title: How equitable is the uptake of conditional cash transfers for maternity care in India? Evidence from the Janani Suraksha Yojana scheme in Odisha and Jharkhand.
abstract: In 2005, the Indian Government introduced the Janani Suraksha Yojana (JSY) scheme - a conditional cash transfer program that incentivizes women to deliver in a health facility - in order to reduce maternal and neonatal mortality. Our study aimed to measure and explain socioeconomic inequality in the receipt of JSY benefits.
  
  
  
  We used prospectively collected data on 3,682 births (in 2009-2010) from a demographic surveillance system in five districts in Jharkhand and Odisha state, India. Linear probability models were used to identify the determinants of receipt of JSY benefits. Poor-rich inequality in the receipt of JSY benefits was measured by a corrected concentration index (CI), and the most important drivers of this inequality were identified using decomposition techniques.
  
  
  
  While the majority of women had heard of the scheme (94% in Odisha, 85% in Jharkhand), receipt of JSY benefits was comparatively low (62% in Odisha, 20% in Jharkhand). Receipt of the benefits was highly variable by district, especially in Jharkhand, where 5% of women in Godda district received the benefits, compared with 40% of women in Ranchi district. There were substantial pro-rich inequalities in JSY receipt (CI 0.10, standard deviation (SD) 0.03 in Odisha; CI 0.18, SD 0.02 in Jharkhand) and in the institutional delivery rate (CI 0.16, SD 0.03 in Odisha; CI 0.30, SD 0.02 in Jharkhand). Delivery in a public facility was an important determinant of receipt of JSY benefits and explained a substantial part of the observed poor-rich inequalities in receipt of the benefits. Yet, even among public facility births in Jharkhand, pro-rich inequality in JSY receipt was substantial (CI 0.14, SD 0.05). This was largely explained by district-level differences in wealth and JSY receipt. Conversely, in Odisha, poorer women delivering in a government institution were at least as likely to receive JSY benefits as richer women (CI -0.05, SD 0.03).
  
  
  
  JSY benefits were not equally distributed, favouring wealthier groups. These inequalities in turn reflected pro-rich inequalities in the institutional delivery. The JSY scheme is currently not sufficient to close the poor-rich gap in institutional delivery rate. Important barriers to institutional delivery remain to be addressed and more support is needed for low performing districts and states.
authors.affiliation: Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands. natwutth@gmail.com.|Department of Public Health, Erasmus MC Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. natwutth@gmail.com.
authors.forename: Nattawut
authors.identifier: 0000-0002-6437-7064
authors.initials: N
authors.lastname: Thongkong
authors.affiliation: Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands.
authors.forename: Ellen
authors.initials: E
authors.lastname: van de Poel
authors.affiliation: Ekjut, Plot 556B, Potka, Chakradharpur, West Singhbhum, Jharkhand, PIN: 833102, India.
authors.forename: Swati Sarbani
authors.initials: SS
authors.lastname: Roy
authors.affiliation: Ekjut, Plot 556B, Potka, Chakradharpur, West Singhbhum, Jharkhand, PIN: 833102, India.
authors.forename: Shibanand
authors.initials: S
authors.lastname: Rath
authors.affiliation: Department of Public Health, Erasmus MC Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
authors.forename: Tanja A J
authors.initials: TA
authors.lastname: Houweling
mesh_terms: D036861:Delivery, Obstetric; D005260:Female; D005380:Financing, Government; D006078:Government Programs; D006268:Health Facilities / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000191:economics*; D054625:Healthcare Disparities / Q000191:economics*; D006801:Humans; D007194:India; D007223:Infant; D007226:Infant Mortality; D008427:Maternal Health Services / Q000191:economics*; D008428:Maternal Mortality; D009042:Motivation; D011247:Pregnancy; D012923:Social Class; D012959:Socioeconomic Factors
keywords: Conditional cash transfers; India; Janani Suraksha Yojana; Maternity care; Socioeconomic inequality