JSY and JSSK Schemes: Indian Maternal and Child Health Programs
Janani Suraksha Yojana (JSY)
JSY is a conditional cash transfer program launched by the Government of India in 2005 under the National Rural Health Mission to reduce maternal and neonatal mortality by incentivizing institutional deliveries through direct financial payments to women who give birth in health facilities. 1
Program Structure and Implementation
- Primary objective: Accelerate reduction in maternal and neonatal mortality through increased institutional deliveries 2
- Mechanism: Women receive cash payments upon delivering in existing public health facilities 1
- Scale: Over 50 million beneficiaries since inception, representing one of the world's largest conditional cash transfer programs for maternal health 3
- State-level variation: Implementation varies dramatically by state, with 5% to 44% of delivering women receiving JSY payments depending on location 1
Documented Impact on Health Outcomes
The program significantly increased institutional deliveries by 42.6% and demonstrated measurable reductions in perinatal and neonatal mortality. 4
- Mortality reduction: Associated with 3.7 fewer perinatal deaths per 1,000 pregnancies and 2.3 fewer neonatal deaths per 1,000 live births 1
- Service utilization: Significant increases in antenatal care attendance and facility-based births 1
- High-risk populations: The scheme successfully increased institutional deliveries among at-risk mothers, including those with eclampsia, pre-eclampsia, severe anemia, and hemorrhagic complications 4
Critical Implementation Challenges
Despite increased facility utilization, significant barriers persist in targeting, quality of care, and actual benefit delivery. 2, 1
Equity and Targeting Issues
- The poorest and least educated women do not consistently have the highest odds of receiving JSY payments, indicating targeting failures 1
- Rural, illiterate, and lower socioeconomic populations showed increased utilization, but gaps remain 4
Infrastructure and Quality Deficiencies
- Poor facility infrastructure and lack of quality obstetric care 2
- Difficulties in accessing incentive payments and corruption in disbursement processes 2
- Negative behavior of healthcare personnel toward beneficiaries 2
- Poor and expensive transport facilities, particularly in difficult terrain 2
Information Gaps
- Widespread lack of awareness about MMJSSA (the Jharkhand state variant) among eligible populations 2
- Inadequate community education about program benefits and procedures 2
Janani-Shishu Suraksha Karyakram (JSSK)
JSSK was launched in 2011 as an expansion of JSY to eliminate all out-of-pocket expenditures for pregnant women and sick newborns accessing government health facilities, covering services from delivery through 30 days postpartum for infants. 5
Program Scope and Entitlements
The scheme provides comprehensive free services including delivery care, cesarean sections, drugs, diagnostics, blood transfusions, diet, and transport for both mothers and sick newborns. 5
Covered Services
- All delivery-related care in government institutions 5
- Free drugs and consumables 5
- Free diagnostic services 5
- Free blood transfusions when needed 5
- Free diet during facility stay 5
- Free transport from home to facility, between facilities for referrals, and facility to home 5
- Coverage extends to sick newborns up to 30 days after birth 5
Implementation Reality and Out-of-Pocket Expenditure
Despite the program's goal of eliminating costs, 83.5% of beneficiaries still incurred out-of-pocket expenses with a median expenditure of Rs. 1,100. 5
Utilization Patterns
- Among 200 delivered mothers studied, 67% (134) delivered in government institutions and were eligible for JSSK benefits 5
- 29% of deliveries occurred in private facilities, falling outside JSSK coverage 5
- 17% of newborns became sick within 30 days of birth 5
Persistent Barriers to Full Benefit Realization
- Unavailability of ultrasound facilities in government institutions 5
- Staff cooperation issues 5
- Poor crowd management in hospitals 5
- Inadequate supervision and service quality maintenance 5
Recommendations for Program Improvement
Continuous evaluation, facility upgradation, and constant supervision are essential to reduce out-of-pocket expenses and increase scheme utilization. 5
- Strengthen sub-center infrastructure, including capacity for conducting deliveries 2
- Deploy additional Auxiliary Nurse Midwives (ANMs) to improve access to maternal and child health services 2
- Conduct regular evaluation studies to identify utilization patterns and remove bottlenecks 5
- Improve targeting mechanisms to ensure the poorest women receive benefits 1
- Focus on quality of obstetric care in health facilities, not just increasing facility births 1
Critical Context: Emergency Obstetric Care Capacity
A major limitation is that 66% of births under JSY occur in facilities unable to provide basic emergency obstetric care, undermining the program's potential to reduce maternal mortality. 3
- Of 29 facilities capable of performing cesarean sections, none could perform all basic emergency obstetric care functions 3
- Only 13% of qualified obstetricians practice at JSY program facilities 3
- Program facilities primarily provide only parenteral antibiotics and oxytocics, with limited capacity for comprehensive emergency obstetric care 3
- Private non-program facilities provide most complicated emergency obstetric care, but most women deliver in public sector facilities 3
The fundamental challenge is that demand-side incentives (cash transfers) will only reduce mortality when matched with adequate supply-side capacity (functional emergency obstetric care facilities). 3