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Incentives For Service Delivery Jhimly Baruah National Health Systems Resource Centre New Delhi, India.

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Presentation on theme: "Incentives For Service Delivery Jhimly Baruah National Health Systems Resource Centre New Delhi, India."— Presentation transcript:

1 Incentives For Service Delivery Jhimly Baruah National Health Systems Resource Centre New Delhi, India

2 The background In India, 67000 women die every year from pregnancy or pregnancy related causes Since the 1980’s successive programmes have attempted to address the high MMR and IMR There have been considerable decline in India’s MMR in the last two decades: from 398 in 1997-98 to 212 in 2007-09 Yet, this is far off from the MMR goal of less than 100 per 100000 live births.

3 The Evolution National Rural Health Mission (NRHM) launched in 2005 : provide equitable, accessible and affordable health care – Reduction in MMR to 100/100,000 is one of its goals – The Janani Suraksha Yojana ( Safe Motherhood Scheme) is the key strategy to achieve this reduction

4 Rationale Institutional deliveries would help the pregnant woman access a team of skilled birth attendants more reliably and it would also improve her access : – emergency obstetric care – reduced maternal and neonatal mortality The scheme offers a package of financial incentives to pregnant women to improve access to institutional deliveries.

5 Rationale The Janani Suraksha Yojana ( JSY) itself was built on two past schemes : – one for referral transport (Rs. 700 i.e. $ 11 ) – maternal entitlement of Rs. 500 ($8) during pregnancy, intended to provide support to improve nutritional status. (National Maternity Benefit Scheme) In JSY the dominant explanation became one of a “cash transfer” that hinged on a condition -whether the pregnant woman chose to deliver in an institution or not. The scheme envisaged that other parallel inputs into facility strengthening would prepare the facilities to meet the increased caseloads that JSY would lead to.

6 JSY :The package of Incentives Low performing states Rs.1400 ($23)to mothers in rural areas Rs.1000 ($16) in urban areas Rs. 600 ($10) to ASHAs Institutional delivery package Rs. 500 ($8) to mothers- being BPL, above 19 yrs of ages, ST/ SC Home delivery package High performing states Mothers : Rs. 700 ($12) in rural areas Rs.600 ($10) in urban areas Rs.200 ($ 4) and 350 ( $6) in tribal areas) to ASHAs Institutional delivery package Rs. 500 ($8)to mothers- being BPL, above 19 yrs of ages, ST/ SC Home delivery package

7 The impact The JSY was immediately successful and the results were impressive : – From 200,000 beneficiaries in 2006, the number of beneficiaries rose to over 10 Million within a span of 4 years and is still rising.. – Resulted in phenomenal growth in institutional deliveries, evident from population surveys (DLHS-3 and CES, 2009) : Institutional Delivery in rural areas increased sharply from 47% in 2007-08 to 72.9% in 2009 – This is also reflected in the resultant decline in Maternal Mortality from 254 maternal deaths in 2004-06 to 212 during 2007-09 (Source: Sample Registration System-RGI). The JSY continued to expand in its reach, achieved scale ( in terms of increased volume of intuitional deliveries in health facilities, but... A number of major concerns began to emerge !

8 Key findings from JSY evaluation Findings from NHSRCs evaluation (Pg0ramme Evaluation of the Janani Suraksha Yojana, NHSRC, 2011-12): Positive “The JSY has unarguably resulted in an increase in institutional deliveries, and has enabled poor women to access public health facilities.” Concerns The first major concern was that there was a disconnect between the quality of care theoretically expected of deliveries in “institutions” and what was actually available in terms of clinical and supportive care in the institutions The second concern was whether this programme was reaching the poorest and most marginalised. Persistence of home deliveries –40% in most districts. Further : High Out of Pocket Expenses on : OPD fee, diagnostic tests, admissions, blood, on purchase of drugs and consumables from the market Spending on transport from home to facility and back Spending on diet which was not provided in the facilities Over all on institutional delivery average spending ranged between Rs 1400 ($23) to Rs. 1600 ($26) – a deterrent to seeking care in the public hospital !

9 The study re-emphasizes that safe motherhood need to be reviewed in a context where care for the antenatal women, post partum mother and newborn need home based care Key consensus emerged on the need to eliminate out of pocket expenses for both pregnant women and sick neonates It became clear that unless such care reached a basic minimum threshold, the number of beneficiaries would increase, but would not be matched by commensurate reductions in maternal and neonatal mortality because the quality of care and the management of complications were not improving in parallel.

10 So what did we do Prioritised a few facilities for strengthening of MCH services - ‘Delivery Points’, by strengthening the supply side,for providing a certain level of care and improving quality of care – Inputs : HR, infrastructure, drugs, equipment, referral transport, institutional linkages Launched the Janani Sishu Suraksha Scheme ( Safe Mother and child scheme) to reduce Out of Pocket expenditure Follow-up Actions

11 The JSSK mandate Objective :Reduce OOP and improve access to health facilities Covers the entire spectrum of ante natal care, intra natal care and post natal care for pregnant women in the institutional setting. Entitlement for pregnant women/mothers include Free drugs and consumables Free Essential diagnostic (ANC,INC,PNC up to 6 weeks) Free diet during stay (Up to 3 days for normal and 7 days in case of C-section) delivery Free blood Free transportation/drop back after48hrs Nil user charges Free entitlements also extended to sick new born up to 1 year of age

12 JSSK : Following up..on implementation  GOI mandate to NHSRC for monitoring of implementation  Concurrent assessment of progress made by states with regard to the entitlements for pregnant women and new born Success User Fee Removed from OPD and IPD Referral transport mechanism firmly in place for home to facility Partial Success Inter facility transfers Drop back home started Drugs and consumables Diagnostics Dissemination of entitlements Yet to take off Provision of diet Grievance Redressal mechanism

13 So what did JSSK do ? Service guarantee : It is ensuring free and cashless services to the poor who pay indirect taxes Works as a tax based assurance – assured and guaranteed services in government health facilities Removed User fee..but OOP persists - removing user fee is not necessary eliminating out of pocket expenditure

14 Summary :JSY and JSSK JSY-financial incentive is a maternity entitlement and a means of empowering women The JSY incentives combined with the JSSK entitlements, paves the way for ensuring equity and rights of the poor Builds pressure on the system – which needs to be accelerated and sustained The success of both the schemes hinges on strengthening of health systems The JSSK is a huge leap forward in the quest – `Health for All’

15 In Conclusion Financial and non financial incentives stimulate the demand for services and work well in resource constraint,setting to trigger behaviour change Incentives work as a enabler – a tipping point at best ! Supply side needs to be strengthened in parallel - necessitates overhauling of old systems. In service delivery, emphasis on quality of care – a minimum threshold needs to be assured The ultimate objective is towards strengthening of health systems

16 Let us ensure these basic health rights for every mother and her India moves towards universal health coverage !

17 Thank you....Terima Kasih ! E mail :

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