Demand-side financing in Promotion of Maternal Health Challenges

and issues
Providing quality maternal healthcare still remains a major concern in India, even after
several schemes and programmes launched by the Centre and state governments.
As per UN Millennium Development Goals (MDGs), though India committed to a 75%
reduction in maternal mortality when you look at the progress made so far suggests that
India is unlikely to achieve its target by 2015. According to a recent estimate, the maternal
mortality ratio has come down to 200 maternal deaths per 100,000 live births from the
previous 600 in 1990 and 390 deaths in 2000. While, Brazil reported only 56, Russia 34 and
China 37 deaths per 100,000 live births.
Since Independence, the broader concept of Maternal Health has been fragmented under
different ministries such as Ministry of Health and Family Welfare, the Ministry of Women and
Child Development, and among state-level policymakers resulting in several policies and
schemes being formulated for better maternal healthcare and control child mortality. The
several launched programmes aimed at promote maternal health can be broadly divided
into four period/phases.
The first phase, which ran for about 15 years, focused on community healthcare and
introduced auxiliary nurse midwives (ANMs) reducing dependence upon dais (traditional
midwives). Second phase started during 1960, where the governments focus shifted to
family planning and maternal health got sidelined by policies for birth control. In the third
phase (Late 1970s & 80s), family welfare programmes made way into the policy book of the
health ministry and focus was on child mortality issues. It created an exclusive department
for family planning under the ambit of the Ministry of Health and Family Planning; maternal
health services were also brought under this department. During the period, maternal health
got sidelined by policies for birth control. However, during the period Indias maternal
mortality issue attracted attention of international agencies including the United Nations,
which later saw a group of UN agencies launching a safe motherhood initiative in 1987. Its
only in the 1990s and after, government shifted its focus more towards providing essential
maternity services including incentives for pregnant women to come to hospitals for check
up and delivery, nutrition, immunization, child survival and trained ANMs. Schemes such as
Janani Suraksha Yojana (JSY), administered by the NRHM, National Maternity Benefit Scheme,
Indira Gandhi Matritva Sahyog Yojana (IGMSY) at the national level and state level schemes
such as Chiranjeevi Scheme in Gujarat, etc.
The introduced demand-side financing (DSF) schemes by the government to promote
maternal health can be divided into four broad categories - unconditional cash transfers
(condition being pregnant, targeted at poor women), conditional cash transfers, short-term
payments and vouchers (aims at providing maternal services through private sector where
public services are not unavailable).
The unconditional cash transfers, for instance, the Dr Muthulakshmi Reddy Memorial
Maternity Assistance Scheme (DMRMMAS) launched in 1995 provided unconditional
payments to women until 2005. Later it was merged with JSY and payments then became
conditional on skilled attendance at birth.

Conditional cash transfers aimed at improving diet of pregnant and breastfeeding women.
Here, in order to avail the cash benefits, women need to attend antenatal care and checkups for neonates, e. g. the IGMSY launched by the central government that provides Rs
4,000 to poor women, and state-level schemes such as the Prasuti Aaraike, Mamata, and
DMRMMAS introduced in Karnataka, Odisha, and Tamil Nadu where cash benefits range from
Rs 2,000 to Rs 12,000.
Under the vouchers or voucher-based schemes category, several state-level maternal health
programmes were launched which have provisions to provide cashless antenatal,
intrapartum, and postnatal services to women with BPL and caste/tribe card holders through
private healthcare centres. For example, schemes such as Chiranjeevi scheme in Gujarat
and Sambhav voucher scheme in Uttar Pradesh. It is one among the most popular DSF
schemes in the country.
Challenges in DSF schemes in India
However, studies show that maternal health programmes that use DSF aiming to increase
utilisation of key maternity services and reduce maternal mortality had flaws that resulted in
not achieving 100% success in the maternal mortality reduction and increasing maternal
health. There are few obstacles in implementing the programmes and monitoring the impact
beyond the utilization of the benefits. The limitations were many such as, studies shown that
the postnatal follow-ups were absent in many cases; incentives were for the ANMs to report
adverse outcomes in their communities, etc.
The outcome of the DSF schemes is largely dependent upon how a certain policy/scheme is
implemented among the needy. There are few shortcomings. First, as most DSF schemes
take into account BPL card or the tribe/caste certification as eligibility criteria, in this
scenario women without the necessary documents such as migrants get excluded from the
benefit. Second obstacle being the age-based criteria of minimum of 19 years for many
schemes, many women are neglected due to this age restriction. Third, the stigma
associated with poverty in India stands as a barrier for the poor women in certain cases,
where they are disrespected as beggars when they ask for their entitlement of the free
healthcare at healthcare centres and being denied medical supplies. Fourth, poverty, social
exclusion, gender-based discrimination still prevails in many parts of the country which
stands as an obstacle to certain cash transfers and short-term payment schemes. Fifth, poor
women with less information or no information about the facilities available at private
healthcare providers under the voucher scheme often left out availing any maternal health
services. Also, in certain cases the voucher schemes under the private providers are not
lucrative enough to attract many beneficiaries. Sixth, as cheques are used in cash transfer
schemes in order to reduce third-party corruption, this poses an obstacle among women
without bank accounts. It often leads to giving the entitled amount in the hands of the family
member who may not use the money for the desired purpose of using it for nutrition and
treatment of the pregnant lady. Seventh, recent studies also found instances where poor
women are often asked to pay for basic health amenities such as for medicines, transport,
health check-ups, food, etc, which stands as a deterrent in bringing more pregnant women
to take up professional help.
Not many studies were done to measure the effectiveness of the DSF to promote maternal
health and reduce the maternal mortality rate. At a time when India failed to avail complete

benefit out of the SDF scheme, studies show similar DSF have been used in improving social
status of women in many ways. In Armenia, for instance, a voucher scheme that focused on
womens right to healthcare services is believed to spread awareness among women and
increased their dignity. Another programme in Mexico, a conditional cash transfer
programme, Oportunidades, that focused on child and maternal health, enhanced the
autonomy of poor women within their family by increasing their income.
The country needs to relook at its policies and schemes which are aimed at improving
maternal health and reducing maternal mortality. The need of the hour is to scrutinize the
DSF schemes or policies, do a proper follow-up of the postnatal care, study the beneficiaries,
rearranging the eligibility and guidelines in order to widen its reach and bring in more
beneficiaries under it, in addition to strengthening its community healthcare facilities and
bringing in more schemes for better autonomy for women. Both the Centre and state
governments should focus on further investments in building more infrastructure in
healthcare system in order to reach the rising 1.2 billion of population in the country.