Step 1: Analyze the Ethical Dimensions of the Public Health Issue and Context

• Who are the main stakeholders and what values and cultural perspectives does each stakeholder bring to this situation?
• What role should the government play in improving the public’s health?

Step 2: Formulate Alternative Courses of Action and Evaluate their Ethical Dimensions

Due to a financial downturn, the government is thinking about eliminating the maternal cash incentive program. Here are 3 possible courses of action:

1. Continue the program as it is now.
2. Continue the program, but only if action is taken to smooth the cultural friction in the program.
3. Eliminate the program.

• What are the ethical implications of these options?

4.12 Case 4: Decoding Public Health Ethics and Inequity

in India: A Conditional Cash Incentive Scheme—Janani Suraksha Yojana

Divya Kanwar Bhati

World Health Organization Collaborating Centre for District Health System Based on Primary Health Care

Indian Institute of Health Management Research University

Jaipur, Rajasthan, India

e-mail: bhatidivyak@gmail.com

This case is presented for instructional purposes only. The ideas and opinions expressed are the author’s own. The case is not meant to reflect the official position, views, or policies of the editors, the editors’ host institutions, or the author’s host institution.

4.12.1 Background

The domestic sphere of home and family defines the lives of most women in India, where they assume the role of caregiver, either as wife or mother. Overall, age and sex govern the household’s hierarchy of authority, older over younger, men over women. Women, especially those living in northern India, experience decreased autonomy and increased inequalities in all areas of life (Iyengar et al. 2009; Bloom et al. 2001). Limited autonomy harms women’s maternal health outcomes, restrict- ing their ability to choose safe childbirth options. In India, most births still occur in the home; less than 41 % occur in an institutional setting (International Institute for Population Sciences 2007).

Worldwide, more than half a million women die each year from complications during pregnancy and childbirth (UNICEF 2009). About 99 % of these deaths occur in developing countries. Based on maternal mortality trends from 1990 to 2008, developing countries, especially India, contribute about 18 % of the global burden of maternal deaths (Dikid et al. 2013). Data during 2007 through 2009 indicated that India’s maternal mortality ratio (MMR) was 212 per 100,000 live births (Registrar General of India 2011). Regional differences in MMR are found in India; during 2007 through 2009 the MMR in northern states was 308/100,000 compared with 207/100,000 in the southern states.

India has had a long history of redistributive poverty-reduction programs, but few programs provide direct cash assistance to the needy (Mehrotra 2010). Cash incentive programs started in the 1990s predominantly in Latin America where their success led to adoption in other parts of the world (Powell-Jackson et al. 2009b). These programs vary in size and scope; examples include programs that address vaccinations, educa- tion, health care, safe childbirth, sterilization, and poverty. An example from an Asian country is the Safe Delivery Incentives Programme (SDIP), which was started in

4 Disease Prevention and Control 117

2005 in Nepal with funds from the U.K. Department of International Development and the Nepalese government (Powell-Jackson et al. 2009a; Karki 2012). The pro- gram provided cash incentives to women who gave birth in health facilities and to health providers for each attended delivery (either in the woman’s home or in a facil- ity). The program implementers or administrators expected that the cash incentive would reduce transportation barriers and delays in maternal care seeking (Bhandari and Dangal 2012). The program was most effective in changing health care-seeking behavior wherever women’s groups highlighted the importance of effective commu- nication of the policy to the public (Powell-Jackson et al. 2008). Women exposed to the program were 24 % more likely to deliver in government health institutions, 5 % less likely to deliver at home, and 13 % more likely to have their delivery attended by a skilled health worker. Deliveries in government health institutions went from 34 % in the first year (2005/2006) to 59 % in the third year (2007/2008). Overall, the pro- gram was well received, however certain aspects of the policy were not accepted, including a condition that limited receipt of the cash incentive to women who had no more than two living children (Powell-Jackson et al. 2008).

India’s conditional cash transfer program, Janani Suraksha Yojana (JSY), is one of the largest programs of its kind in the world (Lim et al. 2010). JSY is funded through the central government, provides welfare to women living in indigent fami- lies, and includes efforts to empower women to choose institutional childbirth rather than home delivery.

JSY represents a novel and useful way to ensure the social welfare of women by integrating cash assistance with childbirth delivery and post delivery care. The pro- gram focuses on poor pregnant woman, especially those living in states with high MMRs and low institutional delivery rates. These low-performing states include Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir (Tiwari 2013). An important component of this program is its focus on monitoring, evaluating, and providing, health care for the mother and her baby (Lim et al. 2010). District-level household surveys have documented a decline in the proportion of home deliveries, which dropped from 59 % in the 2002–2004 survey (International Institute for Population Sciences 2006) to 52 % in the 2007–2008 survey (International Institute for Population Sciences 2010).

Despite indicators of success, the JSY program has raised a number of concerns. One of the aims of JSY is equity in addition to coverage; the JSY program does not include private health care providers. The increased deliveries (from 35 % to 65 %) in public health care facilities may raise issues in the quality and standards of health care (MacDonald 2011). Another concern is that the lack of comprehensive emer- gency obstetric care at many institutions compromises the safety of institutional deliveries (International Institute for Population Sciences 2010). A final concern is that socioeconomic status, caste, and education create large inequities in access to the program’s cash incentives, while women who do gain access lack financial con- trol over the cash incentives (Gopichandran and Chetlapalli 2012).

118 M.J. Selgelid

4.12.2 Case Description

A 19-year-old woman from a poor area in India is pregnant for the first time and only weeks from her delivery date. Wearing a long pardah to cover the lower half of her face and traditional maang tikka jewelry on her forehead to indicate married status, her attire reflects the traditional values embedded in her culture. She wants to deliver her baby in her home village, which is an overnight’s journey away. But her husband and in-laws have other ideas. They have just learned of a government pro- gram that provides a cash payment of 1000 rupees to women who opt for institu- tional delivery over home delivery. Her mother-in-law insists that the delivery take place in their district institution. The woman’s parents, believing the in-laws to be driven purely by greed, support their daughter. With encouragement from her par- ents, the woman disobeys her husband and in-laws to travel to her parent’s home, but goes into labor on the road and loses her child due to complications in the deliv- ery. The young woman not only is disconsolate over the loss of her child, she must now face the wrath of her husband and in-laws.

This is a poignant case, but only one in a dossier full of similar cases that you, as the state director for the maternal cash incentive program, have read that involve clashes between traditional ways and the incentive program. As a result, you have decided to convene an expert panel to consider recommendations to smooth not only the cultural friction the program is causing, but also the program’s impact on the quality and safety of care, as well as access to it.