This is the 20th in our series of posts by students on the job market this year
More than 2.8 million pregnant women and newborns die every year, with India accounting for one-fifth of the total deaths. Improving access to immediate obstetric care could prevent most of these deaths. Lack of maternal care also increases the incidence of chronic diseases in women and their children and has socioeconomic consequences for households and society. One of the primary factors for women to forgo healthcare services is the lack of affordable healthcare services. Thus, to increase the demand for maternal and child healthcare services, agencies implement programs to increase low-income groups' purchasing power. It is done either by increasing their incomes or reducing the prices of services. Since these programs incur a financial burden on governments, it is crucial to study whether such programs alter women’s demand for maternal services. In my job market paper, I evaluate the impact of financial incentives provided under a large-scale maternal healthcare program in India on women's healthcare behavior.
In 2005, India implemented Janani Suraksha Yojna (JSY), a conditional cash transfer program to incentivize women to utilize public institutional delivery. JSY provides a cash transfer to women 'conditional' on the use of public health institutions for childbirth. These cash transfers only cover a fraction and not the total cost of delivery care. The program aims to reduce maternal and child mortality through an increase in formal healthcare services utilization. I use JSY as a quasi-experiment to evaluate whether providing financial incentives, in the form of cash transfers, alters women’s healthcare choices and decisions. Using a difference-in-differences approach, I exploit JSY eligibility variations across individuals and states and the program's timing to estimate its impact. I conduct a test of parallel trends in pre-treatment periods for the outcomes of place of delivery to support my identification strategy.
Once pregnant, women decide where to give birth, home or hospital (public or private), and what auxiliary services to use. Her maternal care decisions are based on her financial constraints and medical awareness. A financially sound woman with information is more likely to use formal healthcare services for childbirth. I study whether JSY incentivizes women to utilize institutional delivery through cash transfers by effectively reducing delivery prices at a public health facility.
My analysis suggests that JSY has a positive effect on its targeted behavior, public in-facility delivery. JSY eligible women are 23 percent more likely to use government health institutions for delivery. This increase in public facility utilization is accompanied by a simultaneous decline in both home births and private facility delivery. In fact, the shift away from private institutions (3.73 pp) is significantly larger than home births (1.79 pp). In other words, women already using delivery care at healthcare facilities are more likely to shift to public institutions than women giving birth at home. The result suggests that many of the program's benefits accrue to those who would otherwise have chosen an institutional delivery. A possible explanation could be the magnitude of the cash transfer along with the rigid bias in low-income communities against the use of modern medicine for childbirth. As already mentioned, cash transfers are a small proportion of the total delivery cost and not enough to shift women away from homebirths. Further, the smaller decline in home births could explain the modest reduction in child mortality, measured by weekly and monthly death rates.
I evaluate the effect of JSY on auxiliary maternal care services and find an unintended effect of the program on women’s postpartum behavior. While the program increases doctor visits during pregnancy and in the early trimesters, it fails to improve postpartum care. My results show that JSY reduces the probability of a mother’s postnatal checkup by almost 17 percent. The reduction is concentrated among mothers who give birth at home and follow up with a postnatal checkup. Since there are financial and time costs associated with a return visit to the hospital, women are unenthusiastic about post-delivery checkups. With the implementation of JSY, women substitute that checkup with care received at the health institution during their delivery stay.
Another important result from the paper talks about the effect of JSY on women’s fertility decisions, and I estimate the impact of JSY eligibility on women's pregnancy timing using a discrete-time hazard model. The program's eligibility conditions require a minimum age of 19 years for first birth. My findings suggest that women shift their first pregnancy by around 3-4 months and postpone pregnancies over the age of 19 years to become eligible for JSY’s cash transfers. I also find that awareness about healthier reproductive practices through ASHAs reduces teen pregnancies, one of the largest contributors to girls’ teenage mortality. Since the program has a significant impact on women’s first pregnancy, it could positively impact girls' high school completion rates.
The research has important implications for maternal healthcare in India and financial incentives based programs worldwide. First, conditional cash transfers are effective in improving the targeted behavior. There are also unintended consequences of changing health decisions and seldom negating the program's overall positive effect. In this case, JSY increases institutional delivery; however, the program reduces the possibility of women’s postpartum checkups. Both behaviors have opposite implications for maternal mortality. Second, comprehensive healthcare services, and not just one particular service, best promote maternal and child health. Taking a cue from countries like Brazil and Mexico, including various auxiliary services such as postnatal care and nutrition assistance under the program’s umbrella, could improve health outcomes, including child mortality. The introduction of a universal healthcare program in 2011 could very well be the result of this implication. For financial incentives-based programs to reach their full implementation potential, maternal health services must be available, accessible, and of acceptable quality. Finally, even if we form a consensus on the positive effects of cash transfer programs and other forms of financial incentives, we require research for estimating the cost-effectiveness of different programs and their comparisons to recommend practical policy changes.
Deepmala Pokhriyal is a PhD student at Andrew Young School of Policy Studies, Georgia State University.