.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]