India & Mexico
Key country characteristics
- India: Lower-Middle Income country in South Asia
- Mexico: Upper-middle income country in Latin America & Caribbean
The Indian government launched the Janani Suraksha Yojana (JSY) CCT program in 2005 in reaction to under-utilization of skilled birth attendants throughout India. The program provided a cash incentive for institutional deliveries, though specific implementation details – such as who received a CCT, the size of the incentive, and parity-determined eligibility - differed by state.1 JSY has since reached 52 million beneficiaries. The anticipated outcomes and impact of this program were increased institutional delivery and in turn decreased maternal and neonatal mortality. Despite a documented increase in institutional births during the five years following implementation of the program, studies have not found a corresponding decrease in maternal mortality. Authors suggest two potential explanations: women with complications who are most likely to benefit from an institutional birth may not be entering the program, and/or while more women are accessing services, the quality of services is poor, and as a result, there is no impact on health.1 Thus, as in the case of the reduced user fee program in Burundi, this program demonstrates the necessity of developing reliable systems to identify recipients and ensuring that the incentivized services are high quality. Quality, in particular, is a demonstrated bottleneck to measurable improvement, even when mechanisms are in place to ensure financial access.
A CCT program established in 1997 in Mexico was designed to address both supply and demand-side interventions to improve quality of care. This program – called Oportunidades – provided cash transfers to women upon completion of a prenatal care plan and educational program. The educational program was designed to empower women to seek care, identify quality care, and advocate for their health needs.2 Women in low-income households within marginalized communities were eligible for enrollment, and compliance with conditions was tracked through certification at public clinics and schools. Higher quality care was measured by indicators assessing receipt of prenatal procedures consistent with national clinical guidelines. Enrollees were found to receive 12.2% more prenatal procedures, and this increase was not attributable to increased utilization alone. Researchers concluded that this improved quality was likely due to the empowerment component of the program; women who received the educational program were able to more effectively advocate for their health needs. Oportunidades demonstrates how CCTs can be used to promote knowledge and health literacy in addition to incentivizing service utilization.