Programme Evaluation of the Janani Suraksha Yojana National Health Systems Resource Centre Technical Support Institution with National Rural Health Mission Ministry of Health & Family Welfare Government of India © NHSRC, September 2011 Ministry of Health and Family Welfare Government of India, Nirman Bhawan New Delhi - 110 011 Reproduction of any excerpts from this documents does not require permission from the publisher so long it is verbatim, is meant for free distribution and the source is acknowledged. This report has been synthesised and published on behalf of the National Rural Health Mission by its technical support institution; National Health Systems Resource Centre (NHSRC) located at NIHFW campus, Baba Gangnath Marg, New Delhi-110 067. ISBN 978-81-908725-7-7 Designed & Printed by: Macro Graphics Pvt. Ltd. www.macrographics.com Message The right to have a safe pregnancy is a fundamental human right. The Janani Suraksha Yojana (JSY) marks an important step in realizing this right, and forms a cornerstone of the MoHFW’s strategy to reducing maternal mortality and morbidity. There is sui cient evidence to show that institutional deliveries are on the rise, and have increased considerably. The programme evaluation of the JSY implementation in the eight high focus states by the National Health Systems Resource Center is timely. It af ords us a valuable opportunity to rel ect on the nature of achievement and provides critical learning on the ef ectiveness of existing strategies for reducing maternal mortality. The study shows that the JSY has worked as an enabling mechanism and motivated women to opt for institutional deliveries. Over half of the women with previous home deliveries reported opting for an institutional delivery. Also, the study demonstrates that JSY has provided equity in terms of access to institutions for deliveries. This is good and welcome news. The study however also highlights gaps that need to be vigorously addressed. The i ndings of the study highlight the importance of planning investments in health facilities whether of infrastructure or of human resource based on need and caseload within a framework of equity. I hope this report is used by oi cers at the state level to review their maternal health strategies, improve quality of care and strengthen oversight and supervisory systems. The newly launched Janani Shishu Suraksha Karyakram (JSSK) further complements JSY and together these schemes present an unprecedented opportunity to ensure quality care in public health institutions for pregnant women. I am coni dent that the States would seize this opportunity and make rapid strides to ensure improved health outcomes for mothers in the country. New Delhi 25th August, 2011 (P.K. PRADHAN) Message The two phase evaluation of the Janani Suraksha Yojana conducted by the National Health System Resource Center has captured facility readiness and ability to manage complications of pregnancy and benei ciary perceptions and experiences. What emerges is a picture that has a basis for hope and optimism but also a cause for concerted action. The findings on the increase in institutional delivery are evidence that Janani Suraksha Yojana has encouraged women to approach public health institutions in search for better obstetric care. Findings on the gaps in infrastructure and human resource distribution have implications for the quality of care which in turn, have consequences in terms of maternal and neonatal mortality and morbidity. Interventions related to the role of the private sector in the provision of obstetric and the ef ectiveness of transport mechanisms for pregnant women need re-examining. The implications of this report are therefore that there needs to be much greater focus on establishing protocols and standards for obstetric and newborn services, multi-skilling of service providers, judicious allocation of scarce human resources and overall a higher level of leadership at state and district levels to better plan for pregnancy and delivery services. The tragedy of maternal deaths encapsulated in the cases that are recorded in the study is a reminder to us that the task of maternal mortality reduction is yet uni nished and that we still have a long path to traverse. This should serve as an impetus for reforms that will ensure universal and equitable access to all women. (Anuradha Gupta) Contents Acknowledgements ix Acronyms xiii Executive Summary xv Section I: Background 1 Objectives of the Evaluation 3 Methodology 3 Section II: Access to Care 7 Social and Demographic Features of Sampled Districts 7 Increased Institutional Deliveries 8 Equity in Access 11 Ef ectiveness of HMIS in Capturing Performance 14 Home Deliveries 16 Section III: Institutional Capacity to Manage Increased Case Loads 21 Distribution of Case Loads Across Facilities 21 Findings from Phase 2 on Site of Institutional Deliveries 24 Section IV: Fund Flows and Payment Mechanisms 29 The JSY Guidelines 29 Fund Flows and Payment Process 30 Out of Pocket Payments (OOP) 38 Section V: Management of Obstetric Complications 45 Expected Standards for Provision of Skilled Birth Attendance at Birth 45 Focus of the Study 46 Access to emergency obstetric care services 47 Actual record of management of complications 48 Comparative Case Studies Across the Eight Districts 51 JSY and the Improved Maternal and Newborn Health Outcomes - Insights from Phase II 60 Section VI: Facility Preparedness to Manage Institutional Delivery Case Loads 75 Human Resources 75 Physical Infrastructure 80 Equipment, Drugs and Supplies 82 Contents | vii Section VII: Quality of Care 87 Use of Standard Clinical Protocols 87 Recording and Reporting Systems and the HMIS 89 Quality of Care and Services Available 89 Staf Behavior, Security and Quality Management Processes 91 Findings on Quality of Care from Phase 2 Study 91 The Subjective Dimension – User Satisfaction 98 Section VIII: Referral Transport Models 103 Section IX: The Role of Asha 111 Section X: Maternal Death in Times of JSY 121 Section XI: Key Findings and Conclusions 129 References 141 viii | Programme Evaluation of the Janani Suraksha Yojana Acknowledgements We thank the Secretary, Ministry of Health & Family Welfare and the Mission Director, National Rural Health Mission for giving NHSRC the opportunity to undertake the study of the l agship Janani Suraksha Yojana (JSY) and for clearly dei ning the objectives of the study. We gratefully acknowledge the contributions made by the members of National Evaluation Team (NET) members (Dr. C.S. Pandav, Dr. Aditi Iyer, Dr. Prasanta Tripathy, Dr. Vandana Prasad, Dr. Nerges Mistry and Dr. Abole Gore) in designing the methodology and tools of the study. We would like to thank the researchers who participated in the qualitative Phase 1 part of the study in 23 districts. (names overleaf). We also acknowledge the organizations who partnered with NHSRC for collecting the data for Phase II of the study – State Health Resource Centre, Chhattisgarh (SHRC) in Raigarh and Koriya districts of Chhattisgarh, Norway India Partnership Initiative (NIPI) in Angul, Orissa, VISTAAR in Garwah, Jharkhand and Kaushambhi, UP; OASIS in Nabrangpur, Orissa and Madhepura, Bihar; Public Health Resource Network (PHRN) in Bastar – Chhattisgarh; Social Medical Partnership (SMP) in Dumka, Jharkhand, Madhya Pradesh Vigyan Sabha (MPVS) in Morena, MP, Foundation for research in Community Health (FRCH) in Bageshwar, Uttrakhand and NHSRC team & Community Health Fellows – Mr. Swarup Pal and Mr. Anwar Hussain in Hanumangarh. We look forward to the continued partnership of NET members and the study teams for further analysis of the data available and for dissemination and dialogue on the i ndings and recommendations with both policy makers and implementers of this programme. Many of the partners have brought in their own resources both i nancial and human to do this study and have ably and enthusiastically supported the entire process. We also thank SG Computer Technology for the entire data entry and analysis. We also place on record our acknowledgements to Ms. Aditi Iyer (IIM, Banglore), Dr. Vandana Prasad (PHRN), Dr. Manmeet Kaur (PGIMER School of Public Health Chandigarh) and Dr. Sarika Chaturvedi (FRCH) for reviewing the report and giving their critical comments. We also take this occasion to congratulate the NSHRC team who worked on this study - collecting data for the Phase 1 of the study and then helping with training, coordination and data analysis for Phase 2 part of the study. The NHSRC team consisted of Dr. Rajani Ved, Dr. Garima Gupta, Dr. Geetha Rana, Dr. Mithun Som and Dr. Sundararaman. The team undertook the i nal analysis, interpretation and drafting of the report and recommendations and takes the responsibility for the interpretations and views expressed here in. Dr. T. Sundararaman Executive Director, NHSRC Acknowledgements | ix Research Teams for Qualitative Phase 1 of the JSY Evaluation State District Research team Bihar Nalanda Dr. Padmanaban, NHSRC Mr. Prasanth K.S., NHSRC Dr. Neha Dumka, NHSRC Madhepura Dr. Neha Dumka, NHSRC Mr. Sudeep Kesh, IIHMR, Delhi Trainee Mr. Chandrapal Thakur, IIHMR, Delhi Trainee Ms. Megha Sharma, IIHMR, Delhi Trainee Dr. Saiz Shamsi, IIHMR, Delhi Trainee Samastipur Dr. Neha Dumka, NHSRC Mr. Sudeep Kesh, IIHMR, Delhi Trainee Mr. Chandrapal Thakur, IIHMR, Delhi Trainee Ms. Megha Sharma, IIHMR, Delhi Trainee Dr. Saiz Shamsi, IIHMR, Delhi Trainee Chhattisgarh Bastar Dr. Kamlesh Jain, SHRC, Raipur Mr. Puni Khokho, SHRC, Raipur Mr. Prem Kumar, SHRC, Raipur Mr. Mahendra Gaware, SHRC, Raipur Raigarh Dr. Mithun Som, NHSRC Mr. Prem Kumar, SHRC, Raipur Mr. Sarita, SHRC, Raipur Koriya Dr. Mithun Som, NHSRC Mr. Mahendra Gaware, SHRC, Raipur Mr. Puni Khokho, SHRC, Raipur Madhya Pradesh Barwani Dr. Geetha Rana, NHSRC Dr. Bhagwan Waskel, Medical College, Indore Dr. Satish Arushe, Medical College, Indore Ms. Mun Mun, SHSRC, MP Mr. Sant Mahato, Sehat Saathi Dr. Pramod Mahajn, CMHO Morena Dr. Sheetal Bishnoi, SPMU, Rajasthan Staf of DPMU, Morena Teekamgarh Mr. Arun Srivastava, NHSRC Ms. Nazira Abrahaim, Community Health Fellow Mr. Dashrath, Sarthak Mr. Sunil, District Community Mobiliser Orissa Nabrangpur Dr.