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Cash on delivery: an impact evaluation of India's Janani Suraksha Yojana program to increase in-facility births

The Government of India launched in 2005 a conditional cash transfer scheme called Janani Suraksha Yojana (JSY) to incentivize women to deliver in a health facility with the goal of reducing maternal and neonatal mortality. We conducted an independent evaluation of the effect of JSY on intervention coverage and health outcomes.

We used data from district-level household surveys conducted in 2002-2004 and 2007-2009. We studied the uptake of JSY as a function of socio-economic and demographic characteristics. We used three analytical approaches (matching, before-after comparison, and differences-in-differences) to evaluate the effect of JSY on antenatal care, in-facility birth, perinatal and stillbirth/neonatal mortality. At the district-level we also examined the relationship between JSY and the maternal mortality ratio.

Implementation of JSY was highly variable across states and districts. While the program is reaching its target population, the poorest women did not always have the highest odds of receiving JSY. All three analytical approaches demonstrate that JSY has a significant impact on increasing antenatal care and in-facility birth. Two of the approaches show a positive impact of JSY on perinatal and stillbirth/neonatal mortality. We find no impact on maternal mortality.

While the findings of this evaluation only two years into the program are very encouraging, they also highlight the need for intensified efforts to enhance the quality of obstetric care in health facilities, especially in areas servicing the poorest women. Continued independent monitoring and evaluations of JSY are critical, as the financial and political commitment to JSY intensifies.