What’s Behind The Out-of-pocket Cost Problem _the Reality Of Jsy A  Cash Less Or Free Deli

Posted by Arti Kartik Sharma
April 28, 2017

NOTE: This post has been self-published by the author. Anyone can write on Youth Ki Awaaz.

  • Arti Parashar

Quite a lot of programs, schemes & campaign have been introduced by the Government to increase the demand for maternal health services including the conditional cash transfer schemes in India (Janani Surakhya Yojana), specifically among poor and marginalized. Though these programs are context specific and differ by design and implementation strategy, still they had the common goal to reduce the out-of-pocket expenditure on maternal care and increase the access to maternal services among the poor and marginalized.But different findings from NFHS 4 Data & ground realities suggests the functioning, utility and limitations of these programs. Despite these programs in place, the progress reported to achieve success in institutional deliveries still some high focused districts are facing the problem of huge amount of out of pocket expenditure.  With a view to reduce the financial burden Govt. of India launched a no. of schemes to benefit & JSY is also one of them.

Janani Suraksha Yojana (JSY)

Janani Suraksha Yojana (JSY), a conditional cash transfer programme to mitigate OOPE and to promote institutional deliveries among the poor,  of India.   It was launched on 12 April 2005 by the Prime Minister of India. It aim to decrease the neo-natal and   maternal deaths happening in the country by promoting institutional delivery of babies. This is a safe motherhood intervention under the National Rural Health Mission (NRHM). It is a 100% centrally sponsored scheme it integrates cash assistance with delivery and post-delivery care. The success of the scheme would be determined by the increase in institutional delivery among the poor families. The scheme is aimed to improve institutional deliveries & reduce MMR & also provide financial assistance during deliveries, promote & motivate women to institutional deliveries

Janani Suraksha Yojana (JSY) programme guidelines

Benefits for institutional deliver y are Rs. 1,400 in rural areas and Rs. 1,000 in urban areas. In Non High Focus states, women are eligible for the cash benefit only for their first two live births and only if they had a below poverty line (BPL) card issued by the government or if they were from a scheduled caste or tribe. Pregnant women can also receive cash assistance for ransport to the nearest government health facility for delivery. Each state determines the amount of assistance, but the minimum is Rs. 250. It is paid to pregnant women on arrival and registration at the facility. Women who deliver at home are still eligibl or a cash payment to cover the expenses associated with delivery, but only if they are 19 years of age and older, belong to BPL household and gave birth to their first or second child. Such mothers are entitled to Rs. 500 per delivery. JSY is being implemented through Accredited Social Health Activists (ASHAs), who identify pregnant women and help them to get to a health facility. ASHAs receive payments of Rs. 200 in urban areas and Rs. 600 in rural areas per in-facility delivery assisted by them in high focus states.

Does JSY reduce financial access barriers?

High OOPE is a well-known constraint to the utilization of delivery services where ready access to cash is not available for many rural households, especially the poor whose ability to pay can be mainly rely on seasonal production /crop .Most  of the women in our country/State have to spent  money (OOPE) despite of free delivery scheme (JSY). They do not have a free delivery as claimed by the public health care system. As mentioned above, in this comparison. Although the direct medical costs are not the driving force behind OOPE, but informal payments to the staff. Through the talk from the some beneficiaries we found women knew they were not supposed to make payments to the staff but they have to do it any way out of fear of not receiving appropriate care in a timely manner or they may be referred to the FRUs or nearest health facility. While Medicines, medical supplies, procedures (surgery, diagnostics and x-rays) food, user fees and referral transport are all supposed to be covered under this program still beneficiaries have to spend up to some extent. While the percentage of institutional deliveries has increased but reality of such schemes exposed when dialogues were made with beneficiaries, here are some case studies which reveal the ground realities of this scheme

However, due to several loopholes in the system, families incur numerous avoidable expenses as mentioned above. For example, Sunita Yadav of village Jhaknaud is Pohri block of Shivpuri district incurred expenditure of Rs 1570 when she Give birth to a child in January this year. This included Rs 400 (to and from hospital) as Janani Express failed to arrive, Rs 655 on food, Rs 5 as registration cost, Rs 380 as tips to nurse, washer man and sanitary staff, Rs 30 for soap and detergent and Rs 100 for clothes of child (which should also be provided by the hospital).

Another example of Anjali is resident of  village Chand Gaon in Mavai block of Mandla district incurred expenditure of Rs 1290 when she Give birth to a child in a PHC of Mavai Block this year. This included Rs 500 (to and from hospital) as Janani Express failed to arrive, Rs 600 on food & purchase of drugs Rs.1800 apart from this ,as registration cost, tips to nurse, washer man and sanitary staff cost of Rs.700  (which should also be provided by the hospital).

Such high expenses deter poor people from seeking government health facilities. It is no more a matter of access as high institutional deliveries indicate, but the lack of facilities mainly health staff in the facilities and the consequent inhumane behavior with the people who approach. This needs to be taken care of at priority.

Consequences of OOPE

-First- high out-of-pocket-expenditure (OOPE) deters families from seeking skilled/institutional care. It also make delivery care difficult to access for a large proportion. Consequently home deliveries increase the risk of maternal mortality.

-Second-Poor families make less use of healthcare services and specifically when their children are ill. Compared to the non poor, they are also less likely to recognize that their children are sick. This disparity in use and perceptions contributes to the higher rates of child and maternal illness and mortality. Out-of-pocket costs are the key factor discouraging parents from taking children for medical treatment, impacting poor more than rich families.

-Third- In such conditions in the absence of health insurance, the effect of high OOP expenditure will clearly impact on poverty, pushing especially those who are slightly above poverty line into poverty, and those already below poverty line, into further impoverishment.


Third It is also equally important to push policymakers to initiate programmes and policies to extend health coverage to a larger number of individuals at low cost with proper monitoring. While many schemes have been considered and launched, the success rates have been very low, that’s why MP remains one of the State with least health coverage & poor health services performing indicators.

Fourth Reason for people not accepting institutional deliveries for childbirth ( specially in Tribal Areas) is either the cost involved in it or the perception that home delivery is completely safe. It is need to be effective monitoring of Govt. schemes at the government level & role of ASHA as community organizer is also essential for the success of the scheme.

Here are some examples which can prove


Here are  some observations which have been drown through NFHS -4 DATA which are showing clear correlation between JSY  assistance/uptake of JSY,   for births delivered in an institution (%) & Out of pocket expenditure. The district where uptake of JSY is low only on those Districts OOP is high & the District where uptake of JSY is high OOP is apparently low.


           Districts with highest OOPE &  with more than average of MP Due to less uptake of JSY

No District OOPE JSY Assistance% Institutional Deliveries %
1 Katni 4229 49 78.4
2 Satna 3568 67 80.7
3 Tikamgarh 2274 51.2 81
4 Sagar 2198 67.9 77.6
 5 Vidisha 1913 58.4 73.7
6. Harda 1870 65.5 79.7
State Madhya Pradesh  


61.1 80.8









It is quite apparent  from the second  table that the District which are getting good assistance through JSY  their  Out of pocket expenditure is near to the ground or very low.

Districts which are in Bottom position in OOPE & highest uptake of JSY


No District OOPE JSY Assistance% Institutional Deliveries %
1 Morena 566 75.3 93.5
 2 Dindori 582 73.9 55.8
3 Sheopur 612 72.8 77.2
 4 Seoni 649 71.3 86
State MP 1387 61.1 80.8





Table:2                                                                                            FIGURE:2





States Average Out of pocket expenditure per Delivery in Public Health Facility (Rs.)  

JSY Assistance

  NFHS – 4 NFSH-3 NFHS – 4
  Urban Rural Total Total (%)
Bihar 1,777 1,718 1,724 NA 53.9
Madhya Pradesh 1,746 1259 1387 NA 61.1
Manipur 10,743 9,609 10,076 NA 26.2
West Bengal 8,783 7,400 7,782 NA 28.7




 Interpretation(Findings) from above table ;Current State of OOPE in M.P.


In order to improve financial access to institutional deliveries, Government of India launched free delivery scheme (Janani Suraksha Yojana) in public health facilities. Still   free maternity care in the public sector involved hidden costs, such as registration fees, purchase of drugs, food costs, tips and transport costs We undertook this comparison to assess the impact of this cashless delivery scheme on out-of-pocket expenditure for institutional delivery in different high focused district in M.P.

  • Despite the free childbirth scheme – Janani Suraksha Yojana (JSY) being in place for over a decade, even poorest of families in Madhya Pradesh have to shell out on average Rs 1387 for childbirth in a health institution.
  • The amount increases to average of Rs 1259 in rural areas – crushing the cash-strapped families. This has come to light in the recently released report of National Family Health Survey (NFHS)-4.
  • This entire ‘out of pocket expenditure’ (OOPE) is incurred by the way of tips to health and paramedical staff, private transport when Janani Express (government maternity vehicle) fails to arrive, food and drugs during hospital stay.
  • This entire cost is avoidable if government system works properly and thus ‘illegal’. OOPE for childbirth is thus pushing back the agenda of safe motherhood to a large extent, experts and activists working for safe motherhood and accessible health services feel.
  • An analysis of the NFHS-4 by NGO Vikas Samvad in context of OOPE and JSY shows a clear correlation between poor JSY implementation and high OOPE.
  • For example, in Katni district, the reach of JSY is only 49% while average OOPE is as high as Rs 4229. In Satna with 67% JSY reach, the OOPE is Rs 3568 while in Tikamgarh the OOPE is Rs 2274 for JSY reach of 51.1%.
  • In contrast, in Morena district with 75.3% JSY reach, the OOPE is only Rs 566 while in Dindori it is Rs 582 for 73.9% JSY reach. Overall for MP, the JSY reach is 61.1% for the average OOPE of Rs 1387.
  • At national level in states like Manipur, the OOPE is as high as Rs 10,076 as the JSY reach is pathetic 26.2% and for West Bengal it is Rs 7782 as the JSY reach is only 28.7%.
  • JSY not only provides for completely free hospitalization, transport, stay, health care, medicine and food for the mother and newborn in a government or accredited private institution, but also has provision for cash assistance of Rs 1000 in urban and Rs 1400 in rural areas. This is so that the health of mother and child is not compromised.
  • Weather the Total deliveries have increased after implementation of the scheme particularly after JSY but still OOPE is high in High focused districts.
  • The findings suggest that if the government wishes to reduce out-of-pocket expenditure one effective option would be , by increasing more efficient supply systems.( of health schemes)
  • Such high expenses deter poor people from seeking government health facilities. It is no more a matter of access as high institutional deliveries indicate, but the lack of facilities mainly health staff in the facilities and the consequent inhumane behavior with the people who approach. This needs to be taken care of at priority.




Findings from the analysis suggest that high OOPE on maternity care can be a serious constraint in utilizing quality maternity care in M.P. & also in India. Therefore, the JSY was launched to reduce maternal and child mortality, and reduce the burden of terrible maternal expenditure on households. The plan was to increase the use of prenatal care and institutional deliveries in public health facilities to counter the economic burden of (terrible expenses ) Out of Pocket Expenditure. Moreover, these are only direct expenditures. Apart from this, there are also indirect costs which need to be factored in women and some of their family members who escorted her may also lose their wages during pregnancy and delivery, which may impact negatively on households in the lower socio-economic status. Thus, Government needs to priorities its rising public health spending in general and JSY entitlements, in particular, to address the exceedingly high OOPE that many women incur for maternity care. Strengthening birth preparedness strategies and identifying complications during ANCs may reduce the incidence of terrible expenses at the time of delivery.

Writer is working with Vikas Samvad


Youth Ki Awaaz is an open platform where anybody can publish. This post does not necessarily represent the platform's views and opinions.