Infant Mortality in India: Evaluating the JSY Cash Transfer Programme

8/6/2019 Infant Mortality in India: Evaluating the JSY Cash Transfer Programme

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Infant Mortality in India

Evaluating the JSY Cash Transfer Programme

A PAE Presentation by Sarah Hauser


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Table of Contents

Research Question

Background

Methodology

Analytical Framework

Analysis

Recommendation


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Research Question

1. Has the JSY cash transfer programcaused a decrease in infant mortality?

2. Has it had the biggest effect on LowPerforming States?

Reduction of the cost of hospital delivery Education of expecting mothers Increase quality of service

3. Which of these areas was the program

most effective in?


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Background

High overall infant mortality rate: 53/1000

India accounts for one in four of under-fivedeaths

Infant deaths account for more than two-thirds of under-five deaths

A serious lag behind countries withcomparable GDP per cap (Vietnam, thePhilippines and Sri Lanka)

Large variation between states: 10 in Goato 70 in Madhya Pradesh

Government Efforts

JSY cash transfer program:

Cash transfers of Rs 600 Rs1400 for below poverty linewomen to incentivise deliveryin hospitals.

Eligibility criteria: above 19,

married, BPL card holder andcash transfer is available foronly the first or second child.

Low Performance States:Every woman is eligible

Total of 9.5 millionbeneficiaries in 2009/2010


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Methodology

Peer reviewed journals, searching for keywords: Infant mortality,India, JSY cash transfer scheme, maternal mortality, National RuralHealth Mission

Use of grey literature: WHO, ADB

1. Extensive literature review


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Semi structured expert interviews with state officer, doctors and nurse

Hospital visit in Delhi

Gathering of supporting material: flyers, handouts etc.

2. Qualitative


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Health interview surveys covering maternal and child health,reproductive health, and use of maternal and child health-care servicesat the district level for India.

Conducted by International Institute for Population Sciences in Mumbai.

Round two of DLHS 620107 households sampled between 20022004

Round three of DLHS: 720320 households were sampled between late2007 and early 2009 with multistage stratified sampling

Correlation between program intensity and infant mortality

Evaluation of before and after data on perceptions

3. Quantitative


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Analytical Framework Findings

Needs Assessment Conditionality Monitoring and

Evaluation

Political Support

PolicyAssessment

Clear identification of thebottlenecks and barriers

to safe delivery:

Access, transportation,

perceived lack of quality

of care and culture.

Broadly conditional on:

-BPL card holder or from

selected castes & above

19 years

-Give birth in a hospital

or accredited health

facility

-- For 1st and 2nd child

only

Very detailed andrigorous plans and

reporting at hospital,

district, state and

national level on monthly,

quarterly and annual

basis.

A national scheme thathas political support from

president down to the

grassroots level.

Financially supported by

World Bank via national

health budget

Issues Targets are unclear:

Original target was to

reduce MMR, reduction

of IMR was an

afterthought

Implementation of

conditions is state

specific -> In LPS all

women are eligible

Very few checks if

mother tells the truth ->

inefficiencies, people

gaming the system

Implementation is driven

by output rather than

outcome.

No incentive to monitorquality of hospital

services

Long term vision is

unclear

Will become very

expensive in the longrun, could have negative

long term effects


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1. Has the JSY cash transfer program caused a decrease in infant

mortality?

y = -10.976x - 1.4076R = 0.0832

-10

-8

-6

-4

-2

0

2

4

6

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%

Absolute Changein Infant Mortality

Program Intensity

Absolute IMR changeAll States

absolute IMR change Linear (absolute IMR change)

Note: Outlier Mizoram removed from the sample


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y = -6.2807x - 2.7116R = 0.3317

-7

-6

-5

-4

-3

-2

-1

0

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%

Reduction in InfantMortality

Program Intensity

Absolute Reduction in Infant Mortality - excluding smallstates

Absolute reduction Linear (Absolute reduction)


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State Intensity

IMR Percentage

change State Intensity

IMR Percentage

change

Madhya Pradesh26.09% -5.4%

Chhattisgarh7.08% -6.6%

Mizoram 23.58% 48.0% Bihar 6.89% -6.7%

Orissa23.03% -5.5%

Arunachal Pradesh5.76% -20.0%

Tamil Nadu

23.02% -16.2%

Andaman & Nicobar

Islands 5.09% 0.0%

Sikkim21.75% 0.0%

Himachal Pradesh5.02% -12.0%

Rajasthan20.95% -6.0%

Manipur4.99% 27.3%

Andhra Pradesh

20.80% -7.1%

Dadra & Nagar

Haveli 4.17% -2.9%

Assam18.83% -4.5%

Haryana4.01% -5.3%

West Bengal12.41% -7.9%

Uttar Pradesh3.49% -5.6%

Karnataka12.25% -6.3%

Delhi2.62% -5.4%

Kerala10.97% -20.0%

Meghalaya2.59% 9.4%

Pondicherry10.48% -10.7%

Jharkhand2.43% -6.1%

Tripura9.79% -5.6%

Punjab2.41% -6.8%

Gujarat7.91% -5.7%

Jammu & Kashmir2.30% -5.8%

Uttarakhand7.61% 2.3%

Goa1.98% -33.3%

Maharashtra 7.13% -5.7% Chandigarh 1.01% 21.7%

2. Has JSY had the biggest effect on Low Performing

States?


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Among non users the

program has failed toreduce the perceivedoverall costs involvedin having a pregnancy

in a hospital.

The information

barrier to hospitalpregnancy hasdropped dramatically.

Barriers to Hospital

Delivery: Information

and Costs

0%

5%

10%

15%

20%

25%

30%

35%

Why did you not seek to deliver your childin a hospital?

2002-04 Survey 2007-09 Survey

3. Which area was the program most

effective in?


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Total amount of money spent in 2009/10:15.4 billion rupees

Total beneficiaries: has grown from 750,000mothers in 2005 to 9.4 million in 2009/10

Cost per beneficiary: 1620 rupees

Associate with costs between 924 million and 1.6 billionrupees

Additional number of lives saved: 570,000 1,045,000

Increase by between 6 11% is associatedwith the reduction of IMR by 1/1000

By doubling the program IMR could bereduced to 36 43/1000

Every 6 - 11% increasein program intensityis associated with areduction of IMR by1/1000.

Costs


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Recommendations

Improvements in efficiency are needed

Conditionality should be more transparent across states

Increase in program intensity is not enough

LPS need to become high program intensity states

Currently there are no incentives to improve quality of delivery, ante natal care etc. This could besolved by incentivising doctors.

Quality improvements need to be incentivised and communicated

Continue education of mothers

Overcome cultural barriers


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Thank You


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Appendix 1.

Has the JSY cash transfer program caused a decrease in infant

mortality?

y = -0.2014x - 0.0331R = 0.0197

-40.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%

I

n

f

a

n

t

M

or

t

a

l

i

t

y

Program Intensity

Infant mortality based on program Intensity - All states

Series5 Linear (Series5)


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y = -0.0861x - 0.0631R = 0.0326

-25.0%

-20.0%

-15.0%

-10.0%

-5.0%

0.0%

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%In

f

a

n

t

M

o

r

ta

l

i

t

y

Program Intensity

Infant mortality per program intensity - below 1% ofpopulation states removed

Series5 Linear (Series5)


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Appendix 2: Absolute Reduction per state

State Intensity

Absolute Reduction

in IMR State Intensity

Absolute

Reduction in IMR

Madhya Pradesh 26.09% -4 Chhattisgarh 7.08% -4

Mizoram 23.58% 12 Bihar 6.89% -4

Orissa 23.03% -4 Arunachal Pradesh 5.76% -8Tamil nadu

23.02% -6

Andaman & Nicobar

Islands 5.09% 0

Sikkim 21.75% 0 Himachal Pradesh 5.02% -6

Rajasthan 20.95% -4 Manipur 4.99% 3

Andhra Pradesh20.80% -4

Dadra & Nagar Haveli4.17% -1

Assam 18.83% -3 Haryana 4.01% -3

West Bengal 12.41% -3 Uttar Pradesh 3.49% -4Karnataka 12.25% -3 Delhi 2.62% -2

Kerala 10.97% -3 Meghalaya 2.59% 5

Pondicherry 10.48% -3 Jharkhand 2.43% -3

Tripura 9.79% -2 Punjab 2.41% -3

Gujarat 7.91% -3 Jammu & Kashmir 2.30% -3

Uttarakhand 7.61% 1 Goa 1.98% -5

Maharashtra 7.13% -2 Chandigarh 1.01% 5


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Bibliography

Asian Development Bank 2008. Conditional Cash Transfer Programs: An Effective Tool for Poverty Alleviation?Availableat: http://www.adb.org/Documents/EDRC/Policy_Briefs/PB051.pdf ; Accessed on 23.02.2011

Bhalotra S, 2007. Birth spacing, fertility and neonatal mortality in India: dynamics, frailty and fecundity, Health Econ. 16:

911928

Black R, Morris S, Bryce J. 2003.Where and why are 10 million children dying every year? The Lancet 361: 22262234.

Figure 1: worldmapper.com

International Institute for Population Science. 2010. District Level Household and Facility Survey, 2007 2008. India.Available under http://www.rchiips.org/pdf/INDIA_REPORT_DLHS-3.pdf

UN Population Fund India. 2009. Concurrent assessment of Janani Suraksha Yojana (JSY) in selected states: Bihar,Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh. New Delhi: United Nations Population Fund India.

World Health Organization. 2010. World Health Statistics. Geneva. Accessible under

http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf

World Health Organization. 2008. Proportion of births attended by a skil led health worker 2008 updates. Geneva.Accessible under http://www.who.int/reproductive_health/global_monitoring/data.html, accessed 09 February 2011
http://www.adb.org/Documents/EDRC/Policy_Briefs/PB051.pdfhttp://www.who.int/whosis/whostat/EN_WHS10_Full.pdfhttp://www.who.int/whosis/whostat/EN_WHS10_Full.pdfhttp://www.adb.org/Documents/EDRC/Policy_Briefs/PB051.pdf

Infant Mortality in India: Evaluating the JSY Cash Transfer Programme

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