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Concurrent Evaluation of MMJSSA in Jharkhand |
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The
Indian Clinical Epidemiological Network (IndiaCLEN)
and
Population Foundation of India (PFI)
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“This report is made possible through USAID/India Task Order # 4390-000-PFI-00 TO-01 and # 4390-000-
IndiaCLEN-00 TO-01”\\
Disclaimer: This report is made possible by the support of the American people through the United States
Agency for International Development (USAID). The contents of this document are the sole responsibility of
the Indian Clinical Epidemiology Network (IndiaCLEN) and Population Foundation of India (PFI) and do not
necessarily reflect the views of USAID or the United States Government.
Cover Design by: sngraphix, New Delhi
Mukhya Mantri Janani Swasthya Abhiyan (MMJSSA) is the name given to Janani Suraksha Yojana (JSY) in
Jharkhand. JSY is the safe motherhood program initiated by Government of India in 2005 as a part of the
Reproductive and Child Health (RCH) under the umbrella of National Rural Health Mission (NRHM). JSY’s
principal strategy links cash assistance to institutional delivery to remove the financial barriers hindering
women from accessing antenatal care, institutional care during delivery, and post-partum care.
Published by:……………………………….
Printed by: ………………………………
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Concurrent Evaluation of the Reach, Effectiveness
and Impact of the Mukhya Mantri Janani Shishu
Swasthya Abihiyan (MMJSSA) in Jharkhand
Indian Clinical Epidemiological Network (IndiaCLEN)
&
Population Foundation of India (PFI)
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Concurrent Evaluation of the Reach, Effectiveness and Impact of the
Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA) in
Jharkhand
INVESTIGATORS
Co-Principal Investigators
Dr. Sanjay Rai (IndiaCLEN)
Associate Professor
Department of Community Medicine
All India Institute of Medical Sciences
New Delhi
Dr. Lalitendu Jagatdeb (PFI)
Joint Director (Monitoring & Evaluation)
Population Foundation of India
New Delhi
State Co-Investigator
Dr Arun Kurma Sharma
Professor & Head
Department of Pediatrics
Ranjendra Institute of Medical Sciences, Ranchi
Report Writing Team
Dr Rema Devi S (Consultant, IndiaCLEN)
&
Dr Manoja Kumar Das (Director Projects, IndiaCLEN)
Team Leader
Dr Narendra K Arora
Executive Director
The INCLEN Trust International
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Central Coordinating Team Members
Dr. K. Suresh
Public Health Specialist
New Delhi
Dr. Kalyan Ganguly
Deputy Director/ Scientist E
Reproductive Health Division
Social Behavior Research Unit
Indian Council of Medical Research
New Delhi
Dr Puneeta Mahajan
Department of Gynaecology & Obs.
Sanjay Gandhi Memorial Hospital,
New Delhi
Dr. Sudha Salhan
Head Department of Gynaec. & Obs.
Safdarjung Hospital, New Delhi
Dr H. K. Sharma
Dept. of Psychiatry
All India Institute of Medical Sciences,
New Delhi
Dr. Rajib Dasgupta
Assistant Professor
Centre of Social Medicine & Community Health
Jawaharlal Nehru University, New Delhi
Dr. S. Vivek Adhish
Professor
Dept. of Medical Care Hospital Administration
National Institute of Health & Family Welfare,
New Delhi
Dr. Kiran Goswami
Additional Professor
Centre for Community Medicine
All India Institute of Medical Sciences, New Delhi
Dr. Arti Maria
Consultant & Senior Pediatrician
RML Hospital, New Delhi
Dr. Sanjay Chaturvedi
Professor & Head
Dept. of Community Medicine
University College of Medical Sciences & GTB
Hospital, New Delhi
State level Investigating Team
Dr Vivek Kashayap
Professor,
Department of Preventive & Social
Medicine
Rajendra Institute of Medical Sciences
Ranchi
Dr Anil Kumar Chaudhary
Professor
Department of Pediatrics
Rajendra Institute of Medical Sciences,
Ranchi
Research Associates
Mr. Buthuel Mgbugua
Dr Sarita Singh
Dr Kiranmala Devi
Dr Harpreet Kaur
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Acknowledgements
Concurrent Evaluation of the Reach, Effectiveness and Impact of the Mukhya Mantri Janani Shishu Swasthya
Abhiyan (MMJSSA) in Jharkhand has been a partnership exercise with every participating institute making
equal contribution.
We are greatly indebted to the support and encouragement extended by the following partners
Department of Health and National Rural Health Mission, Jharkhand
MCH STAR
Indian Clinical Epidemiology Network
Population Foundation of India
Rajendra Institute of Medical Sciences, Ranchi
District health officials of selected districts in Jharkhand
All stakeholders who agreed to share their perception and views about the program
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Concurrent Evaluation of the Reach, Effectiveness
and Impact of the Mukhya Mantri Janani Shishu
Swasthya Abihiyan (MMJSSA) in Jharkhand
Indian Clinical Epidemiological Network (IndiaCLEN)
and
Population Foundation of India (PFI)
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CONTENTS
Executive summary ...…………………………………………………………….
Introduction …………………………………………………………………........
Rationale for concurrent evaluation ………………………………………………
Objectives ………………………………………………………………………...
Technical approach and methodology ……………………………………….…..
Population characteristics, study sites, and characteristics of respondents ……….
Findings from the evaluation
Reach and utilization of services ……………………………………….....
Effectiveness of the scheme …………………………………………….....
Impact …………………………………………………………………......
Limitations of the study …………………………………………………………..
Conclusions ……………………………………………………………… ………
Recommendations ………………………………………………………… ……..
Appendices
Appendix 1: Background characteristics of the mothers …………………… …....
Appendix 2: Percentage of ID mothers and HD mothers and safe delivery,
by select background characteristics in Jharkhand, 2007-08 ……… ….......
Appendix 3: Logistics regression on select background characteristics and
safe delivery among IDM and HDM in Jharkhand, 2007-08 ………………
Appendix 4: Percentage of women who delivered at health facilities by
selected background characteristics by study district in Jharkhand, 2007-08 …....…
Appendix 5: The assistance provided by health workers to mothers during
pregnancy ……………………………………………………………….......
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EXECUTIVE SUMMARY
Background
The World Health Organization (WHO) estimates that 99% of maternal deaths occur in developing countries. Of those
deaths, 86% occur in sub-Saharan Africa and Asia. In 2000, as part of the Millennium Development Goals (MDGs),
the international community committed to decrease the maternal mortality ratio (MMR) by 75% by 2015 and improve
overall maternal health care to achieve MDG 5. Even though a global decline in MMR has been observed, it has been
slow. At the current rate of decline, achieving MDG 5 does not appear realistic.
India: Reproductive Health Indicators
India has one of the highest MMRs in the world with an estimated 254 maternal deaths per 100,000 live births. This
figure translates to 69,000 women who die annually from pregnancy-related causes, such as hemorrhage, pre-
eclampsia and eclampsia, infection, obstructed labor, and complications of unsafe abortion. Compared to global
figures, the number of maternal deaths is much higher in India because of limited access to and utilization of antenatal
care (ANC), lack of skilled practitioners attending deliveries, lack of emergency obstetric care (EmOC), and lack of
postnatal care (PNC). The reality is that encouraging women to deliver in certified and properly resourced medical
institutions can prevent the majority of maternal deaths.
Janani Suraksha Yojana
The Ministry of Health and Family Welfare (MOHFW), Government of India (GoI) launched Janani Suraksha Yojana
(JSY) in 2005 under the National Rural Health Mission (NRHM). JSY’s principal strategy links cash assistance to
institutional delivery with the premise that the financial assistance would remove the financial barriers which have
historically hindered women from accessing ANC, institutional care during delivery, and postpartum care.
Recognizing the need to increase the percentage of institutional deliveries, the GoI focused its attention on 10 low
performing states, including eight Empowered Action Group (EAG)1 states (Uttar Pradesh, Uttaranchal, Bihar,
Jharkhand, Madhya Pradesh, Chhattisgarh, Rajasthan, and Orissa) and the states of Assam and Jammu & Kashmir. In
Jharkhand, the JSY scheme was renamed as Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA) in 2006.
Under this scheme, a cash assistance of Rs 1400 is given to all pregnant women who choose to deliver in public health
facilities.
Purpose of the Evaluation
This evaluation aimed to determine the impact of cash incentives on the acceptability of the MMJSSA and
institutional deliveries in Jharkhand. The objectives were to evaluate the reach and utilization of services provided by
the scheme, effectiveness in its implementation (program management, social mobilization, and intersectoral
coordination), and impact (quality of care provided at the health facility) of the scheme. The evaluation relied on a
cross-sectional design that utilized both qualitative and quantitative research methods to obtain an in-depth
understanding of the implementation of the MMJSSA and issues related to the scheme from both the client and the
provider side. Mainly a qualitative approach was adopted to collect data from several categories of stakeholders
through in-depth interviews (IDIs) and focus group discussions (FGDs). Quantitative data were collected from
facility-based records. The National Family Health Survey (NFHS) and the District-Level Health Survey (DLHS) data
supplemented the quantitative data. Observations of 18 health facilities were done to determine the ability of a health
facility to provide ANC and PNC, skilled attendance at delivery, and EmOC.
Key Findings
1 Some of the states of India having high fertility and mortality have been termed as Empowered Action Group (EAG) states.
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Results from this evaluation regarding the reach and utilization of services suggest that women with below poverty line
(BPL) cards are benefitted by this scheme. However, the most vulnerable and marginalized women—Scheduled Caste
(SC), Scheduled Tribe (ST), Other Backward Caste (OBC), and the illiterate living in rural areas—were found to benefit
the least from MMJSSA’s attempts to promote ANC and safe delivery in health facilities. Overall, 52.2% of villages
had beneficiaries under MMJSSA but fewer than one-third of women were registered in their first trimester of
pregnancy. There was a wide variation in the proportion of pregnant women who had at least three antenatal checkups
across the study districts.
Even though the scheme has been successful in raising awareness in the community about the benefits offered
by MMJSSA, no special efforts have been made to reach the most vulnerable populations living in the most poor and
marginalized communities. Financial incentive is reported to be a major reason for utilizing services, but this assistance
was availed only by 2.8% of mothers. Vaccination, ANC, and facilities for institutional delivery were also reported as
reasons by beneficiaries for utilization of services. The evaluation also suggested that not all the beneficiaries were
aware of the purpose of the incentives. Some of those who were aware did not use the money for its intended purpose.
Mode and timing of the payment of incentives seemed to be one reason why the money was spent on things unrelated to
pregnancy.
In addition, the results reflect several critical issues related to implementation of the scheme. The most cited
issue was a lack of communication at all levels of health functionaries regarding the purpose of MMJSSA, individual
job responsibilities, and monitoring and disbursement of financial incentives. The majority of community-level workers
were not aware that the scheme was intended to promote institutional deliveries to reduce maternal and newborn deaths.
Beneficiaries reported difficulties in receiving incentives because of procedural requirements/documents and changes in
the disbursement policy (e.g., cash/cheque and split/single payment). Cash payment of transportation expenses to the
community mobilizers, Sahiyas, was perceived as an efficient way to encourage them to accompany pregnant mothers
to deliver in institutions. Concerns over increased workload and inability to provide services in already overburdened
health facilities were raised by all levels of health functionaries. Monitoring and evaluation systems were not being used
to show whether critical outcomes were being achieved (e.g., met need for EmOC, reduction in MMR, infant mortality
rate [IMR]).
Evaluation results suggest that there was a lack of joint action between the service delivery component of the
health system and program management under the NRHM for program planning and monitoring. Inputs from the
Primary Health Centers (PHCs) appeared to be minimal while preparing budgets. It was also apparent that the current
processes of fund release from the state to the PHC level suffered from problems involving procedural requirements,
delay in release and lack of funds, and bank-related issues. Also, beneficiaries (i.e., mothers and Sahiyas) raised
concerns over the procedural requirements involved in disbursement. Mothers and Sahiyas also perceived corruption
within the supervisory channels. Some of them complained that they received partial payments because those disbursing
the money withheld some of it for themselves. Also, beneficiaries expressed concern over not receiving their full
payment, frustration over the need for multiple visits to collect the money, and the frequent demands from Sahiyas for
getting payments.
The study also found that even though there was an increase in institutional deliveries in some regions, the
health facilities were challenged to meet the growing demand and as a result the quality of care was compromised.
Mothers who delivered in institutions cited the nonavailability of skilled attendants at time of delivery as an issue. The
findings also suggested that women were not being retained for the recommended 24-48 hours following delivery. The
quality of care during the postnatal period was also considered unsatisfactory. The study suggested that the Sahiyas
were not conducting home visits as per guidelines. When they did conduct home visits, they were not including some
key components of the visit, like recording temperature, checking for bleeding, teaching mothers how to identify
danger signs in their baby, and discussing family planning. There also seemed to be a lack of guidance on who from
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the health community should visit the mother and what services should be provided. In general, written guidelines
were available up to the district level, but were lacking below the block level and not available at subcenters.
Policy Recommendations
A. Expanding the reach of the scheme
1. Conduct three monthly ANC drives and special camps to identify, register the pregnant women from tribal,
SC/ST/BPL, and marginated communities and living in hard-to-reach areas to deliver antenatal services, and
mobilize them for institutional delivery.
2. Ensure operationalization of round-the-clock functional birthing facilities services within reach of the community
for encouraging and sustaining institutional delivery.
Operationalize the 24×7 PHCs, CHCs on an emergency basis, and wherever possible labor rooms in subcenters
can be considered for conducting normal deliveries.
Facility-level upgradation with provision of minimum requisite facilities (functional toilets, drinking water,
light, security for mothers and attendants) for comfortable stay of the mothers to encourage them to stay
longer.
3. Make proactive efforts to involve the private hospitals in the scheme for obstetric service delivery. The
professional associations (FOGSI, IAP, and NNF) and recently formed Consortium for Women, Newborn, and
Child Health (CWNCH) can be made partner to facilitate the process.
4. Improve transportation facilities and options including facilitation of the locally feasible options involving the
private players.
5. Develop and implement strategic multimedia communication packages to allay the concerns, misinformation, and
rumors regarding hospital deliveries addressing cost, surgical, and medical interventions involved in hospital
delivery.
B. Improving effectiveness of the scheme and quality of service
6. Make birth planning a mandatory part of antenatal service package delivered to the pregnant mothers and mention
it in the ANC card. During VHNDs/ANC sessions at AWC/village level, a special session on birth planning should
be included to assist and mobilize the pregnant mothers.
7. To overcome the impending constraints of space and manpower to deliver the services, risk stratification can be
done after birth to identify mother-child dyads who need to be retained for at least 48 hours after delivery and
mother-child dyads who can be discharged earlier.
C. Improving program management
8. Make the incentive payment system simple, prompt, and transparent with minimal documentation formalities.
9. Urgently orient functionaries especially the frontline workers on objectives, activities, guidelines, roles, and
responsibilities in the scheme using both face-to-face interaction and distribution of written document in local
language.
10. Ensure coordinated function during all steps of program development (planning, implementation, and
monitoring) between the program management and service delivery sections of the health department and make
VHSCs functional to improve coordination among frontline workers.
11. Restructure the monitoring and supervision process (person, frequency, and tool to be used), components to
be monitored (reach and quality of service delivery during ANC, delivery, and PNC apart from disbursement),
reporting mechanism and use of the reports for program refinement.
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FULL REPORT
1. BACKGROUND
The current estimated maternal mortality ratio (MMR)
100,000 live births.2 This translates to about 69,000
annually from pregnancy-related causes, such as
eclampsia and eclampsia, infection, obstructed labor,
of unsafe abortion. Three delays, namely delay in
deciding to seek care for an obstetric complication,
the health facility, and delay in obtaining the essential
facility contribute to poor outcomes of pregnancy in
constrained settings.3
JSY beneficiaries:
For Low Performing States (LPS):
All pregnant women delivering in
Government Health facilities including
Subcenters (SCs), Primary Health
Centers (PHCs), Community Health
Centers (CHCs), First Referral Units
(FRUs), general ward of District
Hospitals (DHs) and state hospitals or
accredited
private
hospitals
in India is 254 per
women who die
hemorrhage, pre-
and complications
recognizing and
delay in reaching
care at the health
resource-
irrespective of age of mother and birth
Compared to global figures, the MMR in India order of the child.
is much higher
because of limited access to and utilization of antenatal
attendance at delivery, EmOC, and PNC. High levels
women and limited maternal education also exacerbate
fact is that a majority of the maternal deaths can be
encouraging women to deliver in health institutions
personnel to ensure a safe delivery in a clean
GoI has made many efforts to increase utilization of
facilities for institutional deliveries by introducing
schemes. However, high maternal mortality continues
high at 2.5 times India’s MDG 5 of 100 per 100,000
In High Performance States (HPS):
Women delivering in Government
health facilities like SC, PHC, CHC,
FRU, general ward of DH and state
hospitals who belong to one of the
following categories:
Below Poverty Line (BPL)
pregnant women aged 19 year
and above, up to two deliveries
All Scheduled Caste (SC) and
checkup, skilled
of anemia among
the problem. The
prevented
by
with equipment and
environment. The
public
health
nationally funded
to be unacceptably
live births.
Janani Suraksha Yojana: The Government’s
maternal mortality
Scheduled Tribe (ST) pregnant
women
response to high
The MOHFW, GoI launched the centrally funded JSY scheme in 2005 under the NRHM as a modification to the
National Maternity Benefit Scheme (NMBS). JSY focuses on reducing maternal and neonatal mortality through
increased institutional deliveries. While NMBS was linked to the provision of a better diet for poor pregnant women,
JSY links cash assistance with antenatal care during pregnancy, institutional care during delivery, and postpartum care
immediately following a delivery and at home through the health center network found at each subcenter. JSY’s
principal strategy offers cash assistance to remove financial barriers hindering access to comprehensive maternity and
newborn care. It was envisioned that increases in institutional deliveries would in turn accelerate India’s progress
toward reaching the maternal and child health goals outlined in its national policies and the MDGs.
The JSY scheme: The beneficiaries
Recognizing the need to increase the percentage of institutional deliveries, the GoI focused its attention on 10 low
performing states that include the eight EAG states of Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh,
Chhattisgarh, Rajasthan, and Orissa and the states of Assam and Jammu & Kashmir.
2 SRS Estimates 2004-06, Registrar General of India.
3 Maine D, Akalin MZ, Ward VM, and Kamara M, 1997. The Design and Evaluation of Maternal Mortality Programmes. New York: Centre for Population
and Family Health, Columbia University.
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The scheme relies heavily on Accredited Social Health Activists (ASHAs) who assist the ANMs in carrying
out the scheme’s activities. These activities include identifying and registering pregnant women, preparation of birth
plan for each pregnancy, recognizing complicated pregnancies, determining appropriate referrals, and providing
antenatal checkup and postnatal visits as well as home care for the newborn.4 For the most part, ASHA’s function at
the grassroots level makes its importance in JSY’s overall implementation strategy paramount.
Jharkhand: Safe motherhood indicators
Jharkhand was created in 2000 as the 28th state of India. It is one of the states that consistently perform well below the
national average on each of the five safe motherhood indicators (NFHS III5 and DLHS III6). The development of the
health sector has not fared well either due to low health inputs, lack of resources, and poor governance. This has
adversely affected the quality of EmOC at public health facilities. As of 2007, Jharkhand had no fully functional First
Referral Unit (FRU) as defined in the National RCH II Program. Furthermore, universal coverage of all pregnant
women with an integrated package of quality antenatal checkup services as per national guidelines was 32.8%,
universal coverage of all eligible pregnant women under JSY scheme was 24%, and no health institutions in
PHCs/CHCs offered Adolescent and Reproductive Health Services (ARHS).7 By 2009, the picture had not improved
significantly.
Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA) in Jharkhand
MMJSSA, a derivative of JSY in the state of Jharkhand was initiated in 2006. Under the scheme, a cash assistance of
Rs 1400 is given to all pregnant women who choose to deliver in public health facilities. During the initial
implementation phase of the scheme, women received cash incentives during antenatal checkup registration and/or
first checkup and after delivery at a hospital, but under the current payment plan they receive cash incentive as a single
payment. In Jharkhand, Sahiya is the name given to ASHA in the JSY scheme and is the designated community
mobilizer under MMJSSA. The intended use of the cash incentives is to pay Sahiya for arranging transport at the time
of delivery, for her stay in the hospital at the time of delivery, for postpartum care of the delivered woman and for
follow-up of the child till Bacillus Calmette-Guérin (BCG) immunization.8 Under the MMJSSA, Jharkhand adopted a
split disbursement of incentive to mothers: Rs 500 at the time of registration and first antenatal checkup and Rs 900
after delivery at public health facilities or accredited
private hospitals.
The payment to Sahiya was the same as the national
Jharkhand
JSY guideline for
ASHA. Additionally, if the mother is not accompanied Safe Motherhood Indicators
by the Sahiya, she
also receives Rs 250 for transportation. In early 2009,
modality was changed to a onetime payment after
Jharkhand is predominantly a tribal state
difficult geographical terrain with mostly hilly and
Most of the tribal villages have very weak
communication infrastructure. To promote institutional
tribal women, referral transportation was initiated for
complications during pregnancy or delivery. In all
services have been made available for referral
Maternal Mortality Ratio (MMR)
312/100000 live births.8
44% women have had at least one
antenatal checkup during
pregnancy.4
1/4th of deliveries were attended by
a health professional.4
1/3rd of married women of
reproductive age are using
contraception.4
the split payment
delivery (Rs 1400).
characterized by
hard-to-reach areas.
transportation and
deliveries among
emergency
PHCs, ambulance
transport.8
Present scenario and challenges
4Frequently Asked Questions. http://www.nihfw.org/ndc-nihfw/UploadedDocs/JSY.doc
5 National Family Health Survey-III, 2005-06. http://www.nfhsindia.org/volume_1.html
6 District Level Health Survey-III 2006-07.
7 Program Implementation Plan on National Rural Health Mission (2007-08) Jharkhand, pg 42,
8. Registrar General of India—SRS 2004-06.
8 Program Implementation Plan on National Rural Health Management2008-09. Jharkhand.
http://mohfw.nic.in/NRHM/PIP_08_09/PIP_Jhar.doc
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Results from recent assessments of the JSY scheme and ASHA interventions have shown that major challenges
include management, functionality, and delivery and availability of quality of care and EmOC. There is an urgent need
for the development of a comprehensive strategy for motivating health functionaries in the existing system.
Some studies pertaining to the JSY scheme reveal that there are common challenges related to
operationalization and management. A few studies have attempted to determine why the scheme is not doing well, but
less attention has been given to its actual success or failure, the implementation of its policies, the management and
functionality of health facilities, the regulatory instruments and information feedback mechanisms, and the equity of
access and quality of care at the lower levels of the health services pyramid.
NRHM’s initial strategy to integrate vertical health and family welfare programs at the national, state, district,
and block levels9 was to ensure that provision of EmOC occurred in a safe environment and to promote institutional
deliveries by a skilled attendant. However, available assessments of public health facilities indicate that most of the
facilities are characterized by poor infrastructure (especially at the CHC and DH levels), lack of referral systems, long
delays and procedural complications, and low literacy among health staff. A study report ―Documentation of
Implementation of Mukhya Mantri Janani Shishu Swasthya Abhiyan, Jharkhand,‖ supported by UNICEF in six
districts of Jharkhand10 cited that women who had delivered in government health facilities complained of a lack of
water, electricity, medicines; unacceptable staff behavior; payment to middle persons; and failure to receive entitled
cash payments. Additionally, the report highlighted the problem of unavailability of 24-hour health staff as well as an
inadequate number of obstetricians, gynecologists, and pediatricians posted in public health facilities.
2. RATIONALE FOR CONCURRENT EVALUATION
Most of the studies on JSY conducted so far have been limited in scope, focusing on the benefits and obstacles of the
scheme without systematically assessing the process of program planning and implementation. There is a need to
know the reach, effectiveness, and impact of the scheme. Thus, apart from assessing the process of implementing this
scheme and making midcourse corrections to increase institutional deliveries, this evaluation was important for
determining the impact of cash incentives on the acceptability of the scheme. By exploring clients’ perspectives and
the scheme’s strengths and limitations, modifications could be identified and recommendations for improvement of its
implementation and management could also be made. A consultation meeting with the health officials, GoJ also
highlighted the need to assess the reach and effectiveness of the JSY scheme.
This concurrent evaluation assumes an even greater importance in the context of Jharkhand’s high proportion
of tribal groups. Despite a plethora of welfare schemes for tribal (and other deprived) areas, national and state-level
health service and health outcome indicators point to acute deprivation of tribal groups.11,12 Several recent studies
relate health outcomes and access to health services to socioeconomic characteristics.13 This study explores the issue
of access to maternal health services, focusing on the MJJSSA.
3. OBJECTIVES
The objectives of the study were threefold:
1. Reach and utilization of services
Determine the reach (coverage) and utilization of services under MMJSSA based on available data.
9 National Rural Health Mission 2005-12, Mission Document, Ministry of Health and Family Welfare, Government of India, 2005.
10 Barnes L, Jan SM, and UNICEF. ―Documentation of Implementation of Mukhya Mantri Janani Shishu Swasthya Abhiyan, Jarkhand‖ 2007.
11 www.nfhsindia.org
12 Maiti S, Unisa S, Agrawal PK. Health Care and Health among Tribal Women in Jharkhand: A Situational Analysis. Stud. Tribes Tribals,
2005;3(1):37-46.
13 Diez Roux AV. Commentary: Estimating and Understanding Area Health Effects. International Journal of Epidemiology, 2005,
doi:10.1093/ije/dyh328.
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2. Effectiveness of the scheme (process evaluation)
Document processes involved in planning and management, private sector partnership, and intra-
/intersectoral coordination for MMJSSA.
Assess social mobilization strategies designed to create awareness and increase MMJSSA demand in the
community and its reach to marginalized populations, including those living in tribal areas.
Identify the scheme’s strengths and limitations as well as local innovations.
Identify problems faced by various stakeholders which hamper the success of the scheme.
Understand the determinants of utilization and nonutilization of the scheme.
3. Impact
Assess the quality of care provided at the health facility.
4. TECHNICAL APPROACH AND METHODOLOGY
Study design: This research relied on a cross-sectional design that utilized both qualitative and quantitative research
methods to obtain an in-depth understanding of the implementation of the MMJSSA scheme and the issues related to
the scheme from the perspective of the client and the provider. IDIs and FGDs were used to collect qualitative data
from several identified stakeholders.
Quantitative data were collected from facility-based records. NFHS and DLHS data supplemented the
qualitative data. Observations of 18 health facilities were done to determine the ability of a health facility to provide
antenatal and PNC, skilled attendance, and EmOC.
Selection of study area: Given that Jharkhand is a state with specific districts predominately populated by tribal
people; districts were selected based on ―area effects.‖ In selecting the districts, it was assumed that tribal groups in
tribal majority districts were the most deprived in terms of access to health services and nontribals in districts with the
lowest tribal populations represented would be the least Figure 1: Map of the districts deprived. Urban
slum populations represented another scenario of deprivation.
sampled in Jharkhand
Districts were selected from five regional divisions and stratified based on the percentage of their ST
populations as either Tribal Districts (TDs), Nontribal Districts (NTDs), or Urban Areas (UAs). The selected districts
comprised two high percentage ST populations (TDs Gumla, and W. Singhbhum [Chaibasa]), three with the lowest
percentage of ST populations (NTDs Koderma,
Deoghar, and
Garhwa), and one with the highest urban population
(UA Ranchi) (see
Fig. 1).
Six blocks were selected using the same criteria
selecting the districts—percentage of their ST
instance, from a district identified as a TD, a block with
population was selected (Table 1).
employed
in
population. For
a maximum tribal
Table 1: Scheduled Tribe (ST) population in the
(census 2001)
study districts
S. No
District
ST (%) Block
Urban Area (UA)
1. Ranchi
33.97
Tribal (TD)
Slums
16
ST
(%)
NA
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2. Gumla
3. Chaibasa
Non Tribal
(NTD)
4. Kodarma
5. Deoghar
6. Garhwa
67.24
57.11
Bishunpur 89.34
Khutpani 83.86
0.81
Jainagar 0.22
7.39
Sarwan
8.39
10.58 Kandi
0.21
From every block, two villages were selected as epicenters—one nearest to the block PHC and the other
farthest from the block PHC. Using the selected villages as central starting points, the data collection team moved in a
clockwise direction and covered surrounding villages if necessary until the desired sample size was reached.
Key stakeholders
Managers, implementers, and providers: The study involved key Department of Health and Family Welfare (DHFW)
officials from state and district levels responsible for managing the MMJSSA scheme. Both public and private
providers from district and block levels directly and/or indirectly associated with the implementation of the JSY
scheme were included in the study.
Facilitators: Facilitators include village leaders, representatives of community groups such as Rogi Kalyan Samitis
(RKS) and village sanitation committees (VHSCs).
Beneficiaries (mothers): Beneficiaries of MMJSSA were women who had given birth within the last year at home or
in a health institution. Mothers were recruited at the village level.
Influential family members: Mothers-in-law, fathers-in-law, and husbands were selected for FGDs.
Sample size
In-depth interviews and focus group discussions: In all, 410 IDIs of different categories of stakeholders and 24 FGDs
of mothers-in-law and husbands/fathers-in-law were proposed.
Health facility observation: A checklist was used to
18 government health facilities selected within the
district, one DH, one 24×7 PHC, and one private
same block were observed. This component focused on
general infrastructure, availability of emergency drugs,
room and ward infrastructure, and equipment.
assess the status of
study blocks. In each
hospital from the
EmOC that included
anesthesia, labor
Development of instruments
A team of program evaluation experts, social scientists,
Figure 2: Study team at PHC Kanke
epidemiologists, and
anthropologists at the Central Coordinating Office
(CCO) conducted
several brainstorming sessions to identify key issues to
be evaluated keeping
in mind the interest of policy makers, program managers, implementers, and beneficiaries. Qualitative interview
schedules with open-ended questions were prepared. Structured formats were developed for observations at health
facilities. Topic guides for FGDs with mothers-in-law, fathers-in-law, and husbands were developed and aligned with
the study objectives. To check for reliability of answers, multiple questions were included in every interview schedule
probing the same domains dealing with the critical study objectives. Also, responses from different stakeholders were
compared for data triangulation.
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The draft instruments were developed by the Team Leader, Principal Investigator (PI), Project Coordinator,
and other CCT members in close partnership with the program managers, Maternal and Child Health Sustainable
Technical Assistance and Research (MCH-STAR) project personnel, United States Agency for International
Development (USAID), and investigators from all participating institutions. Topic guides for FGDs were based on the
objectives of the study. Instruments were translated into local languages. Before initiating data collection, pilot testing
of the instrument was done in Ranchi (Jharkhand). Based on the pilot results, schedules, observation formats, and
guides were finalized at a 4-day intense workshop in Delhi and a bilingual instrument was prepared with inputs from
all stakeholders.
Unique serial number: Every instrument was given a four-digit unique serial number that corresponded to an
individual stakeholder, FGD, or facility observation checklist. This system allowed researchers to effectively catalog
data anonymously by using a unique serial number, the district, category of stakeholder, and facility observed.
Secondary data analysis
In order to determine the reach and utilization of services under the scheme, the following state and district-level data
were collected:
Institutional deliveries
Deliveries facilitated by ASHAs
Institutional deliveries by trained birth attendants
The proportion of normal and complicated institutional deliveries
Utilization of the MMJSSA by women belonging to SC, ST, and BPL families
Total number of MMJSSA beneficiaries
Proportion of institutional deliveries that are MMJSSA beneficiaries
Provision of untied funds to different levels of health facilities
Creation and functioning of VHSCs
Availability of mobile medical units
Data from Health Management and Information System (HMIS) and other official statistics were collected
from district and state data repositories.
Implementation of the study
Central coordinating office: The project was coordinated by IndiaCLEN/IndiaCLEN Program Evaluation Network
(IPEN) in partnership with PFI. As this evaluation was a partnership, there was a PI and one Co-PI. In addition, a team
of research staff was stationed at the CCO to coordinate and manage network dynamics.
Central coordinating team: The CCT members included investigators, epidemiologists, gynecologists, social
scientists, health program experts, and representatives from the DOHFW.
State level: One state and two senior investigators from Ranchi Institute of Medicine (RIMS), Jharkhand and a partner
medical college were identified to assume responsibility for state-level coordination activities. They were also a part of
the extended CCT to support quality assurance measures.
Field level: Two junior doctors from RIMS and 12 Research Assistants (RAs) with social science backgrounds or
graduates in social work were recruited.
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Training workshops: Two main workshops were conducted to facilitate the process of implementing the study and for
quality assurance. The first was a regional workshop held in Delhi to finalize the protocol, study instruments, and the
methodology. The second was an orientation workshop and training with ―hands-on‖ field practice conducted in
Ranchi for investigators and field staff to develop a common understanding of the study objectives and protocol.
MCH-STAR team: Technical representatives from MCH-STAR actively participated in CCT meetings, reviewed all
draft documents, participated in the training workshops, conducted quality assurance field visits, and assisted the study
team in report writing.
Data collection
The PI, Co-PI, and state and senior investigators interviewed state-level JSY, and health officials. State and senior
investigators interviewed all district-level health officials. Two junior doctors and 12 RAs (supervised by the state and
senior investigator) constituted the field team. PFI provided additional research personnel involved in collection of
secondary data from health facilities.
Once the field team was in a district, they divided into two equal teams of six. One team conducted interviews
in one of the identified central villages in three pairs of two. The other team of RAs conducted interviews in the
second central village, also in three pairs of two. During interviewing, one RA was the designated interviewer and the
other the transcriber/recorder.
All the interviews were tape-recorded to give
conduct and validity of the interviews, to supplement
during transcription, and to cross-check data points.
for quality assurance measures intended to validate
that collected data were not compromised. The data in
were collected during May-June 2009.
Figure 3: In-depth interview with IDM
credence to the
missed statements
Tapes were also used
quality and to ensure
the selected districts
Quality assurance measures
The objective of quality assurance mechanisms at all
stages of project
design, implementation, and analysis was to minimize threats to the quality of data. The following activities were
undertaken for quality assurance:
State level: The state and senior investigators from the RIMS were responsible for quality assurance for all interviews
with stakeholders. At the end of each interview, the interviewer rechecked the completed instrument to ensure that no
questions were missed or left blank. At the end of each site visit, senior investigators checked all instruments and tapes
to ensure that they were complete. If the interview was rejected for any reason, it was replaced by another respondent
of the same category.
Quality assurance visits by CCT members: The CCT and extended CCT members made field supervisory visits to
ensure that proper interview techniques were being followed. CCT members observed all FGDs and a few IDIs. A
checklist was used when filling out quality assurance forms during the supervisory visits.
Data cleaning and quality assurance: The CCO randomly chose approximately 25% of the tape-recorded interviews
and cross-checked in their entirety against the transcriptions. Electronic copies of all interviews with health officials
were cross-checked against the hard copy for correctness and completeness. Soft copies of all the FGDs were cross-
checked with the audio tape and the hard copy for correctness and completeness of transcription and translation.
Monitoring network progress: An activity plan was prepared for field data collection teams to accomplish the targeted
number of interviews within the stipulated time frame. The state supervisor who sent updates to the CCO using a
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weekly log sheet monitored the progress of interviews completed during the week. Whenever the partner medical
college defaulted in sending the weekly interview log sheets, they were contacted via phone, e-mail, or fax to remind
them of the deadlines. The completed questionnaires were dispatched to the CCO after performing state-level quality
checks at RIMS.
Data triangulation: Responses obtained through IDIs and FGDs facilitated comparison for consistency. For internal
consistency, similar questions in every interview schedule were asked. Responses from the different categories of
stakeholders were matched for confirmation.
Data processing, analysis, and report writing
Responses were free-listed and then grouped into domains which emerged from the data. Free listing is an approach
used to isolate and define relevant themes. It is a useful first step when defining new domains and the best way to
ensure that the concepts and domains are culturally relevant and relate to the objectives of the study.
Reponses were coded according to the domains to which they belonged. Since some responses for a single
question could be placed in more than one domain, efforts were made to code them accordingly. The coded responses
were then entered into the computer using Microsoft Word under the supervision of the CCO and data were analyzed
consistent with stated objectives of the study.
The CCT, along with a team of anthropologists, interpreted final analyses and helped write the final report.
After a final meeting of the CCT and before the final version was printed, a draft report was circulated to all the
partners for input.
The results from the analysis were summarized and cross-tabulated by category of stakeholder. Adjectives like ―very
few‖ (<~10%), ―some‖ (~10-24%), ―approximately half‖ (~25-49%), ―A majority/over half‖ (50-74%), ―most‖ (~75-
89%), and ―almost all‖ (>~90%) were used wherever there was a need to reflect proportion of stakeholders expressing
similar opinions.
5. POPULATION CHARACTERISTICS, STUDY SITES, AND CHARACTERISTICS OF RESPONDENTS
Area profile
Jharkhand state has a total population 21,843,911 according to the 2009 Sample Registration System (SRS). About
28% of the total population in the state consist of ST and 12% SC based on the 2004-06 SRS estimates for Bihar and
Jharkhand.
The population characteristics of the study districts and key health indicators of the state are represented in
Tables 2 and 3.
Table 2: Study district profile
S. No. Name of Type of District ST Population SC Population
District
(%)
(%)
1
Gumla
Tribal
70
4
2
Chaibasa
Tribal
66
5
3
Garwah
Nontribal
16
24
4
Koderma
Nontribal
1
15
5
Deoghar
Nontribal
13
12
6
Ranchi
Urban-slum
36
6
Literacy Rate (%)
Male
Female
64
41
70
36
55
23
71
34
67
32
61
39
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Jharkhand
28
12
indicators of the state
Indicator
Rural
Urban
Birth rate
27.5
18.9
IMR*
49
32
MMR**
* SRS Oct 2009; ** SRS 2004-06, estimated for Bihar and Jharkhand.
68
39
Total
25.8
46
312
Table 3: Key health
In-depth interviews and focus group discussions
A total of 410 IDIs had been proposed; however, 405
conducted. IDIs included 144 mothers who had
deliveries (IDM) and an equal number who delivered at
data were supplemented with 24 FGDs with influential
(mothers-in-law, fathers-in-law, and husbands) (see
IDIs were
institutional
home (HDM). The
family members
Table 4).
Table 4: Number of stakeholders interviewed and
involved in FGDs
Figure 4: In-depth interview with HDM
In-Depth Interviews
State-Level Officers
Health Secretary/Deputy General Health
Secretary
(DGHS)/NRHM
Mission
Director/Director of Health (DH JSY)
District Level
Civil Surgeon (CS)
District Officer for JSY
Planned
Per Per State
District
(n = 6)
-
2
1
6
1
6
Rural Areas/Urban Slums
Medical Officer (PHC/CHC)
2
12
Accredited Private Facility, any Private Facility, 2
12
General Practitioner
ANM
4
24
Trained Traditional Birth
8
48
Attendant(TTBA)/SAHIYA/AWW
Mothers
Home delivery
24
144
Institutional delivery (ID)
24
144
VHSC member/Village Health and Sanitation
2
12
Committee Members/RKS members
Focus Group Discussion
Total 68
410
Mother in-laws
2
12
Husband/Father in-laws
2
12
Total
4
24
Conducted
Per District Total
(n = 6)
1
1
6
1 each in 5
5
districts
2
12
2
12
4
24
8 in 5 district
44
and 4 in one
district
24
144
24
144
2
12
63
405
2
12
2
12
4
24
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Health facility observation
Eighteen health facilities (DH, block PHC, PHC, or 24×7) were observed in six districts (three per district).
6. FINDINGS OF THE STUDY
6.1. Background characteristics of mothers
A majority of the mothers were Hindus, illiterate, between 20-30 years of age, and lived in kuchha houses (Annex. 1).
Mothers who delivered at home were more likely to be from SC/ST communities, without electricity and without a
BPL card; other characteristics were similar.
6.2. Reach (coverage) and utilization of MMJSSA
In order to determine reach and utilization of services under MMJSSA, state- and district-level data were collected to
understand the current scenario of institutional deliveries and home deliveries. Further, the effects of socioeconomic
and demographic factors on institutional delivery, delivery assisted by health personnel, and safe delivery were
examined in six study districts and the state level.
The DLHS-3 provided data on different aspects of maternal and child health (MCH) at the district level in
Jharkhand. For this study, DLHS-3 data on institutional and home deliveries of women who had a live birth in the past
3 years preceding the survey were analyzed. Since the implementation of the MMJSSA in 2006 and the DLHS-3 in
2007-08, an opportunity for secondary analysis availed itself to explore the initial effects of the scheme.
The study mainly focused on the delivery of care to women, that is, institutional delivery and home delivery
attended by health professionals. An institutional delivery conducted in public or private medical sector facility or
delivery at home by doctor or nurse or ANM or Lady Health Visitor (LHV) may be called a ―safe delivery.‖
Differentials in delivery care by socioeconomic and demographic factors in Jharkhand have been examined
through bivariate analysis. Since socioeconomic and demographic and health care behaviors are known to be
interrelated, it is necessary to understand the net effect of a particular socioeconomic and demographic factor on safe
delivery care after controlling the effects of other socioeconomic factors. For this purpose appropriate multivariate
analysis was undertaken. Since, the predictor variable (whether a woman had institutional delivery or a home delivery
assisted by a health personnel [safe delivery or not]) is dichotomous in nature, a logistic regression model was used to
analyze the net effect. The findings of this analysis are in Table 5 and are summarized below.
Key findings of select indicators from secondary data analysis (Table 5)
Fewer than one-third of women in Jharkhand registered in the first trimester of pregnancy. Women from
Ranchi, Koderma, West Singbhum, and Gumla reported higher registration during the first trimester than the
state average. Similarly, there was wide variation in at least three antenatal checkups across the study districts,
the highest in Ranchi (46.4%) and the lowest in Garhwa (20.3%).
The highest (27.4%) institutional births were recorded in Ranchi and the lowest (10.3%) in Gumla.
Only 2.8% of mothers had received financial assistance for delivery under MMJSSA by 2008.
Few of the pregnant women who reside in Ranchi, Gumla, and Deoghar districts were facilitated and
motivated by Sahiyas for ANC. No facilitation or motivation by Sahiya was recorded in Koderma and Garhwa
districts.
At the state level, 52.2% of villages had beneficiaries under MMJSSA in Jharkhand by 2008.
Almost all districts had some villages with a health and sanitation committee. RKS also exists in some of the
villages in the study districts except Koderma.
Table 5: Selected indicators on JSY in study districts in Jharkhand, DLHS-3
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Districts
State
Selected Indicators of JSY
West
Singbhum
Ranchi Kodarma (Chaibasa) Garhwa Gumla Deoghar Jharkhand
Maternal Health (%)
Mothers registered in the first
trimester when they were
pregnant with last live birth/still
birth
46.4
32.1
Mother who had at least three
ANC visits during the last
pregnancy
42.1
32.9
Mothers who got at least one
tetanus toxoid (TT) injection
when they were pregnant with
their last live birth/still birth
67.1
50.4
Institutional birth
27.4
27.1
Delivery at home and other places
assisted by
doctor/nurse/LHV/ANM
10.5
20.8
Mother who received postnatal
care from any health personnel
within 48 hours of delivery of
their last child
38.4
49.4
Mothers who received financial
assistance for delivery under JSY
7.4
3.7
35.0
20.6 36.4
29.3
30.9
40.4
20.3
30
27.2
30.5
65.2
52.7 62.6
44.3
54.9
21.9
10.8 10.3
16.2
17.8
10.9
14
6.6
8.4
8.9
25.4
24.2 27.5
28.5
3.4
3.3 3.0
3.0
29.0
2.8
Percentage of Women Who Received Assistance and Were Motivated by Sahiya for:
Antenatal care
1.5
0
0.1
0
2.1
1.5
0.5
Delivery at health facility
0.4
0
0.0
0
0.2
0.6
0.3
Source: International Institute for Population Sciences (IIPS), 2008.
Aggregate analysis of effect of socioeconomic and demographic factors
Aggregate analysis of the effects of socioeconomic and demographic factors on institutional delivery, home
delivery assisted by health personnel and overall safe delivery indicated that women who were most likely to
seek institutional delivery had the following characteristics: those who lived in urban areas, belonged to the
Hindu community, had 6+ years of schooling, were without a BPL card, married after 18 years of age, had 1-2
children, and had 3+ antenatal checkup visits (Annex. 2).
Overall, safe delivery was highest among women characterized by urban residence, non-ST/SC/OBC, 6+ years
of schooling, 15-29 years of age, with 1-2 children, and with 3+ antenatal checkup visits. Women of ST,
Christian women, illiterate women, and women older than 35 years had very low levels of safe delivery for
both institutional and at home deliveries. Women with BPL cards showed a higher proportion of safe
deliveries, in particular institutional deliveries, than those without.
Relationship between background characteristics of mothers and place of delivery: Several background
characteristics of the mothers were found to play a significant role in institutional delivery as well as in safe delivery
in Jharkhand (Annex. 3). The multivariate results show that ST women were the least likely to have an institutional
delivery/home delivery assisted by trained health personnel/safe delivery compared to non-SC/ST/OBC women,
followed by SC women. Only women with 6 and above years of schooling were more likely to seek institutional
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delivery, assistance for trained health professionals, and safe delivery compared to their illiterate counterpart. The
likelihood of institutional delivery is lower among those who do not have a BPL card. The likelihood of institutional
delivery and home delivery assisted by trained professionals decreases with the number of children ever born, for
example, those women with high fertility. On the other hand, all of these indicators show a significantly positive effect
with increase in the number of antenatal checkups. Religion does not show any significant influence on institutional
delivery, home delivery assisted by health personnel, or safe delivery.
District-level data were analyzed to understand the factors that affect district-level variation. However,
multivariate analysis could not be carried out due to an insufficient number of women in each category.
District results for place of delivery based on selected background characteristics: The district-level analysis shows
similar patterns with the lowest institutional deliveries in Gumla (10.3 %) and the highest in Ranchi (27.4%) district
(Annex. 4). An identical pattern was found in all the districts with different socioeconomic and demographic indicators.
Institutional delivery was the lowest among rural women, women belonging to the Hindu community, and women
without a BPL card. Non-SC/ST/OBC women had higher rates of institutional deliveries in all districts; however, in
Ranchi, Kodarma, and West Shingbhum, OBC women had better rates than those in the other districts. Institutional
deliveries decrease as the age of women increases and by the number of children ever born in all the study districts.
Conversely, institutional deliveries increase with the number of antenatal checkups in all study districts. There is
marginal variation in institutional delivery with pregnancy wastage.
6.3. Effectiveness of the scheme (process evaluation)
6.3.1. Planning, management, partnership, and coordination
Planning and management of the MMJSSA: MMJSSA has focused on increasing institutional delivery with special
attention to rural areas. In comparison to the national JSY scheme, the guidelines for MMJSSA were modified by
dividing the onetime payment in rural areas into two: Rs 500 during the antenatal period (Rs 100 for registration and
Rs 400 for the first antenatal checkup visit) and Rs 900 for institutional delivery. The payment to the Sahiya of Rs 600
was consistent with national guidelines (Rs 250 for arranging transport at the time of delivery, Rs 150 for a woman’s
stay in the hospital at the time of delivery, and Rs 200 for postpartum care and for follow-up of the child through BCG
immunization). There was also a provision of coupons—five coupons for each part of the payment. About 2 months
before data collection, the split mode of payment to mothers was changed to a onetime payment, that is, payment of
Rs 1400 after delivery.
MMJSSA guidelines: A majority of the district officers and almost all of the block PHC-level officers mentioned that
the guidelines were widely available at the health facilities and that the directives from the state were shared with the
staff involved in the scheme in the health facilities, in the field during the monthly meetings at the district, block, and
PHC level and at convergence meetings with the Integrated Child Development Services (ICDS) scheme. However, a
majority of the ANMs did not have the written guidelines of the scheme.
Orientation to the scheme: Some of the ANMs and a few Sahiyas could recall having received orientation specific to
this scheme. In only two districts (Deoghar and Koderma), AWWs were oriented to the scheme. Senior health officials
mentioned that CEmOC training happened in one district hospital, and BEmOC and SBA training had taken place in
some of the districts. Senior health officers acknowledged the importance and usefulness of training but expressed
difficulties in terms of a lack of interest on the part of health personnel in participating in training and challenges with
resource persons selected to conduct trainings.
“They provide help, but they do not provide actual training for this scheme.” (ANM)
“The LHV and nurse are trained, but they only tell us about effective implementation of the
scheme.” (Sahiya)
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Understanding the scheme’s activities: Most of the state-, district-, and PHC-level officials understood that the
purpose of the scheme was to reduce maternal and neonatal mortality, but this was not clear to the ANMs and Sahiyas.
The majority of the state-, district-, and PHC-level officials were aware that the scheme promotes institutional
delivery, but only half of the ANMs and some of the Sahiyas and VHSC members were aware of this intent. Most of
the respondents believed that this scheme was a form of financial assistance for pregnant women which is given to
them after delivery, and more than half thought the purpose was to improve ANC coverage. Identification of high-risk
cases and referral was mentioned by some of the district and block health officials but only by a few of the ANMs.
Motivation and mobilization of the mothers for institutional delivery by field health workers was perceived as an
important activity by most district and block health officials but only VHSC members only by some of the ANMs and
a few of the Sahiyas.
A majority of the RKS/VHSC representatives and some of the ANMs and Sahiyas reported the focus on
poor/BPL families as an important component of the scheme. Some of the Sahiyas and VHSC were unaware of the
activities under the scheme. Among the districts, none of the Sahiyas in the districts of Chaibasa and Garwah
perceived promoting institutional delivery as a part of the scheme. With the exception of the provision of financial
assistance and observed improvements in antenatal checkup, there was a marked decline in comprehension of other
key activities indicated in the scheme according to responses that range from the state stakeholders to those at the
village levels.
“Up until now, registration has been completed by the ANM and Rs 500 is given at the time
of registration. If Sahiya takes care of the beneficiary for 1 week and ensures that the baby
receives his/her BCG vaccination, then she also receives Rs 200 after 1 week. Here women
come to the center for registration and delivery.” (MO)
“I have not heard about this scheme. ANM didi comes once a month and does
immunization. ANM didi also doesn‟t keep us informed of our entitlements through
MMJSSYA. You are the first to inform us of this benefit.” (AWW)
Promotion of the scheme by the Government: A majority of the RKS/VHSC members were not sure or did not know
that the GoJ wanted an emphasis to be placed on effective implementation of the scheme. About half of them thought
that the government had been emphasizing disbursement of monetary incentives, better antenatal checkup and
treatment at hospitals. Very few were of the opinion that there was a focus on covering the poor.
“We see that the government has placed an emphasis on implementing the scheme in rural
areas. We will have to wait and see how many people will benefit from this scheme.” (VHSC
member)
Documents required for getting the incentive: There is quite a bit of confusion about which documents are required
for women to obtain the cash benefits. According to the MMJSSA guidelines, no documentation is required and non-
BPL mothers are also eligible. Almost all the district officers and MOs at PHCs knew that no documents or certificates
were required for pregnant mothers to avail benefits under the scheme. A majority but not all of the ANMs were also
aware about it. However, half of ANMs mentioned the need for a BPL card for release of payment to mothers.
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“No, we do not require any certificate separately. If there is signature of ANM or Sahiya
in the coupons, we do not require any certificate.” (District RCH- officer JSY)
“Beneficiaries need to present a vaccination card, a mother-child card, and the coupon to avail
the benefits. They look for Sahiya and ask for Red card.” (ANM)
Perceived roles of stakeholders: A majority of the district-, block-, and PHC-level officers perceived their role to be
one of active monitoring and supervision of the program activities, awareness generation, facilitating implementation
of the scheme (holding antenatal checkup camps, encouraging and supporting field workers), and solving problems.
Nearly half of the district-level officials and a few MOs reported monitoring the flow of funds as another key role.
Some of them mentioned that their roles included partnering with NGOs and departments. None of the district- or
block-level officers or the ANMs perceived that micro-planning was their responsibility under this scheme.
A majority of the ANMs, Sahiyas, and AWWs perceived their role to be one of providing antenatal checkup
and generating awareness among beneficiaries regarding scheme activities as well as actively motivating women.
Other perceived roles for ANMs included referring women for institutional deliveries and assisting them in getting
financial benefits. Half of the Sahiyas mentioned that they accompany women to the hospital and help them get proper
care at the hospital and conduct postnatal follow-up, including vaccination at AWCs. Only a few of the Sahiyas and
none of the ANMs mentioned their role in assisting mothers to develop a birth plan. Assisting women in getting
financial benefits, creating awareness among women about the scheme’s activities, and supporting Sahiyas in
arranging transport were mentioned as roles played by half of the RKS/VHSC representatives.
“We inform them properly about this scheme so that delivery can be done at the institution only.
Our role is to hold meetings with the staff thrice in a month in which we tell them about this
scheme.” (MO)
“When a woman is pregnant, then for her health I advise her to take TT vaccine and to eat properly.
When a woman is pregnant, we register her into the program. We also report their delivery.”
(ANM)
“I call the pregnant women and register them. I take them to the ANM to get medicine, money, and
timely vaccination/ immunization.” (Sahiya)
“I have no role in this scheme. I do not get anything.” (TBA)
“We organize meetings and camps to provide knowledge /awareness.” (Basti Vikas Manch Mahila
Samitte member Ranchi)
A majority of the district-level officers perceived that the MOs and nurses at the facility level and ANMs and
Sahiyas at the field level were critical to the program. MOs at the block PHC level mentioned ANMs and Sahiyas as
key personnel involved in the program. Few district officers perceived involvement of Sahiyas to be minimal.
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“Mainly ANMs are responsible. She has to provide ANC, give the TT vaccination, and visit the
women. Sahiya is a link between the health staff and the beneficiaries. So Sahiya has an important
role.” (Civil Surgeon)
“At village level there is no contact with Sahiya. Sahiya is usually a wife of an influential person
who acts as a Sahiya on paper alone and collects the money from the hospital. She does not even
touch the patient. This tendency is found in about 40% of Sahiyas.” (District RCH Officer-JSY )
Assistance provided to mothers by health workers under MJSSA: According to ANMs, they participate in awareness
generation, antenatal checkup registration, health checkups during pregnancy, and assisting mothers to get their
financial incentives. Mothers reported receiving antenatal checkup and advice on nutrition from ANMs, but none of
HDMs mentioned efforts of awareness generation by ANMs. AWWs mentioned their role in food distribution,
provision of dietary advice and antenatal checkups, and awareness generation regarding the scheme. According to
Sahiyas, their role appeared to be minimal and limited to antenatal checkup registration, awareness generation, and
assisting mothers in getting financial incentives. Some of the mothers perceived Sahiyas’ assistance as limited to
antenatal checkup registration, advice on diet and general care, and getting financial assistance (Annex. 5).
Services provided during ANC: About half of mothers in either category (HDM or IDM) had three antenatal
checkups. Apart from antenatal checkups, mothers mentioned cash benefits, TT, and receiving advice or counseling
during pregnancy and as part of antenatal checkup.
Planning for the delivery: A majority of the IDMs planned where they would deliver their baby and arranged for
money in advance. Others planned for transportation and other items, such as clothes, soap, a razor blade, and other
items. Half of these mothers did not decide in advance about whether or not to deliver in a hospital and a few had a
plan for home delivery. Among mothers who delivered at home, half had arranged for money. Some of the mothers
planned for transport and selected a hospital, but ended up delivering at home. Very few mentioned they had received
assistance from a health worker during the planning process.
A majority of the HDMs had not made any decision on where to deliver. Among mothers who had not planned
for a hospital delivery, some went to the hospital in an emergency situation. The Sahiya or ANM or AWW motivated
women. However, some of the mothers who planned for a hospital delivery ultimately delivered at home due to
exigency situations like premature labor delivery at night and lack of resources (e.g., transportation) to go to the
hospital.
“No preparation was done. We are poor people, who earn daily and eat. How can we deposit
money?” (HDM)
“I thought of delivery at home. But Sahiya came and told me to come along with her to
Bilaspur.” (IDM)
“I first went to Sadar hospital but there was no facility, so I went to a private nursing home.”
(IDM)
“We had to go suddenly; previously we thought that it would happen at home. But due to
complications we had to go to the government hospital.” (IDM)
Financial processes related to the scheme
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Process of fund release: This scheme is 100% centrally sponsored. According to senior-level officials, the fund flow
from state to district to PHCs and then to subcenters is periodic and based on demand. The disbursement mechanism
used in Jharkhand was a coupon system. ANMs distributed five coupons—two for the mothers (during pregnancy and
after delivery) and three for the Sahiya (for transport, for staying with the mother, and then after the child is
vaccinated). According to the district-level program managers, requests were made to the state to release funds before
the money was exhausted. At the district level, money was deposited with the district health society. Release of funds
to PHCs and CHCs was periodic and on demand. At CHC/PHC the fund was deposited with the RKS, which was then
released to the MO in charge of disbursing funds and of program management.
For release of funds from the district level to the PHCs, a utilization certificate was considered a ―must.‖ The
level of utilization that was necessary to satisfy the release of the next installment ranged from 50 to 70% among the
district-level officers. According to most of them, the fund for the scheme was earmarked in the state budget and there
was no scarcity of funds. The fund was released by cheque to the lower health facilities and from there to the clients.
The MO in charge and the Block Accounts Manager or clerks were the people responsible for the disbursement of
payment to clients at CHC/PHC level and for keeping expenditure records. Some of the PHC MOs also mentioned that
they submitted the statement of expenditure (SOE) at monthly intervals to the district authorities. Usual modes of
payment to clients were by cash (coupon) or cheques (both account payee and bearer cheques). The clients were paid
sometimes through the ANMs. In addition, beneficiaries who were receiving cash were now receiving cheques as a
result of a shift in payment method. However, many of the places were still using the outdated cash disbursement
system. For the payment to clients, a signature from the ANM and Sahiya were necessary as mentioned by the MO
PHCs and ANMs.
“If fund is not available at the district level, then we reallocate funds from other places like RCH
and make the amount available. Due to a lack of money or funding, the program should not be
affected.”(Civil Surgeon)
“If you have already spent 60% of the money, then you can request more money from the state.”
(District RCH Officer-JSY)
“Those PHC who have used 70% and above then we disburse money as per their requirement.”
(Civil Surgeon)
Budget preparation: Issues related to budgeting were discussed with state- and district-level program managers.
According to them, the central government provided complete funding for the scheme. Half of the civil surgeons were
not involved in preparing the budget for the district, but most of the district RCHO/JSY officers were involved in
preparing the budget for the district. Some of the district officers mentioned that the estimates from the block level
were also considered while preparing the budget. Final budgets for the district were prepared by the district program
managers and submitted to the state level for consolidation. The state-level program managers finalized the budget and
sent it to the central government for approval.
“We don‟t prepare the budget for this scheme at our level. This is prepared by the government and
concerned departments and they determine accordingly how funds are to be allocated.” (Civil
Surgeon)
“We are not doing budgeting of MMJSA. We have to do only the expenditure.” (Civil Surgeon)
Untied fund: As part of the NHRM, each subcenter is provided with Rs 10,000 as part of an untied fund-to-fund
urgent yet discrete activities that required relatively small sums of money. When asked about the knowledge and
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utilization of untied funds available at the village level, most VHSC representatives were not aware of such a fund.
The few who were aware of the fund responded that they had not received any money or the fund was not utilized
because of a lack of coordination between themselves and the ANM as well as a lack of clarity within the guidelines
explaining how to use this fund.
“Some money goes to the VHSC untied funds in the amount of Rs.10,000, however, besides there is
no guideline on how to spend the money. A lot of money has gone to the VHC but is not spent
because of lack of confidence.” (District RCH Officer JSY).
Disbursement of incentive to mothers: Most of the district-level officers, MOs at block PHCs and ANMs reported
that financial incentives were disbursed to the mothers by all three modalities: cash, cheque account payee, or bearer
cheque. There had been a shift from cash to cheque-based payments a few months before the survey, but some of the
facilities studied were still disbursing by cash. Most stakeholders reported that they were aware of the shift in payment
schedule which occurred a few months in to the survey and that the original split payment (Rs 500 at the antenatal
checkup registration and Rs 900 after delivery) was no longer being honored. Now, mothers received a single payment
of Rs 1400 after delivery in a government hospital. Almost all of the stakeholders mentioned disbursement of payment
to the mothers 24-48 hours postpartum. The reported payment mechanism differed among the districts and different
stakeholders. Most of the stakeholders mentioned having a mechanism for identification of the beneficiaries and
verification of documents before making a payment by cheque or cash, either by Sahiya, ANM, or hospital staff.
“Since March, the process has changed. People no longer receive money when they register. They
receive money only when they deliver their baby.” (Civil Surgeon)
“Payment against the coupon has been stopped now. Now Rs 1400 is given to the mother and it is
given postdelivery. If you don‟t have an institutional delivery, then coupon will lapse. Payment has to
be done within 24 hours.” (MO PHC)
“Now pregnant women don‟t get money before they deliver; they get money after delivery and they
get a bearer cheque.” (Civil Surgeon)
“So, it was decided to give bearer cheque at state level and we give the bearer cheque to the
beneficiaries. But if some Sahiya and some NGOs involved in the scheme say that they don‟t have an
account, in those cases we make a payment in cash.” (Civil Surgeon)
“We give them cash within 48 hours of delivery at the time of discharge.” (MO PHC)
“Since some days in it coupon of registration is given similarly, and payment is given, then
beneficiaries is identified its signature is taken, then after cheque is given. Before giving cheque
ANM, Sahiya, or any person will identify the beneficiaries.” (MO PHC)
Disbursement of incentive to Sahiyas: Most of the Sahiyas received their share of incentive by cash as well as by
cheque. No significant variation across the districts was observed. According to most of the stakeholders, payments to
Sahiyas were made in cash for the cost incurred for transport. For the other components (e.g., the stay at the hospital,
the PNC visit, and the BCG vaccination) a certification from the ANM was needed. Some of the stakeholders also
mentioned the need to verify from the mothers whether Sahiyas were in fact staying with the mothers and that they
were administering the BCG vaccination to their child before disbursing payment to the Sahiya.
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“Sahiya, who provides the service 24 hours, receives Rs 150 at the time the service is provided,
they also receive money after they serve the women, and then again when they visit the child 1
week after its birth. Once the newborn is vaccinated with BCG, Sahiya receives a certificate
from the ANM that the newborn is vaccinated then and only then do we release money
immediately to her.” (Civil Surgeon)
“Transportation cost is paid directly in cash because sometimes they use their money, some time
it is holiday, or Sunday hence we pay to Sahiya in cash form against her transportation
expenses.” (District RCH Officer- JSY)
“Sahiya gets a signed paper written by the patient stating that she took care of her for 1 week
after the child is born and that she gave the child BCG also.” (MO PHC)
Client perspective of purpose of financial incentive: Under the scheme, the purpose of the financial incentive is to
cover the transportation costs associated with institutional delivery, antenatal checkup, and postnatal care during the
first week after the child is born. A majority of the IDMs and HDMs who did not receive any money and even a few
who received money were unaware of the purpose of the money. Most believed that the money was given to improve
the nutritional status and health of the mother by consuming good food (e.g., milk, meat, fish, fruits, and vegetables).
They also thought that this would keep the baby healthy. Other reasons for the money mentioned included buying
medicine, tonics, and injections, transportation to health facility, and for other nonhealth purposes such as clothing.
Actual utilization of incentive money: When asked about how the mothers spent the money they received, half of
IDMs and HDMs reported that they purchased foods (e.g., milk and milk products, meat, fish, cashew) and medicine.
A few of them reported spending the money that they received on transportation to reach the hospital and others stated
that they purchased clothes for their baby or for themselves or household items. A few mentioned that the husband or
family members took the money away. When asked about the person who decided to use the incentive money, half to
a majority of mothers reported that they themselves decided how to spend the money. In some cases, family members
alone decided how best to use the money. About half of IDMs decided where to deliver in consultation with their
husbands.
“For buying clothes, oil, soaps for child and for myself.” (HDM)
“Sahiya gave Rs 350. Conducted birth ceremony, fed people with sweets because we had a boy. We
felt happy.” (HDM)
“Bought tonic, Horlicks, and medicine were taken.” (IDM)
“Received financial assistance and celebrated Chhathiyari (a ritual).” (IDM)
Delivery expenses incurred by families: The majority of the IDMs mentioned spending less than Rs 250 on
transportation to reach the institution. The majority of them spent more than Rs 500 on medicines. Half of them paid
more than Rs 250 to the hospital staff. Total spending by the majority of the IDMs was more than Rs 1000 and was
higher compared to the mothers delivered at home.
Private sector involvement in the scheme
Accreditation of private hospitals for the scheme: Senior officials from five districts mentioned having accredited
private hospitals linked to this program. The number of accredited hospitals varied from none to 12 per district. Two
of the civil surgeons were not aware of the number of private hospitals accredited under the scheme, but the district
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JSY officer was aware. In Garwah, no accredited private hospital was reported by district officials. A majority of
block PHC MOs and ANMs and almost all VHSC representatives were unaware of accredited private hospitals in their
area. A MO of one of the private hospitals mentioned non-renewal of the accreditation Memorandum of
Understanding (MOU) for the year. According to the officers, the huge differences in the fees charged at the private
hospitals and the money provided under the scheme were deterrents for attracting private hospitals to participate in the
scheme.
“In private hospitals the scheme is not available.” (ANM)
“We don‟t have any such hospital in our neighborhood. They do things on their own and we work
separately from them.” (ANM - 4112)
“No, I have not heard.” (Basti Vikas Manch Mahila Samitte member)
“We had an MOU with the Government regarding private hospital partnerships. Our MOU expired
this March.” (MO private hospital)
Understanding of the activities under the scheme: About half of the MOs in the private health facilities visited were
unaware of the activities under this scheme. The other half mentioned financial incentives to mothers, promoting
institutional delivery and improving antenatal checkup as the key activities. Out of the 12 private hospitals visited,
only two hospitals were accredited to participate in the MMJSSA scheme. However, none of the facilities had written
guidelines for the scheme. The MOs in these facilities denied having received any specific orientation on the scheme.
Among the MOs from the private sector, about half had knowledge of the need for documentation of the
payment of incentives. A few of them mentioned the need for a BPL card or SC/ST card for payment.
“When SC, ST, and BPL women are given services then for that caste certificate should be
available for BPL, BPL card should be there.” (MO private hospital)
Effect of the scheme on workload: About half of the doctors from private facilities included in the study thought that
there had been an increase in workload since implementation of this scheme. Doctors perceived that they had enough
staff at the facilities to handle the workload and there was no problem. Doctors from almost all the private hospitals
mentioned services being provided round the clock.
Number of deliveries in private hospitals: When asked about the proportion of deliveries conducted in private
hospitals under this scheme, a majority of the district- and PHC-level officers, ANMs, and Sahiyas were unable to
give any definite answer. The proportion of private hospital deliveries as perceived by various categories ranged from
less than 10% to more than 50% of all deliveries. All 12 private hospitals visited were conducting cesarean sections
and also deliveries at night. The proportion of caesarian sections in these private hospitals ranged from 13-75%.
Intra-/intersectoral coordination
Coordination among the field workers: Various types of stakeholders were asked about the level of coordination
among the field level workers like Sahiyas, ANMs, and AWWs in scheme activities. A majority to most of the
stakeholders opined that there was good coordination among the three grassroot-level functionaries. Most of them
thought that all three functionaries worked together in the field and met on specific days and cooperated in delivery of
maternal and child health services. The difficulties in coordination among health and ICDS workers in the field
mentioned by some of the stakeholders were:
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Conflict between AWWs and Sahiyas on incentives for scheme-related activities (e.g., AWWs not getting any
financial incentive)
Communication gaps and personal conflicts (e.g., ego problems)
Unsatisfactory performance of respective workers
Lack of clarity in role assignment leading to duplication of services
“There is lack of coordination. Sahiya is taking interest. ANMs do not have problems because
Sahiyas are doing the ANM‟s work. Since Sahiyas are getting Rs 150, AWWs are not taking interest
because they don‟t receive any financial incentives. Sometimes we feel that things were better when
Sahiyas were not there.” (District RCH Officer-JSY)
“Their mutual coordination is not good. In my view the government is paying the ANM and AWW,
but the Sahiya is getting nothing. The coupon that the Sahiya gets, ANM does not pay her for it so
there are differences.” (VHSC member)
Coordination for program implementation: According to health functionaries ranging from the district through
subcenter level, several mechanisms were reported to be in place to ensure smooth coordination for program
implementation. The mechanisms mentioned by respondents were monthly meetings at district, block, and PHC and
village levels. The village-level meetings were being attended by all field-level health workers and VHSC members
which offered the opportunity to come together and share or exchange ideas. According to stakeholders, meetings at
district and block levels offered opportunities for coordination with ICDS officials. Any gaps in coordination were
identified and solutions suggested during these meetings. Apart from the Health Department, the Department of
Women and Child was reported to be involved in the ICDS process as were the AWCs at the village level. According
to them, the program emphasized teamwork by sharing work related to antenatal checkup, immunization, and by
sharing common guidelines for ensuring uniformity in implementation. The program also stressed joint responsibility
for delivering services and the opportunity to raise issues with senior staff or involve them in case of any difficulty, as
reported by most of them.
“Sahiya meets with ANM once a month. It is compulsory that AWW, Sahiya, and ANM meet at least
once a month at the Anganwadi center on the day we are providing outreach services to the village.
Coordination is good; if there is any problem, we sort it out.”(Civil Surgeon)
“Ask anything to ANM didi she scolds, but doesn‟t tell you how to improve or any new information
about MMJSSYA. However, I work well with the AWW didi.” (Sahiya)
“I don‟t know at what time she (ANM) arrives at work or where she keeps her office. Sometimes she
calls then I go. Everyone gives their advice.” (Sahiya)
“Sahiya does not work. I have to do all the work alone because of which there is some difficulty.”
(AWW)
“From last October ANM has been misbehaving. One day though I was unwell, I reached late and
she complained to the CDPO. She conducts vaccination in the middle of the village. The
coordination is not good.” (AWW)
“Yes, CDPOs and Anganwadi workers are there. They have coordination among us. CDPO and CS
have meeting. Also in the meeting of Anganwadi, women are informed not only about Janani
Suraksha Yojana and immunization, but also about other health issues.” (State Level Officers)
Coordination with the senior officers: The scheme-related activities were coordinated with seniors at higher levels
mainly through meetings held at regular intervals. These meetings included individuals at the state, district, and
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peripheral levels and they occurred in person or by phone. Staff coordinated events through meetings with senior
officials during their visits to health facilities during training sessions.
A majority to most of the health functionaries at all levels had no difficulties in coordinating with their senior
officials for program-related activities. A few of the functionaries at different levels perceived that it was difficult to
contact seniors. Their reasons for citing difficulties included a lack of support from seniors, interpersonal conflicts
among health staff, and an absence of a mechanism to ensure coordination at the grassroots level.
“There is no difficulty. Whatever happens, we talk about it in the monthly meeting, what is said
there, it happens.” (Civil Surgeon)
“If there is confusion over anything or if we want to take some information, then we talk to state
RCH officer or state program officer directly. Resolve it over telephone.” (District RCH Officer-
JSY)
Coordination between the health system and private hospitals: Most of the district-level officials and some of the
PHC MOs perceived some problems while coordinating with private facilities. The difficulties they mentioned were a
lack of cooperation between themselves and the private hospitals, especially in recording and reporting, not attending
regular meetings, nondisbursement of incentives, and demands for advance funds. Private hospital MOs perceived
health officers to be less responsible. Regular meetings at the block and district level and discussion with staff from
private hospitals were mentioned as the mechanisms used to address differences. Measures used to solve these
difficulties included reviewing reports and MOUs on an annual basis, orientation of private providers, addressing
grievances through mediation, and supervisory monitoring.
“Look, we are not getting much cooperation from the private practitioners.” (State Level Officer)
“Some difficulties such as we ask them to send reports regularly, they don‟t send them on time. They
send one by one. Later on it creates problem in releasing fund. They do not send reports that they
are supposed to send every month. We can only release fund every month when we receive a
report.” (Civil Surgeon)
“There are small problems. They do not want to maintain records. They feel it is unnecessary and
that it is an extra burden so there is not enough cooperation.” (Civil Surgeon)
“But they do not want to keep it by saying that why we should keep coupons, why should keep staff
who will keep record.” (District RCH Officer, JSY).
Monitoring and supervision
Process of reporting: According to stakeholders at various levels, reports are generated as per a specific format
designated by each health facility level and submitted to the next higher level every month. A copy of each monthly
report is sent to the ICDS office as well as to the block and district levels. Some ANMs mentioned that they send
weekly reports of home deliveries and institutional deliveries to their MO. A common reporting format was being used
at the block level, but there was a separate format at the district level. Reports were usually transmitted to higher levels
by hand via courier.
It was also mentioned by the district officers that redundant measures of documentation were used at the
district level (i.e., Health Management Information System [HMIS] and hard copies). District officers felt that this
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added to workloads and it would take some time before streamlining could take place. Most reports were discussed
during monthly meetings at the PHC, block, and district levels.
Half of the Sahiyas kept records of activities, namely basic demographic data on beneficiaries, details of
antenatal checkup, child immunization, and payment of financial incentive on their own. Another half of the Sahiya
mentioned that they do not keep any records because they are illiterate.
Officials within the state health services division were unaware of reporting requirements and were not
submitting any reports. The RCH division of NRHM was reported to be responsible for compilation and use. The
health services division was minimally involved.
According to MOs involved at the district level, the information available from the reporting system helped in
program planning and improvement. The report was utilized for monitoring program activities. It was also used as a
guide for budgeting. The reports assisted in identifying gaps, reaching difficult-to-target areas, and developing plans
for follow-up with field staff to improve the reach of the program, according to district officers. Also, these reports
were used to identify the training needs of staff.
“We have no record. All records are kept by the ANM.” (Sahiya)
“I do not maintain a report of the activities done under this scheme, but I keep a record of money
given to the pregnant women.” (AWW)
“I write all the names, prepare the reports. Nurse has asked me to prepare the reports.”
(Sahiya)
Monitoring processes: A majority of district providers and MOs at PHCs opined that there were mechanisms in place
for monitoring the scheme-related activities. As described by MOs, these processes were based on verification of
incentive disbursements, monitoring of forms and reports received from different levels, field visit reports and direct
supervision of field activities, and monthly meetings at district, block, and PHC levels. The monitoring mechanisms
primarily focused on tracking the funds and beneficiary numbers from reports. Half of the providers mentioned that
program monitoring of activities was supplemented by cross-checking information collected by staff during monthly
meetings at PHC, block, and district levels and convergence meetings with ICDS.
Regarding supervision, a majority of district- and block-level officers mentioned that it was done through field
visits by supervisors on planned days such as routine immunization days or pulse polio days, routine contacts with
field workers, verification of records, and periodic meetings. Additionally, a few of them mentioned conducting
surprise visits. Half to a majority of district and PHC officers mentioned that there was no fixed schedule for
supervisory visits and monitoring. Some to half of them mentioned visiting the field once a week to twice a month,
while some of them mentioned visiting once a month or less frequently.
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“Monitors are available at the district level and supervisions are at PHC level. LHVs have 3-4
subcenters to visit. We visit personally homes where Sahiyas have identified the pregnant
mothers.”(District RCH Officer-JSY)
“There is no mechanism for Sahiya monitoring in our area. Yes, our ANM tell which Sahiya is
working well and who isn‟t working well like she brings children to the subcenter or AWC. ANM
reports that this Sahiya is performing well.” (MO)
“Subcenter or field visit. A checklist has come for monitoring of SBA. We talk on this point. I help
them in their monitoring. Monthly registration should be done. We discuss all this in monthly
meeting. We do spend many hours in monthly meeting.” (MO)
Tracking of beneficiaries: Regarding mechanism for tracking beneficiaries and cross-checking appropriate
disbursement of funds, a majority of the district officers, PHC Mos, and ANMs mentioned that the beneficiaries are
being tracked through house visits by ANMs or other supervisors like LHVs. Additionally, they also mentioned
undertaking cross-verification of records or available documents. NGOs also carried out cross-checking in some areas
reportedly. The focus of tracking was primarily on the number of beneficiaries and funds disbursed. Half of the
providers were of the opinion that no cross-checking is needed as the payment was made by cheque or in the presence
of higher responsible authorities.
“Yes, we have this mechanism, one supervisory staff is present or at some place there are local
NGOs, CBOs also do and our health staff, the supervisors, doctors do as well.” (State Level
Officers)
“We have NGO coordinators in each PHC whenever they come to PHC they identify and list the
women who have not received cash/payment and to report to the MOIC. Instructions have been also
given to MOIC to ensure payment of left out women.” (Civil Surgeon)
“For cross-checking we have our Sahiya, Anganwadi sevika, and local staff. In case of any problem
they complain.” (MO)
6.3.2. Social mobilization strategies
Awareness generation: The perception of providers and VHSC members was explored to identify the most effective
channel of communication in order to motivate communities to utilize services under the scheme. Half to a majority of
all stakeholder categories thought that interpersonal (one-to-one) communication by health functionaries (e.g., during
house visits and contact with the health system) was an important channel of communication. Half of the district
officers, PHC Mos, and ANMs mentioned village-level meetings as an appropriate channel. Use of mass media (e.g.,
TV, radio, newspaper, mike announcement, street plays [Nukkad Natak], displays of banners/posters, and distribution
of pamphlets and printed materials) was mentioned by a majority to most of the officials from district level to PHC
level. Spreading messages through NGOs was mentioned by a few of the district and PHC MOs. There were no
differences in suggestions made by key informants on how to improve awareness between the tribal and nontribal
districts.
Half to a majority of all the health functionaries did not remember any special effort being made to raise
awareness specifically among poor and marginalized populations. Half of the stakeholders mentioned house-to-house
visits conducted by Sahiyas and NGO members to raise awareness about the scheme, announcements in local
languages in villages on immunization days, and village-level meetings as effective ways to disseminate information
to beneficiaries. Half of stakeholders mentioned monetary incentives as an attraction for the poor. Few of them
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mentioned any priority in registration for antenatal checkup or payment of incentive to them. Few stakeholders
perceived that the Sahiyas were supposed to do this activity.
“Sahiya, AWW, these people organize meetings in the villages they tell us and time to time we are
provided knowledge.” (Civil Surgeon)
“Since the government has selected Sahiya, the health of the mothers has improved because Sahiya
goes to each and every house of the region and communicates very well. She is giving iron tablets
to the mothers to eat daily.” (Mother in law, Institutional, FGD-4175)
“First in IEC, hoardings and pamphlets are made, which are to be in PHCs and subcenters.
Second is our ANM who conducts village discussion.”(District RCH Officer, JSY)
“Posters, newspapers, advertisement are best communication medium.” (MO, private hospital)
“There are peer educators in the villages. They are paid to spread the messages in the village at
household levels. Peer educators create awareness through banners.” (MO)
“I spread the knowledge in convergence meeting to the staff, ANM, and Anganwari worker with
Sahiya .They spread the messages by going door to door.” (MO)
“ANM and AWW together give information regarding this scheme at AWC.”(Sahiya)
“People are informed through house visit about this scheme. Sahiya was elected from this area. This
area is not too big so whatever thing happens it is informed through household visit. People come
together in Anganwadi and get information especially on the day of immunization.”(VHSC)
“We have not done any special effort. Additionally, in hard-to-reach area this is not necessary that
especially we go there for JSY.”(District RCH Officer-JSY)
“We make them (ANM) understand in the meeting. She is supposed to go door to door to search
women for registration whether they are from BPL or any level.” (MO)
The role of various local partners: The role of nongovernmental organizations (NGOs)/community-based
organizations (CBOs), VHSC, local leaders, family members, women’s groups, and traditional birth attendants
(TBAs) in supporting scheme-related activities was explored from all stakeholder perspectives.
Involvement of NGOs: State-level officers acknowledged the involvement of NGOs in training the health workers.
However, a majority of district-level officers and MOs in the PHC, ANMs, and Sahiyas felt that NGOs did not play
any role. About half of the district officers and some of the ANMs who acknowledged the NGOs role in the program
mentioned their involvement in recruitment of Sahiyas and training of health workers, awareness generation,
monitoring of the program, and facilitating transportation for the mothers to the facilities.
Village Health and Sanitation Committee (VHSC), women groups, and local leaders: State and district officers
believed that VHSC/VHSCs assisted in awareness generation, recruitment of Sahiyas, and registration of pregnant
women. A majority to most stakeholders did not see any role played by women’s groups. Some stakeholders
mentioned that these groups were involved in raising consciousness. All stakeholders also perceived the role of local
leaders as negligible.
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Mothers’ awareness about the program: Half of ANMs believed that mothers knew about the financial incentives,
vaccination, and antenatal checkup provided under the scheme. Some of them believed that mothers knew about the
free treatment provided at hospitals and the support available for transportation. Most of the mothers from both
categories, that is, HDMs and IDMs, reported that they had no knowledge of the MMJSSA. A few responded by
saying they had heard about the name of the scheme, but did not know about the specific benefits. A few were aware
of benefits like money, food items, and medicine as part of this scheme. When probed specifically about monetary
incentives, a majority of them recalled that there is a scheme that provides financial assistance to pregnant women.
When asked about nonmonetary benefits, some respondents mentioned food items, vaccination, medicines, iron folic
acid (IFA) tablets, and vitamins. Covering the cost of transport to the hospital was also talked about.
Apart from interpersonal communication maintained by ANMs, AWWs, and Sahiyas, few of the clients
learned of the scheme from their family members, neighbors, or peers. Health workers (ANMs, Sahiyas, or AWWs)
motivated half of the mothers for antenatal checkup registration. Family members played an important role in
motivating mothers for antenatal checkup registration and continued care. Some mothers made the decision by
themselves.
“Nothing is available in our village. Those people will only know who got money in their village. I
don‟t know because in my village we don‟t get anything.” (Home delivered mother)
“Many people do not know about the plan run by the government. That‟s why they are unable to
reach there.” (Father in law, institution delivered mother)
“Sahiya had told me that on going to the government hospital one gets free injection, medicines,
and money also, so I went.” (Institution delivered mother)
6.3.3. Strengths, limitations, innovations
Strengths/Impact of the program: The state and district program managers were asked their perceptions regarding the
impact of MMJSSA on maternal health in Jharkhand. Almost all of them were of the opinion that the expectations of
the scheme had been met since institutional deliveries had increased and maternal mortality had decreased. Awareness
about program services had also improved among beneficiaries and more and more were utilizing the benefits under
the scheme.
Benefits to the clients: Antenatal registration and care was perceived as a benefit from the scheme by almost all the
mothers, irrespective of the place of delivery. Half of the HDM mothers and a majority of IDMs identified financial
incentives as the other key benefit. Some to half of the mothers expressed availability of rations (e.g., supplementary
nutrition), IFA tablets, vitamins, and vaccination as other benefits. About half of the mothers in either category did not
perceive any additional benefit from the scheme. Almost a quarter of HDMs and IDMs did not receive any benefit
under the scheme.
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“Received coupon but I haven‟t received cash. I have filled the coupon and madam has taken it, but
I have not got the money.” (Institution delivered mother)
“Received financial assistance and celebrated Chhathiyari (a ritual).” (Institution delivered mother)
“I got Rs 400 in which nurse took Rs 100.” (Home delivered mother)
“Under this scheme got Rs 500 and it was spent on buying medicine and fruit.” (Home delivered
mother).
Effect of MJJSA on referral of mothers: The most important reasons for referral to a higher facility included
complication during delivery and high-risk pregnancies. Lack of manpower (nonavailability of doctors, anesthetists,
and other staff during night) and lack of facilities (blood transfusions) were other reasons reported by a few MOs and
ANMs. According to few of the block PHC MOs, the provision of vehicles were being made or facilitated by the
hospital for referral, but this facility existed even before the scheme was introduced.
“Lots of changes in referral have occurred. In cases of any complication, cases are referred from
PHCs for proper treatment such as cesarean here.” (Civil Surgeon)
“Suppose there is obstructed labor or a patient has to undergo a cesarean section which is not
possible at the PHC level, then we make arrangements.” (Civil Surgeon)
“If there are complications, for example anemia, obstructed labor, cord prolapse, hand prolapse,
breach presentation, eclampsia, pre-eclampsia, etc that can be done at the district hospitals,
therefore for these reasons we refer them.”(Civil Surgeon)
Possible influence on existing infrastructure in health facilities: Responding to a question on changes in
infrastructure at the health center, a majority of the state- and district-level officials and MOs at PHCs perceived
significant improvement in health facility infrastructure after the scheme was introduced. About half of the
stakeholders from state level to ANMs mentioned improvement in the availability of equipment, medicines, and
supplies as well as facilities for investigation after implementation of the scheme. Nearly half of the MOs reported
improvement in basic amenities such as electricity, generator, and water supply at the health facilities.
“Enough changes have occurred. Today our hospital has enough equipment, is warmer, and the
needed facilities are all available. Without this scheme hospitals would not get such facilities.
People are benefitting from this scheme.”(Civil Surgeon)
“Certainly some change has occurred like earlier the labor room was not there, after this scheme
was implemented, the labor room was made. (MO)
“My health subcenter was repaired; earlier it was in bad condition. Now we have a chair and
table; we also have a special table to do the checkup.” (ANM)
Possible influence of MJSSA on existing health services: According to half to a majority of stakeholders, there was
improvement in overall availability of medicine and supplies with this scheme. After inquiring about the difficulties
faced by the functionaries at different levels, a majority of the district providers, block PHC MO, and ANMs reported
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that there was no difficulty in this regard and that sufficient stock was available. Most of the officials from the district
and block PHCs mentioned that they have 24-hour facilities with doctors and other staff on duty, including at night to
promptly attend to women in labor after routine working hours. However, nearly half of PHC MOs and some of the
district providers and ANMs mentioned nonavailability of equipment and an interrupted supply of electricity. Nearly
half of ANMs and some of the MOs mentioned scarcity of medicine as a problem. Problems with transport of
medicine to peripheral centers and lack of laboratory facilities for investigation were also perceived as problematic by
a few MOs and ANMs.
“Women have become more aware. Mothers and children are taking the recommended vaccinations
at the appropriate time.” (AWW)
“There have been changes among people. This scheme has helped for women to go for
institutionalized delivery.” (Sahiya)
“A lot of positive change has occurred. My baby remains healthy. A lot of change in child
vaccination has occurred. Previously females did not vaccinate their child but now they ask where
ANM is, why they don‟t come.” (Sahiya)
“Earlier many women went home for delivery, but now there is a lot of improvement. Now many
women go to hospital; very few women deliver at home.” (AWW)
Changes in utilization of MCH services: Almost all Sahiya and AWWs perceived that the scheme had improved the
utilization of maternal and newborn health services in their areas. Increased institutional deliveries, increased
utilization of immunization services (for mother and child), and nutritional services were the major improvements they
perceived. Some of them also mentioned that the role of Sahiyas and AWWs were more accepted and recognized by
the community. A few also mentioned improved use of Anganwadi services.
Changes in health of mother and newborn: All stakeholders were asked about the impact of the scheme on maternal
and newborn health in their area. A majority to most from all categories of respondents perceived a reduction in
maternal mortality as one of the major impacts of the scheme that occurred as a result of delivery at institutions,
improved hospital facilities, and better quality services. Similarly, half to a majority of stakeholders thought that there
had been improvement in nutritional status and reductions in anemia among mothers as a result of the scheme. This
was perceived as an achievement due to utilization of proper antenatal checkup and improved affordability by way of
financial incentive offered under the scheme. Half to a majority of district officers, MO, and ANMs perceived that the
decrease in infant mortality was the major impact on child health. Nearly half of the MOs and ANMs mentioned
improved child health by way of improved coverage of immunization and vitamin A. Awareness about program
services and adoption of healthy maternal and childcare practices like family planning and breast-feeding were
perceived as an impact of the scheme by half to a majority of MOs and ANMs.
“Decrease in the maternal mortality rate and increase in institutional delivery.” (District RCH
officer-JSY)
“In maternal and child health schemes many improvements have been done. Earlier child mortality
rate was high and now it has been reduced.” (District RCH 0fficer-JSY)
“Hospital delivery has increased and maternal death has gone down.”(ANM)
“Earlier they got their delivery done by untrained Dai, but now they come to the hospital, or if they
are not able to come, then they call trained Dai or nurse for delivery.” (ANM)
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Effects on other public health activities: About half of the district- and block PHC-level officers and ANMs were of
the opinion that the scheme had increased general awareness regarding public health programs. Respondents thought it
had helped increase the coverage of immunization and vitamin A and that it had had a positive impact on other
national health programs like tuberculosis control and family planning due to better contact with the health system and
functionaries. Some of the MOs and ANMs perceived no impact on other health programs.
“Qualitative improvement has taken place in the work system of ANM and LHV. Manifold quality
improvement has taken place. By seeing the report it looks like that the number of institutional
deliveries has increased. From 15-16% it has increased to 80% due to MMJJSA scheme.” (Civil
Surgeon)
Influence of MMJSSA on the workload of health care providers: Most of the respondents mentioned that their
workload had increased after implementation of this scheme due to increased numbers of hospital deliveries and the
need for extended work hours. Disbursement of financial incentives and maintenance of accounts also increased the
workload of PHC MOs. From the perspective of ANMs, the increase in workload was due to an increase in antenatal
registration and coupon distribution. The need to explain and convince clients about the scheme and its benefits added
to the workload of the staff at the health facilities and in the field according to a few ANMs and PHC MOs. Some
stakeholders opined that the increased workload was being managed by extending workdays and by hiring additional
manpower by posting specialists in hospitals or specialists working as generalists. Some of the civil surgeons and a
few of the ANMs, however, did not perceive any increase in workload due to the scheme.
“Yes, the workload has definitely increased. The environment of PHCs has changed and it has
become more crowded; people come and go 24 hours a day. The timetable of the labor room is not
fixed; 24 hours there are patients.” (MO)
Limitations of the scheme: Manpower-related issues (e.g., shortage of staff, nonavailability of trained staff, excess
workload), facility-related issues like space constraints, and nonavailability of equipment and drugs were mentioned as
the difficulties faced by health care providers. Other problems reported by some of them included clarity and changing
scheme guidelines, poor compliance from beneficiaries, procedural delays, shortage of funds, and lack of clarity in
modes of disbursement.
Increases in the number of institutional deliveries and a concomitant shortage of staff were viewed as
presenting a difficult situation to be handled by just a few MO PHCs. Disbursement of financial incentive and
maintenance of accounts was seen as an additional burden by PHC MOs. A few of them also mentioned that the
provision of monetary incentives in the scheme was having a negative impact because beneficiaries of other programs
were also expecting the same.
A few MOs, half of the ANMs, and RKS/VHSC representatives pointed out that the scheme had a minimal
impact in rural and inaccessible areas and among the poor, especially those without BPL cards.
Most district-level officials remarked that even though many of the program expectations were met
satisfactorily, there was room for improvement in a few areas, such as timely disbursement of benefits, adequacy of
resources, and quality of services to maximize the effectiveness of the scheme.
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“Due to lack of staff, I am overextended. So there is a problem. There should be two nurses
here.” (ANM)
“There is less staff. Only an ANM is working. Nobody knows about the time of delivery in the
night. I reside here 24 hours. I face difficulty in residing and managing.”(MO)
“Transportation is a problem from the residence to the hospital.” (Sahiya)
“Till now, no kind of problem has been encountered; I‟m rather enjoying work.” (AWW)
“Many times there is no electricity, so it becomes problematic to conduct deliveries. Life-saving
drugs should be available and they are not available.”(MO)
“We do require some equipment like x-ray, ultrasound facilities, blood test like blood sugar
hemoglobin, TLC, DLC, and urine should be done otherwise it‟s a problem.”(MO)
"Earlier money or coupon had to be given for all children. Now it has to be given for up to two
children only. So there is a fight in the village. People with 8-10 children also want money. They
quarrel because village people do not understand. They say that other have got why not they are
getting.” (ANM)
Local innovations
Attempts to solve the problems: A majority of the district officers, PHC MOs at and ANMs did not respond to the
question about efforts made by various stakeholders to address the difficulties faced by the beneficiaries. Almost all of
the Sahiyas and VHSC members remained silent on this issue. Some of the innovations identified included:
Managing funding shortages by reallocation from other budget heads
Streamlining disbursement of backlog payments by arranging camps
Disbursement by bearer cheque, on the same day of delivery, and involving the Sahiyas and ANMs as
solutions to the problems related to disbursement
Faster disbursement on the same day of delivery
A speedy mechanism for addressing grievances
Providing pink clothes to girl and blue clothes to boy babies to improve client satisfaction
The grievance management mechanism: The stakeholders from state to Sahiya and VHSC representative level were
asked about the existing mechanism for addressing grievances at their facilities. About half to a majority of the
stakeholders across the levels mentioned that the grievances were solved at the local PHC level by the MOs. In case of
difficulty, the matter is referred to district officers. A few stakeholders did not know about any mechanism, and a few
Sahiyas and VHSC members expressed their dissatisfaction with the response from the concerned officers.
Interestingly, other opinions indicated that there were no problems requiring a mechanism to lodge a complaint.
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“These are the three stages for addressing grievances. Mostly all the complaints are sorted out
there. If in case it does not happen, they complain to RCH office or the civil surgeon. Mostly all the
problems and complaints are sorted out at the MOIC.” (Civil Surgeon)
“I, as the MO in charge, conduct inquiries into the problem. If it could be solved at my level, then
fine, if otherwise, then I forward the complaint to the next higher authority.” (MO)
“I have complained to the doctor, but they say that I should not do this and nothing is said to
resolve this.” (Sahiya)
“How will he complain, when is his pocket filled up with money in advance? Now, you accept the
complaint or keep it in your pocket.” (VHSC member)
6.3.4. Scheme success-hampering problems faced by various stakeholders
Difficulties faced by beneficiaries while availing services: Most mothers who delivered either at the hospital or at
home did not report any difficulty. However, a few to some mothers did report difficulties related to inadequate
facilities and services, harassment by staff, no checkup during antenatal checkups and nondisbursement, partial
disbursement or delay in getting the money, and the need for multiple visits.
“After delivery, I spent 1½ hours in the hospital. The nurse says that everything is all right and you
can go to your home. Then we came back to our home.” (IDM)
“I stayed 24 hours, after that I decided to go because the bed was dirty, there was no electricity,
and the place had mosquitoes.” (IDM)
“After 1 hour, my family members insisted to go because it was cold. There was no facility. After
checking the doctor was also gone.” (IDM)
"I stayed there only 10 minutes. I was bleeding. Without making discharge slip, nurse told me to go
home. Nurse is not paying attention so I was not in the mood to stay.‟ (IDM)
Difficulties faced by ANMs and Sahiyas in the field: When ANMs and Sahiyas were asked about difficulties they
encountered while accompanying or attending women in labor, nearly half of them reported problems with transport
particularly at night, lack of communication facilities, and fears about personal security (resulting in their own
reluctance and objection from their family members). ANMs also expressed their inability to conduct home deliveries
because they have no experience in tackling complications and due to lack of medicine and instruments. ANMs and
Sahiyas from tribal and nontribal districts reported similar types and frequency of difficulty.
“There were difficulties, but I had to go. I had to leave my child at home and go. There was a problem in
locking the door and somebody asked where I was going at night.”(Sahiya)
“Vehicle problem arises. After 10 p.m., guardians tell to deliver at home due to vehicle problem. Here the
condition of road is also not good. When delivery happens at night, then our elders say not to go to hospital
due to lack of transport facility.” (Sahiya)
“There can be problems at night. A staff member was killed and discarded. We don‟t go alone at night,
cannot go alone. I will not go.” (ANM)
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Delay and difficulties in fund release at state/district level: About half to a majority of the district officers and PHC
MOs, who perceived problems in fund release, mentioned that the delay had been due to a lack of funds and delayed
release from the state to district. Another half of the district-level officers perceived delays in disbursement to PHCs
and subcenters due to nonsubmission of utilization certificate. Some of the subcenters also perceived the absence of a
bank at the places where the PHCs and subcenters were located as a difficulty for fund transfer. Nearly half of district
and block PHC MOs did not mention any problem regarding fund release.
Perceived problems of accessing funds by beneficiaries: Problems faced by beneficiaries in getting money under the
scheme were elicited from all the stakeholders, including field-level functionaries. About half of the state- and district-
level stakeholders considered staff-related issues as reasons (e.g., absence of staff, bad behavior, shifting
responsibility, and corruption) for difficulties faced by the beneficiaries. Another cited lack of funds, bank, and cheque
payment-related issues (not having bank account, absence of banks in some areas, shortage of cheques) as reasons.
Some to half of them also experienced difficulties because of official procedures like the need for documentation and
repeated visits to get the money. A majority of Sahiyas mentioned bribe and favoritism in making the payments as
additional difficulties by the beneficiaries. Most of the state-level stakeholders to the level of Sahiyas stated that they
were not aware of any problem faced by the beneficiaries to get money under the scheme.
Difficulties faced by the mothers in getting the incentive: Half of the IDMs and a majority of HDMs did not receive
any financial incentive. About half of the IDMs received full payment of the incentive, either split payment or lump
sum. Some of the IDMs received partial payment only and in most of the cases the second payment (after delivery)
was missing.
Among IDMs who received the payment, almost all received the money after 7 days of delivery. Some of the
mothers mentioned problems such as the need for repeated visits, required documents, and demand for bribes.
“I received coupon, but I haven‟t received cash. I have filled out the coupon and Madam has taken
it, but I have not received the money.” (IDM)
“Money was not given immediately. We had to run after them for 10-15 days. Then I got the
money.” (IDM)
“Out of Rs 500, I got Rs 300 and Rs 200 went to the Anganwadi didi who took it away.” (IDM)
“After visiting 5-6 times we got the money.” (IDM)
“We gave Rs 50 and then only we got the money.” (IDM)
“I had to go daily. I went for 8-10 days. Every day they used to tell that funds have not come yet.”
(IDM)
“ANM didi gave me Rs 450 saying that she did not have Rs 50.” (HDM)
―We took our daughter-in-law there; we got Rs 500. Then the delivery took place. We haven‟t got
the money till now. We went there 3 days but we didn‟t get it. It has been 2 months now.” (Mother-
in-law, IDM)
Difficulties faced by Sahiyas: Half of the Sahiyas said that they didn’t face any problems receiving money. The
difficulties mentioned by the other half were a delay in disbursement, lack of funds, and partial payment including
reduced payments due to bribes.
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“We have submitted two coupons of Rs 500 in September and we have not received any money yet.
There are difficulties. The making of one cheque takes 5-6 months; sometimes money comes, but my
money has not arrived yet.” (Sahiya)
“For 5-6 months women have not received any money. Two women have come 2-4 times. After that
it didn‟t happen then I said to other women that 4 times I have faced problem but didn‟t get any
money, so other women left it.” (AWW)
“We have to come 4-5 times. We are given Rs 100-200 at a time. It‟s a long distance. We lose to
pay for traveling.” (Sahiya)
“In first time, bada babu gave cheque and took Rs 50 then gave Rs 1150 cheque and told me that I
will only receive this much money.” (Sahiya)
“They scold us. We have to go again and again and for that we have no mode of transport. We have
to go and come by rickshaw. They gave us the wrong mobile number when we asked.” (Sahiya)
“On this, they said that you are becoming cleverer that‟s why you will not get anything. Accountant
always does his work as per his own wish.” (Sahiya)
Difficulties related to reporting process: District providers, block PHC Mos, and ANMs were asked about any
problems that they faced in record keeping and reporting. Incomplete reports from lower levels (block and PHCs),
improper maintenance of records, lack of proper support facilities like computer, fax, and Internet for compilation and
transmission of the reports, and shortage of manpower compared to the increased workload were mentioned as key
problems by the district health providers. Apart from these, some of the block and PHC MOs cited problems with
reporting format, duplication of reporting, and incomplete and improper reporting from subcenters as problems.
ANMs complained about laborious reporting formats (lengthy formats, too many formats, and formats in English),
shortage of time due to increased workload and other competing priorities, distance, and the need to travel for
submission. A few ANMs mentioned the variable frequency of reporting for different programs and schemes as a
problem. Half of the district providers, Mos, and a majority of ANMs mentioned that timely reporting was being done
and there were no difficulties.
“Difficulty comes. In large area various problems come in compiling. If a computer is available,
then it will become easy.” (MO)
“There is only one staff; I am left alone. Weekly report submission is difficult. There is a lot of
work like immunization, TB, malaria, filaria reports have to be prepared for all.” (ANM)
“Difficulties are there. In so many formats the reports are demanded. The same thing has to be
filled in all different formats, which is very time consuming. The same thing has to be filled in the
NRHM checklist and one we got of 24 pages, which is new. It is a very lengthy process. Report
writing is very lengthy process.” (MO PHC)
6.3.5. Determinants of utilization of the scheme
Reasons mothers prefer hospital deliveries: All the stakeholders were asked why more women recently started
coming to hospitals for delivery. Most of the providers, ANMs, and VHSC members felt that the financial incentive
was the key reason, but fewer Sahiyas and mothers held a similar opinion. Safe delivery was the other key reason
perceived by half to a majority of the health workers and VHSC members. Half of the mothers agreed. Improvement
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in the health facilities for delivery closer to home with availability of emergency services was expressed as the other
important reason by half to a majority of the providers, ANMs, and VHSC members but supported by only some of
the Sahiyas and mothers. A few respondents also perceived deliveries at home to occur in an unclean environment and
therefore mothers preferred delivering their child in a hospital. There were others who said that in the hospital they
spend less money but receive a lot of services.
Influence of family members and effect of social mobilization were perceived by some to half of the
stakeholders including mothers as reasons for preferring hospital delivery. Nonavailability of trained birth
attendant/Dai in villages was reported as the reason by some of the stakeholders across all categories but not by the
mothers. Few to some of the district and PHC MOs mentioned that some sections of society always opted for hospital
delivery (e.g., educated families).
“At home, delivery takes place in an unclean environment and the child is taken by someone with
dirty hands. The person delivering the child doesn‟t even wash their hands. There are microbes in
hands. Due to this reason, child should be born in hospital.” (Father-in-law, IDM)
“The nurse cares for me very well. The nurses took after in breakfast very well. After delivery they
gave me an egg, some milk, and an apple. When it is cold, they provided a blanket and nothing
else.” (IDM)
“Because of the money that the government provides them, the number of deliveries at hospitals
has increased.” (MO)
“See 80% of women expect financial incentives and 20% expect the service.” (MO PHC)
“There‟s no facility available at house. These days Dais (the lady who helps in the delivery at the
house) are also not found. That‟s why people mostly go to the hospital as doctors, nurses, and
medicine are available there.” (Mother-in-law, IDM)
“I will advise you to go to the hospital to take advantage of all the facilities like a nice injection,
medicine, blood, saline, water, money, etc; in hospital all facilities are provided. What is there at
home?” (IDM)
“I shall advise to you go to hospital, because there is a scheme for the benefit of pregnant women.
Under the scheme mothers receive free treatment and medicine is available. Anganbadi Sevika told
me that Rs 1000 would be given to me.” (HDM)
“I will go there and I will advise everyone to go there. You don‟t need much money and money is
also given there once you deliver.” (IDM)
“Proper care is taken of mother and child. The child and the mother receive proper attention.
Every morning they clean the child. They ask to feed milk and take the baby to wash on time.”
(IDM)
Choosing the specific facility for delivery (government vs. private): Half to a majority of mothers considered quality
of services (e.g., good treatment, more attention by doctors, good nursing care), confidence in the health facility (e.g.,
good treatment and outcome), and their financial condition as their main considerations when choosing the specific
health facility for delivery. Some mothers mentioned good infrastructure (e.g., room for stay, electricity, diet, and
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cleanliness), convenience, and personal reasons as the other reason. Most of the IDMs reported that they came directly
to the health facilities where they delivered. Few of the mothers were referred by another health facility for expert
management or timely management because the doctor or nurse was not available at that facility.
We asked mothers what place of delivery they would recommend to a close relative or friend. Almost all
mothers responded that they would advise other women to deliver only in a hospital. A majority of mothers in both the
categories expressed preference for government hospitals because no money was charged. Others did not like
government hospitals because they didn’t have faith in the medicine supplied in government hospitals, most of the
time medicine was not available, and they were not given proper attention. Half of the IDMs preferred private
hospitals because government hospitals were far away and expensive to access, and good quality care/service was
available in the private hospitals. Very few mothers responded that they advised home delivery.
“We don‟t have money in hand. Private hospital charges more money. In government hospitals you
are not charged any fees and we get medicine free of cost. That‟s why we go to the government
hospital.” (IDM)
“In private hospitals there is more security and in government hospitals we are treated very
slowly.”(HDM)
“We are poor people and we live far away. It is difficult to get to the hospital which.”(IDM)
“Proper attention is not paid in the government hospital. When we went there, they were not
talking.”(IDM)
“We fear taking government medicines and there medicines are also not available. They say that
medicines have finished.” (HDM)
Preference for home delivery: The major reasons why women preferred to deliver at home, as perceived by half to a
majority of the district officers, PHC MOs, ANMs, and Sahiyas, were the poor accessibility to the health facility (i.e.,
distance and lack of transport), cost of treatment (i.e., lack of money, hospital delivery perceived as expensive),
influence of elders/family members, lack of awareness about the benefits of delivery at hospital, and fear of surgery
and injection. About half of the district officers, PHC MOs, ANMs, and Sahiyas also mentioned personal and
traditional beliefs and practices, and previous experience of delivery at home as other reasons. Some of these
stakeholders also perceived misinformation/rumors (i.e., injections are given and operations being done) spread by the
Dais about delivering at the hospitals. Few to some of the stakeholders also mentioned unexpected events (i.e., sudden
delivery, delivery at night). Some of the ANMs mentioned that lack of faith and confidence in the hospitals and
inadequate facilities prevent many mothers from going to a health facility
Role of financial incentive in promoting institutional deliveries: Stakeholders involved in program implementation
and facilitation were asked about their opinion on the role of monetary incentives for promoting institutional deliveries
in their area. Most of the officers at the state, district, and PHC level and ANMs were of the opinion that financial
incentives were primarily responsible for the increase in institutional deliveries, but only half of the ANMs, Sahiyas,
and VHSC members agreed. According to the VHSC members and Sahiyas, the financial incentive was partly
responsible for the increase in institutional deliveries. Only half of the mothers agreed that financial incentives are the
primary reason for increased HDMs. According to half of the Sahiyas and VHSC members and some of the district
officers and PHC MOs, improvement in the facilities for delivery at the hospitals is responsible for increased
institutional deliveries. Some of the stakeholders across categories acknowledged the role of Sahiyas and ANMs as
mobilizing force.
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A few MOs expressed apprehension that the financial incentive encouraged having more children or using the
money for expenses other than for the intended purpose of the scheme.
“Going to the hospital is expensive. We have to spend money on transportation and buy medicine
and injections also.” (HDM)
“The people do not want to go to hospital because of fear of injection, cost, and operation.” (ANM)
“Delivery is easy at home. Many people are there. I fear going to hospital and taking injections.
Dai comes and helps in delivery.” (HDM)
“There is no facility and services are not good. Many people say that there are no facilities. They
do not take care. Beds are not good. They leave the patients alone. That‟s why people do not go
there.” (HDM)
“We don‟t have money to go to hospital. When delivery is fine at home, then why go elsewhere.
People at the hospital don‟t behave well and sometimes abuse us, saying „can‟t you speak
properly‟.” (HDM)
“In rural areas lots of rumors are there regarding deliveries. For example, the staff working in the
labor room were treated as untouchable. The labor room was untouchable.” (Civil Surgeon)
“The patients are not looked after well (in the hospital). The doctors run away; nurses also run
away. Sahiya too run away.” (Mother-in-law, IDM)
“There is no guarantee whether I‟ll get money or not so I didn‟t go there and also I had no
money.” (HDM)
“All delivery held safely at home. So I prefer at-home delivery because my first daughter was
delivered at home. Don‟t face any difficulty.” (HDM)
“I thought to go to government hospital because there was good care and facility. There is no
facility of motor. I was searching auto but did not find one.” (HDM)
“The Dais in the village misguide people that there will be a lot of problems in the hospital.
Nobody will listen to you there.” (Civil Surgeon)
Possible impact of withdrawal of financial incentives: The stakeholders from state to VHSC level were asked about
the possible consequences if the financial incentive were to be withdrawn. A majority to most of the stakeholders
across categories opined that the proportion of institutional deliveries would come down. According to them, the BPL
and those families residing in remote areas would revert to home deliveries due to the cost of hospital delivery and
transport cost and would come to the hospitals only in emergency or for a complication. A majority of VHSC
members and half of the ANMs and Sahiyas opined that a segment of aware and health-conscious people would still
access the facility. They also expressed that the mobilizing role of health workers would play a significant role. Half of
the VHSC members and some of the health functionaries expressed that if proper facilities were provided, hospital
delivery would not decrease.
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“There will be no effect. The poor get the money. If financial incentives are withdrawn, then 10%
of all deliveries will be done in hospital, 90% at home. The government should not stop this
scheme.” (VHSC member)
“Yes, they will go to hospital in case of difficulty. More than half of population go to hospital
without money reason.” (ANM)
“Main thing is that if patient gets some money, then come to hospital by hiring a vehicle. They
have no money for hiring a vehicle, and then they will go for Dai.” (MO, private)
“Institutional delivery will go down. People will prefer home delivery.” (MO)
“Now women have become intelligent. They know the benefits of delivery done at the hospital. The
women who are educated don‟t think about profits or loss in delivery at home or hospital. They will
certainly go to hospital.” (ANM)
6.4. Impact of MMJSSA
The immediate impact of the scheme was evaluated by assessing the quality of services rendered through antenatal
checkup, facilitation for transportation of pregnant mothers for delivery, care at the time of delivery in a health facility,
services provided during the hospital stay, and postnatal care.
Quality of antenatal care: During antenatal period about half of the mothers were given advice on diet and general
care (i.e., rest, avoiding hard work, and personal hygiene), information on danger signs and on the benefits of
delivering in a facility, and assistance preparing to do so. A majority of HDM mothers and about half of the IDMs
mentioned that they didn’t receive any specific advice or counseling from doctors, ANM, AWW, or the Sahiya during
their last pregnancy.
Accessing the place of delivery: Most mothers used motorized transport to reach the place of delivery. Ambulances
were used by very few mothers. Sahiyas accompanied about half of the mothers to the place of delivery and stayed at
the hospital with them. Sahiyas also arranged transport for some mothers.
Quality of care provided at the time of delivery in a health facility: When IDMs were asked about their experience of
delivery, half of them were satisfied with the care and treatment given to the mother and the baby. These mothers
mentioned that there was an adequate facility like bed, boiled water, linen, and medicine. Medical assistance made the
delivery much easier and problem free according to some of them. Nurses or ANMs conducted a majority of the
deliveries. About half of the mothers mentioned that doctors conducted their deliveries.
Good behavior of health personnel, cleanliness, and provision of timely or emergency services were other good
experiences women reported having at facilities. However, some of the mothers also had bad experiences due to the
unavailability of a trained doctor or nurse to handle delivery, which led to a Dai handling the delivery. Among those
who were dissatisfied, the reasons were lack of drinking water, beds, cleanliness, and necessary infrastructure as well
as lack of assistance at night. Women also reported buying medicine from private chemists and not receiving
information about prescriptions that they were given.
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“It was very good. Nurse used to look after me properly. Doctors were also good.” (IDM)
“Medicine and breakfast was given on time. Nice. Arrangement of everything was good. Facility of
bathing, latrine, for washing mouth, and of every arrangement was there. There were persons
allotted for wiping and dusting. I used to get medicine, breakfast timely.” (IDM)
“In Sadar hospital service was not good. Nurses demand money and told not to tell anybody. So I
do not like it. Service was not done well in the hospital. Nurse leaves me alone when child is half
out.” (IDM)
“Nice experience, good arrangement, no money is required there; I had a pleasant experience.”
(IDM)
“Doctor is not available in hospital. I had to buy everything. I bought saline, medicine, and
everything. There are no facilities.” (IDM)
Care of the mother and the baby during hospital stay: Nearly half of the IDMs reported having received no service
after delivery for themselves or their babies. According to half, the immediate postdelivery services provided were
assistance with personal hygiene and availability of clean clothes, availability of a bed and clean bed linen, visits at
regular intervals by doctor, nurse/ANM, treatment as needed, and provision of diet.
In terms of receiving advice, nearly half of the mothers reported that they had not received advice. Mothers,
who did receive advice, reported receiving information and suggestions related to rest, work and general health care
including care of stitches and dietary intake, and family planning. Some women also reported receiving advice on the
importance of adhering to the prescribed medicine and information about how to collect their financial incentive. Very
few mothers recalled receiving advice on breast-feeding.
“Provided medicine, they were attending me throughout; I was happy there as good services were
provided. They were giving medicine and injection as per the schedule.” (IDM)
“There they did not give anything. Earlier, people who went there, got injection and medicine, but I
did not get anything.”(IDM)
“After delivery I stayed only 1 hour, but in between I didn‟t receive any service.”(IDM)
Mother’s hospital stay and discharge: Half of the district- and PHC-level officers, ANMs, and Sahiyas reported that
many mothers were being discharged within 24 hours of delivery. The main reason for early discharge noted by half of
the district and PHC MOs, ANMs, and the Sahiyas was due to either the mother or family member requesting a
discharge after a normal and uneventful delivery, or because of financial, domestic, or personal problems at home.
However, half of the mothers who experienced normal delivery reported being asked to leave or were discharged
early. The reasons for requesting early discharge by a few mothers were a lack of resources at hospitals and poor
service quality. This was reiterated by MOs, ANMs, and Sahiyas.
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“We have made a policy of 24 hours stay but due to domestic problems, women are in a hurry to go,
so we discharge them. Sometimes because of unavailability of space and overcrowding also we
discharge them.” (Civil Surgeon)
“They come after 2 hours. As the doctor leaves immediately, how women can stay.” (TBA)
“There is no facility at hospital. Because of lack of facilities in the hospital, they come home after 1-2
hours.” (AWW)
"Back in home little children live alone. Ask for leave of their own and at times even doctor relieve
them too.” (TBA)
Care for the baby after delivery: During the hospital stay a majority to most of the mothers mentioned that the health
providers wiped, bathed, weighed, and wrapped the baby. Regarding specific advice for babies, half of the mothers
reported that they were given advice on care of the baby, which included proper covering, keeping the baby warm and
clean, bathing after 2-3 days, oil massage, medicines as per prescription, and cord care. Doctors and nurses advised
and assisted some of them in early initiation of breast-feeding. However, very few of them mentioned any assistance
from Sahiya or the ANM. Some mothers reported advice on breast-feeding, feeding frequency, and exclusive breast-
feeding. A few mothers were given advice on vaccination.
“To keep the child well, do not rub mustard oil. Do bath with soap and keep baby neat and clean.”
(IDM)
“Doctor told to come again and to collect money and no advice was given.” (IDM)
“Did not advise anything; nurse took Rs 150. There were three nurses who said we need something
as a tip.” (IDM)
“Cleaning was done by nurse then; oil massaging and finally the baby was wrapped in a cloth and
handed over to me.” (IDM)
“Sister came and only examined the baby and went away.” (IDM)
“The baby was not crying and so water drops was placed in his eyes. When the baby cried, then he
was weighed.”(IDM)
Behavior of the staff: Almost all the IDMs said that the behavior of health personnel toward them was good.
However, a few had bad experiences, including rude behavior, scolding, and staff asking for money.
“Behavior was good with me and my family member. I had previously gone there so they recognized
me and behaved well.” (Institution delivered mother)
“The nurse‟s behavior was very rude toward me and family in Sadar hospital. Don‟t talk accordingly
with me, used to scold.”(Institution delivered mother)
“We don‟t have faith in government facilities. There‟s a lot of carelessness in government services.”
(Father-in-law, Institution delivered mother)
“They do not treat us nicely. But being compared to the previous position it‟s all right now. When
delivery takes place, they want money from us whether it‟s a boy or a girl.” (Mother-in-law,
Institution delivered mother)
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Accessing the same facility in next pregnancy: Most IDMs expressed that they would like to go to the same hospital
if they become pregnant again. The reason for their preference was good-quality services and good behavior, adequate
facilities (e.g., infrastructure facilities, operation theatre, medicine and injection, clean environment) promoting health
of mother and newborn. Low cost of delivery was another motivating factor expressed by half of the mothers. A few
mentioned that they would approach that facility in case of complications that required expert management. Some
women reported that they would not be able to make the decision to deliver at a facility on their own rather; the
decision would be made by family members or would be contingent on being accompanied by their husband, an
ANM, or Sahiya. Some who would not like to approach the same health facility again mentioned several reasons such
as lack of medicine and injections, fear of hospital procedures (i.e., operation and interventions), misbehavior of staff,
and higher cost.
“If I will be pregnant again, I will go to the hospital because all facilities are available there like
medicine and injections. All facilities are provided in hospital, nurses are there, so I will go only
there.” (IDM)
“I will not go to Sadar hospital because there the nurse didn‟t behave nicely with me. They will
harass me. I will not deliver there.” (IDM)
Postnatal visits after discharge: Most of the ANMs mentioned visiting mothers 2-3 times after delivery in their
homes. The postnatal services provided to mothers reported by ANMs included checking for postpartum hemorrhage
and genital injury, care of stitch, and looking for fever. A majority of the ANMs mentioned that during their home
visits, they advised mothers about good food and general PNC, including rest, work, personal hygiene, following
doctor’s instructions, and family planning. Some ANMs mentioned providing advice for immunization and general
care of the baby and cord care. Weighing the babies and advice on breast-feeding were not mentioned by any of the
ANMs as part of the PNC services after they deliver.
“We go 3 times after delivery; within 24 hours, after 1 week and after 6 weeks.” (ANM)
“I do not go. Old ANM was visiting my home 3-4 times.” (ANM)
A majority of the mothers recalled that being visited by some health worker during the postnatal period. Half
of them reported receiving visits only once, but some reported two visits. According to half of them, they were visited
on the first day after delivery itself and another half were visited 3-4 days after delivery. Sahiyas, ANMs, and in some
instances AWWs made postnatal visits. Half to majority of the mothers were advised about their general care. None of
them reported receiving any advice on family planning, or being checked for bleeding and fever.
Regarding the newborn, a majority of the mothers recalled receiving advice on immunization, general care of
the baby (e.g., keeping warm, cleaning), and going to the hospital in case of any problem. A few reported that their
babies were weighed and some reported receiving advice on breast-feeding.
Availability of obstetrics health services at the health facilities: According to the officials, only three district
hospitals Ranchi, Gumla, and Koderma were conducting caesarean sections regularly. In district hospitals of Deoghar
and Chaibasa, the emergency obstetrics services were infrequently used and also many of the emergency obstetric
drugs were not used regularly.
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Among the 12 block hospitals from the six districts visited, none of the hospitals had all the components to
deliver EmOC. The cesarean section facility was not available in any of these block hospitals and blood transfusion
facilities were available in only two of the facilities. None of the block hospitals had all the drugs for EmOC.
7. LIMITATIONS OF THE STUDY
In general, the limitations of any study are primarily related to (i) accuracy of the information; (ii) representative
nature; (iii) cultural inappropriateness; and (iv) subjectivity of the investigators, which can create biases in data and
their interpretation. This study suffered from the following limitations:
This research is a multisite qualitative study that includes interviews with several categories of stakeholders
comprising various types of respondents. Thus, there might be a larger issue with respect to the validity and
reliability of the information obtained.
Convincing others about the validity and reliability of qualitative research can be challenging. Hence, there was a
need for building quality assurance mechanisms at all stages of project design, implementation, and analysis.
It may be difficult to interpret results in ways understandable to the end users so that the results are effectively
disseminated and used.
Secondary data analysis and its interpretation were limited because the HMIS in Jharkhand state is in the process
of establishing standard practices with respect to collection, compilation, and consolidation of data and regular
monitoring. In addition, problems of underreporting exist.
As data on MMJSSA are available for only 1 year (2008-09), changes in utilization of MMJSSA by beneficiaries
could not be observed.
8. CONCLUSIONS
This evaluation has systematically assessed the current scenario of the reach of the scheme and utilization of services,
implementation process, strengths and limitations, and impact of the scheme. The findings provide information on
how increased numbers of institutional deliveries have affected quality of care, and how the infrastructure of health
facilities, essential drug supply, availability of medical equipment, and human resources have affected the reach,
effectiveness, and impact of the MMJSSA.
Reach (coverage) and utilization of services under MMJSSA
In 2008, 52.2% of villages in Jharkhand had beneficiaries under MMJSSA, but fewer than one-third of women were
registered during the first trimester of pregnancy. There was wide variation in getting at least three antenatal checkups
across the study districts—the highest occurred in Ranchi and the lowest in Deoghar.
The district-level analysis showed the lowest institutional deliveries in Gumla (10.3%) and the highest in Ranchi
(27.4%) district. There was an identical pattern found in all the districts with different socioeconomic and demographic
indicators. Institutional delivery is lowest among rural women, women belonging to Hindu communities, and those who
do not have a BPL card. Non-SC/ST/OBC women have higher rates of institutional deliveries in all districts; however,
in Ranchi, Koderma, and West Shingbhum, OBC women have better rates than those in the other districts.
Only 2.8% of mothers availed financial assistance for delivery under MMJSSA. Sahiyas facilitated and
motivated women in Ranchi, Gumla, and Deoghar districts, but this facilitation was missing in Koderma and Garhwa
districts.
Overall, safe delivery was highest among women characterized by urban residence, non-ST/SC/OBC, 6+ years
of schooling, 15-29 years of age, with 1-2 children and with 3+ antenatal checkup visits.
The most vulnerable and marginalized women, those of SC/ST/OBC, and the illiterate living in rural areas
benefit the least from MMJSSA’s attempts to promote antenatal checkup and safe delivery in facilities. The scheme
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seems to specifically benefit women with BPL cards. The study indicates that many poor marginalized families are
without BPL cards.
Effectiveness of the scheme (process evaluation)
Availability of guidelines and sharing with health workers: MMJSSA, being a new scheme with cash incentives,
requires a common understanding by all stakeholders. Written guidelines describing the scheme do exist but were
available only at the district hospitals and block PHCs. Most of the subcenters did not have them. For mobilizing and
improving awareness of mothers and community members, adequate knowledge about the scheme at the village-level
workers is critical. Absence of the guidelines at subcenter level compromises this component of mobilization.
Nonavailability of guidelines indicated the lack of emphasis on this aspect of dissemination of the benefits.
Training/orientation about the scheme: The cascade system of orientation/training of health functionaries was
suboptimal. Up to the PHC level, functionaries and officials were trained through proper training sessions. However,
below the PHC level, mostly monthly meetings were used for orientation on the scheme. The vision, guidelines, and
role of functionaries had not percolated to the field health and ICDS workers for effective mobilization and awareness.
Lack of written guidelines and poor orientation to the scheme were reflected in differential and suboptimal
understanding of the activities of the scheme and documentary requirements for incentive disbursement among
different levels of functionaries.
Understanding about the scheme and activities: The understanding of the purpose and components of the scheme and
the activities was better among the state and district stakeholders. However, the comprehension declined progressively
across the stakeholders from the state to subcenters and then village level. Most of the ANMs and the Sahiyas did not
perceive this scheme either as an effort to reduce the maternal and infant mortality or in promoting institutional
deliveries. It appears that the underlying philosophy for specific activities of the scheme and the purpose has not
adequately percolated across the stakeholders at the different levels of functionaries.
A majority of the community representatives were unaware of the thrust given by the government on effective
implementation of the program. Most of the mothers were unaware of the scheme by its name and were unable to
differentiate between the new or additional benefits of this scheme and the routine services available to them.
However, almost all were aware of the financial incentives. This indicates that the financial benefit was communicated
as the primary benefit for the beneficiaries and also perceived as the key gain from the scheme by the mothers and
community members. This understanding compromises the overall purpose of the scheme and process of bringing the
mothers to hospitals for safe deliveries.
Documents needed for payment: According to the guidelines, all pregnant mothers in Jharkhand accessing
government hospitals and accredited private hospitals, irrespective of the parity and economic status, are entitled to the
incentive. Even though only documents of antenatal checkup and delivery at hospital/discharge card are necessary,
some of the functionaries insist on red/BPL card, which annoyed the beneficiaries. Change in eligibility norms from
two children to any number of pregnancies and to all mothers irrespective of their socioeconomic status has further
created confusion. It is quite probable that the changed guidelines and eligibility criteria were not adequately
communicated to the workers at the grassroot level in a uniform manner.
Roles played by stakeholders: The district- and PHC-level officers perceived their role as facilitating, supervising, and
monitoring program activities and financial expenses. None of them perceived planning as one of their identified
activities. Surprisingly more than half of the ANMs, Sahiyas, and AWWs did not perceive promotion of institutional
delivery as a key role. This further demonstrates a lack of communication with the key health functionaries about the
scheme-related activities. It also appears that cross-checking is neglected by the supervisors about these primary but
very essential components of scheme implementation.
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Changes in facility infrastructure after introduction of the scheme: Under the NRHM, there has been emphasis on
infrastructure development to support institutional deliveries. The effective implementation of the scheme and
activities under the Program Implementation Plan (PIP) were envisaged to change the infrastructure facilities at the
health centers, leading to better services and thereby improving the health of mothers and children. A majority of the
stakeholders at the district, block, and subcenter and field workers perceived improvement in the infrastructure,
facilities, equipments, investigation services, and supply of medicines and other consumables in the facilities since
implementation of this scheme.
Response to the increase in institutional deliveries—availability of services: Although most of the DHs had the
facilities for providing CEmOC, only about half of the observed facilities were delivering services regularly. Most of
the block hospitals did not have facilities for providing BEmOC. The use of essential drugs at these facilities
correlated well with the regularity of service delivery at these facilities. Although the deliveries were happening in
these hospitals, the competence and facilities to handle obstetric emergencies were limited. According to the officials,
all of the DHs and most block PHCs were providing 24-hour obstetric services. About half of the block hospitals were
unable to provide the optimal obstetric services at night. Mostly lack of manpower and inadequate facilities made it
difficult to run the services at night. The reported figures of deliveries at night correlated with the availability of senior
doctors at the block hospitals. About half of the PHC MOs felt that more than half of the deliveries were still
happening at home despite the recent increase in hospital deliveries.
The current status of available services would not benefit the health facilities and the scheme in the long run
unless the facilities were improved and the emergency services were readily available.
Effect on the workload of health functionaries: The MMJSSA caused institutional workloads to increase at all levels.
Workload of the ANMs and other field workers increased because of increased ANC registration and demand for
antenatal checkup services. Payment of the first installment of Rs 500 along with the ANC registration was most likely
a major reason for increase in the workload. The added responsibility of having to explain the benefits of the scheme
to mothers and families increased the workload of ANMs, Sahiyas, and other hospital functionaries. ANMs did not
perceive the postnatal visit as a reason for their increased workload. From mothers it was apparent that the ANMs
were not visiting them at home as needed. Therefore, the increased workload was mainly linked to the activities
involving financial transactions at the subcenter level.
Workload at the PHCs and DH increased due to increased number of deliveries at these facilities. Along with
the increased utilization of facilities for delivery, referrals from smaller facilities to larger facilities have also increased
as reported by the functionaries at all levels. The deliveries at the subcenter levels have decreased and these deliveries
shifted to PHCs and to block health facilities. Therefore, there has been a visible shift in the number of deliveries
being conducted at higher-level facilities. This is not helpful in the long term and could further minimize the role of
subcenters and ANMs.
The increased workload was claimed to be handled by increasing working time. At some facilities, additional
human resources were deployed to handle the increased workload. Despite all these efforts, the quality of service was
not a priority according to most of the health functionaries.
Difficulties faced by health functionaries: With an increase in the number of mothers delivering at hospitals, the
health functionaries faced difficulties like space constraint, shortage of human resources, and nonavailability of
equipment, drugs, and ward supplies like linen (bed sheets, blankets). Due to lack of adequate human resource, about
half of the block health facilities are unable to provide round-the-clock obstetric services. Additionally, the change in
the guidelines and lack of clarity on the guidelines also contributed to the confusion. There have been attempts to
streamline the ANC registration, disburse money, and improve client satisfaction. Overall, the attempts to address the
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difficulties were few. According to the functionaries, there was a need for better infrastructure with improved basic
facilities, better equipment and laboratory facilities, and skilled human resources. There was a general opinion that the
subcenter facilities must be improved and should be better supplied in order to serve the mothers and the community
better.
Most of the health officials and functionaries believed that no significant effort to overcome the problems was
made. In their opinion, most of the efforts had been targeted at making funds disbursement systems more efficient
with improved monitoring of payments.
Role of health workers in the scheme: Most of the ANMs did not perceive their role as providing counseling to the
mothers on diet, danger signs of mothers and babies, or birth planning. The role of AWWs appeared to be primarily
focused on distribution of supplementary food and related advice during antenatal period. AWWs were less involved
in awareness generation among the mothers for institutional delivery. The role of Sahiyas appeared to be minimal in
all stages of pregnancy-related care, including antenatal checkup, birth planning, and advice to mothers.
Birth planning appeared to be missing from the perceived activities of health workers. The same was
corroborated by lack of birth planning for majority of the mothers who delivered at home. Probably the opportunity of
motivating mothers and converting home deliveries into institutional deliveries was lost due to lack of clarity and
needed skills among the health workers.
Service delivery
Antenatal care: According to the mothers, most were registered with the Anganwadi center for antenatal checkup. The
ANC primarily constituted TT injection and IFA tablets. Other services partially received by the mothers included
weighing, checking for pallor, blood pressure, and fundal examination. It appeared that the essential advice for
mothers to take care of themselves was not optimally delivered during their visits to Anganwadi centers for receiving
antenatal checkup. The advice given by various health functionaries to only half of the mothers primarily focused on
diet and general care. Information on danger signs during pregnancy and birth preparation was reported to be missing
from advising and counseling services. It appeared that improving motivation for antenatal checkup and then assisting
in planning for delivery was not considered an important activity of the health functionaries at village level or ANMs.
As described by the mothers, birth planning and planning in advance about the place of delivery emerged as
important determinants for the ultimate place of delivery. A majority of the mothers who delivered in hospitals had
decided in advance to have a hospital delivery while most of them who delivered at home were indecisive about the
place of delivery. This further emphasizes the need for assistance from field health workers to assist with appropriate
birth planning and to encourage hospital delivery.
Institutional delivery: Most of the mothers who delivered at the health facilities reached the facility within 1 hour and
used motorized transportation. The transport cost provided in the scheme was adequate for half to a majority of the
mothers for reaching the facilities. The role of Sahiyas in facilitating and accompanying pregnant women to health
facilities was limited to only some mothers. Transportation, personal problems, and security issues were reported to be
the major difficulties faced by the Sahiyas in assisting and accompanying the mothers during odd hours.
About half of the ANMs were not involved in any delivery in recent months, and overall it appeared that
though on an average each ANM conducted about one delivery in every 2 months. Most ANMs were not in the habit
of conducting deliveries. This has implications for the SBA training and retention of skills by the ANMs over time due
to infrequent use of their skills and the increasing hospital deliveries.
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Care during hospital stay: Half of the mothers recalled receiving some services and advice during their postdelivery
hospital stay. Services and advice for mothers were focused on general care (rest, work, and personal hygiene) and
diet. For the babies, the services focused again on general care (cleaning, covering, and keeping the baby warm) and
vaccination. Few of the mothers received information on how to initiate breast-feeding and on exclusive breast-
feeding. Only half of the mothers mentioned of introducing their baby to the breast within 1 hour of birth. Probably,
inadequate human resources in comparison to the workload and lack of competency were the reasons for providing
inadequate services.
Hospital stay and discharge: It appeared that most mothers left the hospital within 24 hours and some within 6 hours
after delivery. While the health providers blamed the mothers and family members for requesting early discharge,
mothers mentioned that they were discharged or asked to go home by the health providers. Lack of facilities, shortage
of human resources and poor service quality were the other reasons for early discharge. It appears that the health
functionaries were not convinced about the need to retain and serve the mothers for the desired period; likewise, the
mothers were unwilling to stay in uncomfortable conditions for a longer period.
Postnatal visits: The health workers visited a majority of the postpartum mothers at home at least once. The share of
postnatal home visits was larger for Sahiyas followed by the ANMs and least by the AWWs. A significant number of
home visits were made on the first day. It appears that the Sahiyas considered and reported the contact with mothers
while accompanying them from hospitals to home as home visits. Delivering in an institution did not ensure adequate
postnatal visits by health workers. The advice and checkups for problems were suboptimal for both mothers and
newborns. The emphasis on breast-feeding was missing.
Intra/Intersectoral coordination: Mechanisms were in place for coordination among the health and ICDS
functionaries at different levels. There was also a system for coordinating functionaries at different levels of facilities.
According to most stakeholders, functionaries from health and ICDS at village level had good coordination. Although
most of the stakeholders did not mention any coordination problems, a few issues were raised during the course of the
study like irregularity of meetings between different levels, lack of clarity in individual responsibility, personal
conflicts, and incentives to Sahiya only but not to the AWWs. The role of ICDS functionaries and AWW is not clearly
emphasized in the scheme and the mode of coordination also needs further clarification to ensure motivation and
continued involvement for common gain.
Monitoring and supervision: The existing reporting system was being supplemented with the HMIS e-system at
district level and both the systems were in place at the time of conducting this study. It appeared that the health service
delivery wing was not involved in monitoring of the scheme and most of the monitoring was limited to RCH section
of the NRHM. The interaction and coordination between the leadership of these two critical wings of program
management and service delivery appeared minimal. This study showed that poor monitoring and evaluation systems
were persistent problems. They have been both ineffective and unreliable in providing information to show critical
outcomes of the scheme in terms of reducing the levels of maternal and neonatal mortality. So far, the focus of
monitoring and supervision has been on beneficiary validation and fund tracking without any emphasis on quality of
services.
Social mobilization: According to most of the health providers, the generation of public awareness of the scheme
came largely from interpersonal communication by health workers, hoardings/pamphlets, and mass media. It was clear
that the health functionaries were still not thinking beyond the traditional social mobilization and communication
campaign efforts. Looking at the awareness and understanding of the mothers who participated in the study, it
appeared that the reach of the awareness efforts was limited. There was no special or additional effort to reach the poor
and marginalized communities.
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The role of the NGOs appeared to be primarily in Sahiya training and limited in the MMJSSA scheme.
Similarly, the involvement of the local bodies (Mahila Mandals, women’s groups and local leaders) was negligible in
the scheme implementation. More opportunities can be created for interaction between key stakeholders from outside
the health sector to improve social mobilization.
Financial processes
Budget preparation and process for release of funds: Involvement of civil surgeon in budget and planning related to
the scheme was minimal in half of the districts while the MMJSSA officers were doing the tasks. It appeared that there
was a lack of joint action between the service delivery component of the health system and program management
under the NRHM for program planning and monitoring. Inputs from the PHCs appeared to be minimal while
preparing budget. The primary focus of the health system was to spend the money. It was apparent that the current
process for fund release from state to the PHC level suffered from problems of procedural requirements, at times lack
of funds, problem with timely release, and bank-related issues.
Knowledge of untied funds was limited at the VHSC level. Wherever the fund was available, it was not
utilized due to the lack of clarity in the guidelines and operations. This was in part due to the lack of a structured
orientation of the VHSC in most districts and a lack of dialogue between the VHSC members and the ANMs about
how to use these funds effectively.
Disbursement of incentive to beneficiaries (mothers and Sahiyas): A majority of the HDMs and some of the IDMs
did not receive any incentive. Some of the IDMs and the HDMs received partial payment. The partial payment was
probably a mixture of nonreceipt of one component of the split payment schedule (during pregnancy and after
delivery) and corruption. Nonpayments to mothers who delivered at home were probably due to nonrecording by the
health workers and reporting to the system. Mothers expressed their unhappiness over the disbursement process
(specifically the number of visits required), the number of documents and unclear procedures in place, and the hospital
staff asking for bribes and bank-related procedures. It appeared from the mothers’ responses that the split payment
modality resulted in partial payment in many of the cases.
Most of the Sahiyas received their incentives. Sahiyas faced problems such as delay in payments, partial
payment, and corruption in the disbursing offices.
The mechanism for addressing grievances is not optimal in most of the districts and health facilities. Despite so
many nonpayments, a grievance mechanism was found to be nonfunctional in most places.
Financial incentive: Client perspective
Purpose of financial incentive: The mothers and family members did not adequately understand the purpose of
financial incentives provided under the scheme. The awareness among the HDMs was poor compared to the IDMs.
Only some of the IDMs and HDMs had some idea about the purpose of the money. The primary purpose of the
money, as perceived by mother, was for buying good food to improve their health. Actual usage of the money also
matched with the purpose perceived by the mother/families in most of the cases. The other purposes perceived by
mothers were meeting out-of-pocket expenses during delivery and meeting expenses for other household items for the
mother and baby after delivery. It is likely this understanding emerged from the split payment schedule which meant
that mothers were receiving money during the pregnancy and then again after delivery. Focused and strategic
communications that target pregnant women need to be delivered by health functionaries to dissolve these perceptions.
On another note, it was quite reassuring to learn that mothers do participate in deciding how the money was to be
spent.
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Actual expenditure on delivery: The majority of the IDMs spent more than Rs 1000 for delivery at hospital. These
expenditures were likely to be toward transportation costs, payment (use a different word ―bribing‖ as payments can
be perceived as eligible expenses) to the hospital staff, and medicines related to hospital delivery. It appeared that the
money given to mothers was largely utilized for delivery-related expenses.
Client behavior
Preference for institutional delivery: According to the health care providers, mothers prefer to come to the hospital to
have safe delivery, at a low cost, and for monetary incentives. Other factors were availability of facilities and trained
care providers (doctors and nurses). A majority of the mothers had made prior plans to deliver in a hospital and some
reached the hospital due to suspected emergencies or complications. Sahiyas and health workers for institutional
delivery mobilized some of the mothers. The comments suggest that the system could only mobilize some mothers
who had not decided to come to the hospital for delivery. Most of the mothers expressed their willingness to come
back to the facility for delivery during their next pregnancy. Some of them mentioned that they would not like to come
back to the government facility and expressed a preference to go to a private facility. Mothers and family members
expressed that while choosing a specific health facility, they consider the quality of care and availability of adequate
facility as the parameters.
Preference for home delivery: A majority of the home delivered mothers had planned to deliver at home or did not
decide about the place of delivery. Some had to deliver at home due to unfavorable conditions to go to hospital. A
majority of the home delivered mothers perceived that hospital delivery was costly and involved interventions like
cuts, operations, and injections. They also mentioned that the local Dais and birth attendants had been spreading
misinformation about unnecessary procedures and surgical interventions being a common practice in the hospitals.
Perception of higher cost incurred at hospitals was an important issue preventing one segment of the community from
accessing the hospitals. Personal reasons and sociocultural influences also reflected the lack of adequate awareness
generation effort. Lack of proactive efforts by the field health workers and poor transport facility were other reasons
for preference for home delivery.
It appears that mobilization efforts and facilitation by the Sahiyas, ANMs, and AWWs for antenatal checkups,
birth planning, and accompanying to health facilities were not sufficient. There was a visible gap in the process of
spreading the appropriate information to the community about the scheme and the benefits provided by the health
facilities. It suggests that the current efforts to generate awareness were not directed at reducing misconceptions within
the community about institutional delivery.
Role of financial incentives in pushing institutional delivery: Most of the health functionaries were of the opinion
that the financial incentives provided under the scheme were the main reason for increased institutional deliveries.
However, only some mothers agreed to this. Although some of the officials perceived the role played by Sahiyas and
ANMs in promoting hospital deliveries to be important, beneficiaries, on the other hand, did not.
Most of the stakeholders expressed their apprehension that hospital deliveries would decline if the financial
incentive was withdrawn. They also perceived that the poor and marginalized communities would again revert to
home delivery. Most of the stakeholders suggested improving birthing facilities at hospitals and health centers within
the each reach of the people as a strategy to continue institutional deliveries. Additionally, a specific focus on
infrastructure improvement including basic amenities at hospitals including security was also suggested. Also,
improved involvement of the field workers for mobilizing women in the community was opined as a strategy. Few of
the officers and health workers also favored continuing the scheme until achievement of full institutional deliveries
followed by a phased withdrawal of the financial incentives. Overall, it appeared that the financial incentives were the
key stimulus to increased hospital deliveries under this scheme, but without improving the hospital facilities and
mobilization at community level, it would be unable to maintain the momentum and sustain the generated interest.
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Private sector involvement in the scheme implementation: The involvement of the private sector hospitals in
MMJSSA implementation was through accreditation of the hospitals based on benchmarking criteria. Among the 12
hospitals visited in the six districts, only two hospitals were accredited under this scheme. Those two hospitals also did
not have written guidelines available at the time of the visit. Interaction with some district- and block-level health
officials indicated that they were ignorant of the accredited private hospitals in their area. This clearly reflects lack of
interest on the part of the health system to increase the accreditation of private hospitals under this scheme. Lack of
involvement of private hospitals was evident from the poor understanding of the doctors working in these private
hospitals in regards to activities denoted in the scheme.
The issues of difficulties in reporting, monitoring and fund disbursement were highlighted as the major
problems encountered while coordinating with private hospitals.
Impact of the scheme: Quality of care
The scheme has no doubt increased institutional deliveries in different regions of Jharkhand, but wherever a sharp rise
in the number of beneficiaries has been reported, the existing infrastructural facilities at hospitals have been
challenged to provide quality care. Mothers and newborns have not been retained for the recommended 24-48 hours.
Despite the dangers posed to mothers and newborns due to such practices, the women are still sent home within hours
of delivery with the excuse that families insist on going home early due to various domestic problems.
Quality of care in the hospital/institution: The overall experience of the mothers who delivered in the hospital was
good. Some of the mothers were satisfied with the quality of medical care and behavior of staff at the hospital. There
were some instances of dissatisfaction related to the quality of care, facilities available, and rude behavior of the staff
as mentioned by mothers. Some mothers complained of having to pay for medicines and hospital staff taking bribes.
Some of the mothers expressed dissatisfaction over nonavailability of skilled personnel for conducting deliveries and
others expressed annoyance at the cost of services that they incurred because it was higher than expected. It appeared
that overall health facility strengthening had improved the confidence of mothers, family members, and the
community and that the beneficiaries’ expectations were not very high. The difficulties addressed by the women are
valid and should be reconciled to further improve the quality of care and beneficiary satisfaction.
Quality of care during postnatal care/home visits: The services and advice given by the health workers during the
home visits were more general and some of the key components of care were missed by the workers (e.g., checking
temperature, checking for bleeding, family planning, educating about identifying danger signs associated with
newborns). Counseling on breast-feeding was not done in most cases. It also appeared that there was a lack of clear
guidance as to who should visit the mothers at home and what services are expected to be delivered at home.
Additionally, there was no visible linkage between incentive payment to Sahiyas and the activities of the postnatal
visit and services delivered other than BCG vaccination.
Impact of MMJSSA on maternal and child health: Almost all of the health functionaries perceived that the scheme
had significant impact on reducing maternal and infant mortality, and improved utilization of the MCH services
(immunization, antenatal checkup, and IFA supplementation). The scheme also stimulated better utilization of the
other health programs like TB control and family planning. The health providers also felt that additional services
related to MCH care could be linked to capitalize upon the gains of the scheme.
The real impact on the MMR and the neonatal mortality rate is yet to be documented because the focus of
monitoring and supervision so far has been on beneficiary validation and fund tracking without any emphasis on
quality of services.
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9. POLICY RECOMMENDATIONS
A Expanding the reach of the scheme
1. Conduct three monthly ANC drives and special camps to identify, register the pregnant women from tribal,
SC/ST/BPL, and marginated communities, and living in hard-to-reach areas to deliver antenatal services and
mobilize them for institutional delivery.
1.1. Ensure operationalization of round-the-clock functional birthing facilities services within reach of the
community for encouraging and sustaining institutional delivery.
1.2. Operationalize the 24×7 PHCs, CHCs on an emergency basis, and wherever possible labor rooms in
subcenters can be considered for conducting normal deliveries.
2. Facility-level upgradation with provision of minimum requisite facilities (functional toilets, drinking water, light,
security for mothers and attendants) for comfortable stay of the mothers to encourage them to stay longer.
3. Make proactive efforts to involve the private hospitals in the scheme for obstetric service delivery. The
professional associations (FOGSI, IAP, and NNF) and recently formed Consortium for Women, Newborn and
Child Health (CWNCH) can be made partner to facilitate the process.
4. Improve transportation facilities and options including facilitation of the locally feasible options involving the
private players.
5. Develop and implement strategic multimedia communication packages to allay the concerns, misinformation, and
rumors regarding hospital deliveries addressing cost, surgical, and medical interventions involved in hospital
delivery.
B. Improving effectiveness of the scheme and quality of service
6. Make birth planning a mandatory part of antenatal service package delivered to the pregnant mothers and be
mentioned in the ANC card. During VHNDs/ANC sessions at AWC/village level, a special session on birth
planning should be included to assist and mobilize the pregnant mothers.
7. To overcome the impending constraints of space and manpower to deliver the services, risk stratification can
be done after birth to identify mother-child dyads who need to be retained for at least 48 hours after delivery and
mother-child dyads who can be discharged earlier.
C. Improving program management
8. Make the incentive payment system simple, prompt, and transparent with minimal documentation formalities.
9. Urgently orient functionaries especially the frontline workers on objectives, activities, guidelines, roles, and
responsibilities in the scheme using both face-to-face interaction and distribution of written document in local
language.
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10. Ensure coordinated function during all steps of program development (planning, implementation, and
monitoring) between the program management and service delivery sections of the health department and make
VHSCs functional to improve coordination among frontline workers.
11. Restructure the monitoring and supervision process (person, frequency, and tool to be used), components to
be monitored (reach and quality of service delivery during ANC, delivery and PNC apart from disbursement),
reporting mechanism, and use of the reports for program refinement.
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Age of respondent
Annexure 1: Background Characteristics of Mothers
Institutional Delivery
Home Delivery
Mothers (%)
Mothers (%)
15-19
15%
13%
20-24
44%
36%
25-29
25%
31%
30-34
13%
12%
35-39
3%
7%
Above 40
1%
1%
Religion of the head of the house
Hindu
60%
57%
Muslim
17%
10%
Christian
4%
3%
Other (specify)
20%
30%
Caste or tribe of the household
Scheduled Tribe
30%
41%
Scheduled Caste
13%
22%
Other backward classes
42%
27%
Other caste
15%
10%
Reading and writing ability of mothers
Yes
42%
38%
Education of mothers (highest grade completed)
7th grade or less
19%
24%
8th -10th grade
19%
11%
11th -12th grade
2%
1%
>12th grade
1%
1%
Illiterate
59%
63%
Type of house
Kuccha
61%
74%
Semi-pucca
21%
16%
Pucca
17%
9%
Electricity
Yes
58%
48%
Radio transistor
Yes
23%
22%
Color television
Yes
14%
13%
Mobile phone
Yes
39%
30%
Does hold any agricultural land
Yes
40%
34%
Does hold a BPL card
Yes
41%
43 %
Household members covered by health
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7.3 Page 63 |
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scheme/insurance
Yes
4%
3%
Background
characteristics
Residence
Rural
Urban
Religion
Hindu
Muslim
Christian
Others
Caste/Tribe
Scheduled Caste (SC)
Scheduled Tribe (ST)
OBC
General
Woman’s Education
Illiterate/ No schooling
0-5 years schooling
6+ years schooling
BPL card
Yes
No
Age of women (Years)
15-19
20-24
25-29
30-34
35 +
Age at marriage (Years)
< 18
> 18
Children ever born
1
2
3–4
5+
Pregnancy wastage
No
Yes
ANC visits
No ANC
1
2
mothers and safe delivery
by select background characteristics in Jharkhand, 2007-08*
Home delivery
Institutional
Safe Number of
delivery Assisted by trained Without any delivery women
health personnel
assistance
13.9
7.7
57.7
5.5
21.2
8.3
17.6
7.9
10.9
5.3
8.6
4.8
14.5
8.3
8.4
5.1
21.7
9.1
45.8
8.6
12.5
6.5
17.5
8.5
36.5
10.2
12.8
7.5
20.5
7.5
23
11
22.2
8
18.5
7.8
14.4
6.1
8.5
5.4
14.5
8.1
22.4
6.7
30.6
9.8
21.2
7.9
12.6
6.8
6.7
5.2
17.5
7.2
22.4
10.2
4
4.9
13.8
8.8
16.4
9.7
78.4
36.8
70.5
74.5
83.8
86.6
77.2
86.6
69.2
45.7
81
74
53.3
79.8
72
66
69.8
73.7
79.5
86.2
77.3
70.9
59.7
70.9
80.6
88.1
75.3
67.4
91.1
77.4
73.9
21.6
63.2
29.5
25.5
16.2
13.4
22.8
13.5
30.8
54.4
19
26
46.7
20.3
28
34
30.2
26.3
20.5
13.9
22.6
29.1
40.4
29.1
19.4
11.9
24.7
32.6
8.9
22.6
26.1
10392
1074
7438
1386
691
1952
1691
4108
4655
999
7770
1377
2320
7693
3775
755
3571
3661
2149
1330
6350
5117
2757
2739
3746
2185
10331
1135
5077
664
2117
63
Annexure 2:
Percentage of ID
mothers and HD
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3
38.9
9.5
51.6
48.4
3608
All women
18
7.5
74.5
25.5
11420
Source: Computed from DLHS-RCH, 2007-08 data files.
Note: *for only the last birth in the three years preceding the survey. Among ever married women aged 15-49 years. For some of the factors,
the numbers in categories may not add up to total due to missing information.
Annexure 3: Logistic regression results of ID and HD mothers, and safe delivery by select background
characteristics in Jharkhand, 2007-08$
Background characteristics
Institutional Home delivery assisted by Safe delivery
delivery trained health personnel
Residence
Rural @
Urban
2.064**
0.972
1.767**
Religion
Hindu@
Muslim
0.898
0.968
0.916
Christian
1.010
0.967
0.992
Others
0.980
0.981
0.973
Ethnicity
Non SC/ST@
Scheduled Caste (SC)
0.768**
0.964
0.817**
Scheduled Tribe (ST)
0.480**
0.591*
0.493**
OBC
1.075
1.056
1.052
Educational level (Years of Schooling)
Illiterate/ No schooling @
0-5
0.928
0.919
0.911
6+
1.394**
1.289**
1.390**
BPL card
Yes@
No
0.908*
0.989
0.931
Age of women (Years)
20-24@
15-19
0.765
0.942
0.816
25-29
1.073
1.031
1.067
30-34
1.247*
1.048
1.186
35 +
1.172
0.989
1.189
Age at marriage (Years)
< 18 @
> 18
0.885*
0.982
0.931
Children ever born
1@
2
3–4
5+
Pregnancy wastage
No @
Yes
ANC visits
No ANC @
1
2
3+
-2 log likelihood
R square Nagelkarke
No. of women
1.227**
0.791*
0.526*
1.136
1.016
1.173
2.596*
7618.643
0.388
11420
1.115
0.818*
0.665**
1.220*
1.085
1226*
1.506**
5199.702
0.095
9386
1.191
0.710
0.561
1.194**
1.024
1.170*
2.240**
9775.024
0.346
11420
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7.5 Page 65 |
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Source: Computed from DLHS-RCH, 2007-08 data files.
Note: $for only the last birth in the three years preceding the survey. Among ever married women aged 15-49 years. Safe delivery= institutional delivery and home delivery
assisted by doctor/nurse/LHV/ANM and health personnel @: Reference category, ** Significant level at 1 percent, * Significant level at 5 percent
Annexure 4: Percentage of women who delivered at health facilities by selected background characteristics in
study districts in Jharkhand, 2007-08
Background
characteristics
Residence
Rural
Urban
Religion
Hindu
Muslim
Christian
Others
Ethnicity
Scheduled Caste (SC)
Scheduled Tribe (ST)
OBC
Non SC/ST/OBC
Educational level (Years
of Schooling)
Ranchi
14.5
83.3
31.8
44.0
36.8
17.3
12.0
18.3
34.4
84.0
Koderma West
Garwah
S Singbhum
22.9
16.1
10.9
60.0
71.7
50.0
27.6
43.7
11.5
33.3
100.0
11.3
0.0
13.5
-
0.0
9.5
11.1
23.5
36.6
8.1
7.5
8.4
5.4
28.6
44.0
10.7
35.0
92.3
54.8
Gumla Deoghar
9.7
14.6
46.2
57.6
14.4
18.7
21.3
10.8
8.2
0.0
7.0
0.0
11.8
12.9
7.1
17.8
15.4
12.1
24.7
35.4
Illiterate/ No schooling
22.3
20.9
14.3
8.3
8.4
12.0
0-5
20.0
23.2
2.2
15.0
6.9
17.3
6+
46.2
58.1
43.6
23.2
17.5
35.1
BPL card
Yes
38.7
32.3
30.8
12.7
11.5
19.0
No
16.9
16.8
13.0
8.1
8.5
9.5
Age of women (Yrs)
15-19
21.1
49.0
32.0
22.9
14.7
14.6
20-24
34.6
36.7
26.3
13.1
14.7
17.2
25-29
29.7
27.2
22.3
13.0
9.9
19.0
30-34
23.1
16.3
25.3
5.7
9.6
12.9
35 +
15.4
5.1
11.9
4.9
4.3
20.0
Age at marriage (Yrs)
< 18
21.2
25.1
15.9
7.7
8.6
13.5
>= 18
33.7
34.4
24.7
18.2
12.6
22.2
Children ever born
1
39.3
42.4
36.7
25.9
25.5
19.3
2
34.4
33.0
24.5
13.0
11.2
17.8
3–4
20.5
28.0
19.8
7.9
4.7
13.2
5+
10.4
5.5
8.4
2.4
4.7
17.2
Pregnancy wastage
No
27.7
27.8
21.5
12.0
9.8
17.1
Yes
31.3
22.9
26.7
6.7
13.3
16.9
ANC visits
No ANC
7.1
7.2
5.0
2.2
2.8
4.8
1
25.0
57.1
20.6
10.5
9.3
16.0
2
20.0
35.2
13.2
12.0
8.2
18.3
3+
47.1
49.5
40.3
32.2
21.3
39.1
All women
27.4
27.1
21.9
10.8
10.3
16.2
Source: Computed from DLHS-RCH, 2007-08 data files.
Note: $for only the last birth in the three years preceding the survey. Among ever married women aged 15-49 years. For some
of the factors, the numbers in categories may not add up to total due to missing information.
65