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

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.