JSSK Intervention and Maternal Mortality & Morbidity in India
By: Nikki Mahendru
During the 21st century, the Indian government has focused more on improving the sexual and reproductive landscape of its’ citizens, specifically to reduce the incidence of maternal mortality within the country. With a population of close to 1.3 billion, of which, 21.9% of people live below the poverty line, and 68.4% of its population live in villages, there exists an unequal distribution in quality of care and access to healthcare (1). The focus of the Indian government during this era with respect to reproductive health had previously been focused on population control. However, given the most recent interventions implemented by the government, they are slowly shifting away from population control methods and looking to improve access to existing healthcare systems for their expecting mothers. The Indian government has targeted reducing the MMR in two main ways as demonstrated by the allocation of its’ public health funds: (1) 68% of its family planning funds have been on the funding of female sterilization, and (2) 13% on recruiting Accredited Social Health Activists (ASHA) to work as skilled attendants during deliveries in rural areas (2). Sexual and reproductive health progress has therefore been largely focused mostly on reducing MMR to below 70, in accordance with SDG 3.1. Initiatives during this time have been through the lens of accessing existing systems, rather than through reproductive rights or transforming gendered norms lenses. The most recent and successful country wide initiative with respect to maternal mortality, Janani Shishu Suraksha Karyakram (JSSK), will demonstrate this idea of bridging the disparity in accessing healthcare systems as opposed to working to influence the broader cultural and societal that have impacted the perception and reception of sexual and reproductive health in India.
Since 2014-2016 the maternal mortality rate across India dropped from 130 to 113 in 2016-20183. This is indicative of the broad progress made to improve maternal mortality across the country. However, in disaggregating this data, there are marked differences between wealthier states with a greater proportion of literate populations versus that of poorer states4. The poorer states have been categorized by the Indian government as the “Empowered Action Group States (EAGs)”, which include Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal, and Uttar Pradesh. States like Kerala have an MMR of 46 while states like Uttar Pradesh have an MMR of 199, as recorded in 20164. Furthermore, in directly comparing the MMRs of rural areas of EAGs versus urban areas of wealthier states, the MMR comparison reads 397 versus 1154. Taking a closer look into the differences between rural and urban regions and its’ impact on MMR, it can be seen that the disparity in MMR between such regions is inflated by (1) lack of awareness regarding the risk factors of pregnancy (2) differential development due to socioeconomic level (3) poor infrastructure in healthcare, terrain, and communication5. These areas also have disproportionately high fertility rates when compared to the national average, indicative of an unmet need for contraceptives and lack of family planning. Given the expenditure of the Indian government on family planning programming as a means to control population, it is clear that these states have historically not been on the receiving end of such funding.
The Janani Shishu Suraska Karyakaram (JSSK) Scheme (program), was launched on June 1st, 2011 by the Indian Ministry of Health and Family Welfare, in an effort to benefit expecting mothers in the rural areas of EAG states and across India and reduce maternal mortality (6). The purpose of the program is to ensure that women have the ability to deliver in government institutions with adequate infrastructure, skilled attendants, and proper quality of care. The intervention would provide free services to pregnant women, including those who need C-sections, as well as proper care of sick newborns for 30 days after birth. Among the provision of free delivery, it would also include free drug treatment, diagnostics, blood transfusion, transportation, and food, with the dissemination of government funds and reimbursements to expecting mothers. The program has a 3-pronged approach: (1) to encourage women to seek care beyond their households and communities (2) to eliminate out of pocket expenses incurred by expecting mother before, after, and during delivery, and (3) to connect women who would otherwise deliver at home due to the inaccessibility of quality health care institutions through the provision of transportation (7). The JSSK program compounds on the Janani Suraksha Yojana (JSY) program instituted in 2005, wherein women received subsidized rates and cash assistance for delivery and post-delivery care. After recognizing that transportation in physically connecting women to healthcare facilities, as well as out of pocket expenditures remained a barrier to women receiving adequate gestational care, the JSSK program was implemented. In addition to aiming to provide free services and transportation, the JSSK program retains the integration of community health workers (otherwise known as accredited social health assistants, ASHA), in linking communities to healthcare facilities (8). The ASHA, women who are selected by local communities based on national guidelines, receive training by the Indian government over the span of a year, and are expected to work to create awareness regarding sexual and reproductive health. They are specifically incentivized to disseminate information regarding birth prepared ness and registering women for 3 antenatal visits and 2 post-natal visits and facilitate access to healthcare services for mother and child. They also serve as the point women in disseminating information regarding JSSK and receive monetary compensation for each woman that is registered in a public health care facility and gives and institutional birth ()8. It has been found the ASHA have also helped during the time of delivery and care in the institutions in playing the role as negotiators between patient and providers in better establishing a working relationship between vulnerable populations and larger institutions. They have also negotiated to reduce additional out of pocket expenses not covered by JSSK (9).
Target outcomes of the JSSK program included the increase in institutional deliveries in rural areas, increase in number of women who received proper antenatal, delivery, and postnatal care, reduction in maternal and neonatal mortality, and reduction of out of pocket expenditures. On average institutional deliveries increased greatly among all states, and in regions like rural Haryana it nearly tripled (10). Since 2005, the number of institutional deliveries as a consequence of JSSK have increased from 40.7% to 72.9%, with the number of institutional deliveries averaging an increase of 37.5% across various states. This is the only consistent change across all states (9). Of the institutional deliveries a large majority of deliveries were in public sector hospitals rather than private sectors. Alongside the increase in institutional deliveries, the number of women registered for antenatal and post-natal care increased as well (11). A non-significant decrease in MMR of 6.84% was observed following the intervention in Rajasthan, one of the EAG states (12). However, the overall uneven decrease in maternal mortality rate across India as mentioned previously has been attributed to the success of this program in mainly urbanized regions, with disparities remaining within rural regions. The neonatal death rate reduced by 1.32%, with an increase in NICU admission rate and a significant decrease in preterm mortality by 12.99% (13). Out of pocket expenditures remained consistent and high, with an average expenditure of $11.14 with an ASHA present and $16 without. This was largely due to overcrowding in public sector hospitals resulting in the necessity for women to pay hospital staff for beds, buy supplies from private clinics, and laboratory expenses through private laboratories.
The JSSK program ultimately had a significant impact on the number of institutional deliveries across all of India. It also provided sufficient ante-natal registration through the use of ASHA workers. However, with respect to its goal to decrease MMR in regions plagued by high fertility rates, low socioeconomic status, and low literacy as in the EAG states, the JSSK intervention alone is not sufficient. While the intervention attempts to address the structural factors like faulty infrastructure, communication, lack of economic mobility, by increasing access to public institutions both economically and physically, on the ground efforts do not meet the stipulated goals. The primary reason for this is continued lack of awareness among vulnerable populations regarding the details of how to effectively utilize the program. A large majority of out of pocket expenditures resulted from women not knowing that transportation is subsidized. On the ground, there is an inherent limitation regarding the resources available to provide for the Indian population. With public institutions overly burdened by the implementation of JSSK, women who would have otherwise opted to stay at home were forced to expend their income on entitlements that would have otherwise been free. Additionally, often times the transportation that was to be provided to these women were non-responsive, largely due to constraints in the population to be serviced. Thus, the number of women having institutional deliveries were often the same women who were pushed further into poverty due to the lack of proper resourcing available, preventing them from seeking care in the future. It is clear that JSSK is instead an attempt to remedy the symptoms of an overburdened healthcare system. Given this, it is clear that this is not a scalable intervention, as the underlying structural barriers within existing healthcare systems are not remedied.
JSSK does little to address the broader cultural and gendered norms within the same rural populations that are affected by biases with respect to women’s health care and mobility. Given that child marriages are a large component of rural and lower socioeconomic status families, the heightened rate of MMR within these regions that JSSK intended to alleviate, were not addressed. Since early pregnancies have a higher risk of complication and need for medical attention, while JSSK gets these women into the healthcare system it does not serve as a preventative measure in stopping such practices. Additionally, in considering the gendered lens within these regions, the patriarchal familial structure is a large component of the cultural context, limiting female mobility in family planning and asserting her healthcare. While the ASHA volunteers serve as a vestibule for the female voice within this intervention there is not a gender transformative approach to increase female agency in the space of reproductive health and wellness. Finally, JSSK does not include extended provisions for unsafe abortion related mortality which is a preventable cause of maternal mortality. This further disadvantages those within socioeconomic and regionally vulnerable groups.
In sum, JSSK is an early attempt from shifting the focus of maternal mortality from population control to providing equitable access to women across the heterogenous regions in India. However, even in physically accessing public healthcare institutions, proper treatment is inhibited by over burdening out of pocket costs associated with a strained healthcare system, indicating that this is not the ideal form of scalable and sustainable intervention to address maternal mortality. Furthermore, had JSSK been supplemented by efforts to increase family planning and gender transformative education within EAG states and their rural regions, it would have provided a more effective intervention to reduce stigma associated with healthcare systems, female centered care, and increasing awareness regarding the early warning signs of a high risk pregnancy. Thus, it is critical that future interventions compound on the early efforts made by JSSK by asserting rights based and eventual gender transformative lenses, to alleviate the burden of maternal mortality within the most vulnerable populations in India.
References
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