What gets measured gets done - but about outcomes?
Nirvikar Singh’s recent piece on Janani Suraksha Yojna (JSY) (see link) is a welcome call to address the ‘social determinants’ of health. The causes of the causes, so to speak, of illness and mortality, like education, environment and income are indeed key indicators of women’s health status and survival.
Specifically regarding JSY, however, most evaluations miss one critical issue: the quality of services. While JSY promotes institutional delivery for a woman through a financial incentive, there is no guarantee that she receives the proper services that she deserves. In fact, most JSY-used facilities are overcrowded, often with more than one woman sharing a bed.
Accountability mechanisms rightly focus on the question of inputs - are funds being disbursed – but what measure of the recipient’s care? The true measure of JSY’s success will be to see if more women are actively seeking care before, during and after delivery from a properly equipped institution. And more critically, do they receive quality care?
If we are to look at the larger issue of gendercide and ‘saving India’s women’, we must look much further than institutional delivery. The deeper accountability issue is if women can access basic health services, well before pregnancy. For example, I find that gynecological infection is the most common health complaint amongst SEWA’s members across 9 states of India. Yet if they try, women cannot access basic treatment at the primary or block level in most parts of rural India. Gynecologists are not posted, pap tests are not available, and laboratory diagnosis for reproductive tract infections is unheard of – leaving women with expensive private care or none at all. Even she is undernourished, hemoglobin testing, food supplements and iron pills are limited to pregnant women.
Thus by the time a pregnant woman interacts with the public health system under JSY, the underlying causes of maternal mortality have long taken root. After her 24 hour delivery stint at the hospital, she is likely to remain far from institutions, at least until the next delivery.
To truly improve women and mother’s health, primary women’s health services – health information, nutritional support and gynecological care to start – must be available at the local level. In addition to the ASHA worker, we have a legion of dais highly skilled at providing women with doorstep health services. Though a pregnant woman may travel long distances for a delivery with a financial incentive, she certainly cannot sacrifice a day’s earnings for primary care. Locally available health care will promote her overall health status, which of course also equips her for a safer delivery at an institution if she chooses. And when she does seek that care under JSY, she must be entitled to quality.
Sapna Desai is Health Coordinator for the Self Employed Women’s Association (SEWA) Bharat, a national federation of women workers across 9 states.