title: Addressing maternal healthcare through demand side financial incentives: experience of Janani Suraksha Yojana program in India.
abstract: BACKGROUND
  Demand side financing (DSF) is a widely employed strategy to enhance utilization of healthcare. The impact of DSF on health care seeking in general and that of maternal care in particular is already known. Yet, its effect on financial access to care, out-of-pocket spending (OOPS) and provider motivations is not considerably established. Without such evidence, DSFs may not be recommendable to build up any sustainable healthcare delivery approach. This study explores the above aspects on India's Janani Suraksha Yojana (JSY) program.
  
  
  METHODS
  This study employed design and was conducted in three districts of Orissa, selected through a three-stage stratified sampling. The quantitative method was used to review the Health Management Information System (HMIS). The qualitative methods included focus groups discussions with beneficiaries (n = 19) and community intermediaries (n = 9), and interviews (n = 7) with Ministry of Health officials. HMIS data enabled to review maternal healthcare utilization. Group discussions and interviews explored the perceived impact of JSY on in-facility delivery, OOPS, healthcare costs, quality of care and performance motivation of community health workers.
  
  
  RESULTS
  The number of institutional deliveries, ante-and post-natal care visits increased after the introduction of JSY with an annual net growth of 18.1%, 3.6% and 5% respectively. The financial incentive provided partial financial risk-protection as it could cover only 25.5% of the maternal healthcare cost of the beneficiaries in rural areas and 14.3% in urban areas. The incentive induced fresh out-of-pocket spending for some mothers and it could not address maternal care requirements comprehensively. An activity-based community worker model was encouraging to augment maternal healthcare consumption. However, the existing level of financial incentives and systemic support were inadequate to motivate the volunteers optimally on their performance.
  
  
  CONCLUSIONS
  Demand side financial incentive could enhance financial access to maternal healthcare. However, it did not adequately protect households from financial risks. An effective integration of JSY with similar social protection or financial risk-protection measures may protect mothers substantially from potential out-of-pocket spending. Further, this integrated approach may help upholding more awareness on maternal health rights and entitlements. It can also address maternal health beyond 'maternal healthcare' and ensure sustainability through pooled financial and non-financial resources.
authors.affiliation: The World Bank, Washington, DC 20433, USA. sajisaraswathyg@gmail.com
authors.forename: Saji S
authors.initials: SS
authors.lastname: Gopalan
authors.forename: Varatharajan
authors.initials: V
authors.lastname: Durairaj
mesh_terms: D036861:Delivery, Obstetric; D005260:Female; D017048:Health Care Costs; D006293:Health Promotion / Q000191:economics*; D006297:Health Services Accessibility / Q000191:economics; D006301:Health Services Needs and Demand / Q000191:economics; D006302:Health Services Research; D006801:Humans; D007194:India; D008427:Maternal Health Services / Q000191:economics*; D011247:Pregnancy; D011787:Quality of Health Care; D012424:Rural Population / Q000706:statistics & numerical data