Assessing demand-side financial interventions for maternal and neonatal health in Bihar, India

Abstract

India has implemented demand-side financing programs, including Janani Bal Suraksha Yojana (JBSY) and Pradhan Mantri Matru Vandana Yojana (PMMVY), to reduce financial barriers and improve maternal and neonatal health outcomes. This study assesses their implementation and equity in Bihar, India. A cross-sectional survey across eight districts (N = 1,247) with qualitative interviews (n = 42) revealed severe deficits in awareness, coverage, and timeliness. Notably, 69.7% of women were unaware of PMMVY, and 13.7% were unaware of JBSY. Registration rates were low: 56.0% for JBSY and 2.4% for PMMVY. Only 39.0% of JBSY beneficiaries received payments within 30 days post-delivery. Significant socioeconomic inequities emerged: women from scheduled castes/scheduled tribes and those without formal education were markedly less likely to register or receive benefits. While JBSY beneficiaries incurred lower out-of-pocket expenditure (INR 1,509 vs. INR 2,619), persistent costs, delays, and informal payments undermined financial protection. Qualitative findings identified complex documentation, low digital literacy, and distrust in banking as barriers to Aadhaar-linked direct benefit transfers (DBT). Overall, the potential of conditional cash transfers remains constrained by low awareness, delayed payments, restrictive eligibility, and structural inequities. Strengthening impact requires robust awareness campaigns, simplified DBT systems with grievance redressal, targeted outreach to marginalized groups, and supply-side improvements.

Keywords

Conditional cash transfers / Maternal health / Health equity / Out-of-pocket / xpenditure / Scheme awareness / Direct benefit transfer / Implementation science / Bihar

References

[1] Ahmed, S., Shommu, N. S., Rumana, N., Barron, G. R. S., Wicklum, S., & Turin, T. C. (2016). Barriers to access of primary healthcare by immigrant populations in Canada: A literature review. J Immigrant Minority Health, 18(6), 1522-1540. https://doi.org/10.1007/s10903-015-0276-z

[2] Banerjee, R., Singh, B. S., Sahrawat, N., et al. (2025). Effect of India’s flagship conditional maternity benefit scheme on utilization of maternal and child health services: Evidence from a statewide evaluation study. BMC Pregnancy and Childbirth, 25(1). https://doi.org/10.1186/s12884-025-07416-3

[3] Bano, N., Dahiya, R., & Kumari, A. (2020). A Review Critical: Impact Assessment of Janani Surakshya Yojana (JSY) in Terms of, Knowledge, Attitude and Service Utilization Pattern of Women Beneficiaries. International Journal of Current Microbiology and Applied Sciences, 9(12),3553-3562. https://doi.org/10.20546/ijcmas.2020.912.422

[4] Bogg, L., Diwan, V., Vora, K. S., & DeCosta, A. (2016). Impact of alternative maternal demand-side financial support programs in India on the caesarean section rates: Indications of supplier-induced demand. Maternal and Child Health Journal, 20(1), 11-15. http://doi.org/10.1007/s10995-015-1810-2

[5] Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa

[6] Brinda, E. M., Rajkumar, A. P., Enemark, U., Prince, M. J., & Jacob, K. S. (2012). Nature and determinants of out-of-pocket health expenditure among older people in a rural Indian community. International Psychogeriatrics, 24(10), 1644-1653. http://doi.org/10.1017/S104161021200083X

[7] Comptroller and Auditor General of India. (2017). Performance audit report on reproductive and child health under National Rural Health Mission. Government of India. Available from: https://cag.gov.in/uploads/download_audit_report/2017/Report_No.25_of_2017_-_Performance_audit_Union_Government_Reproductive_and_Child_Health_under_National_Rural_Health_Mission_Reports_of_Ministry_of_Health_and_Family_Welfare.pdf

[8] Devkota, H. R., Clarke, A., Murray, E., Kett, M., & Groce, N. (2021). Disability, Caste, and Intersectionality: Does Co-Existence of Disability and Caste Compound Marginalization for Women Seeking Maternal Healthcare in Southern Nepal? Disabilities, 1(3), 218-232. http://doi.org/10.3390/disabilities1030017

[9] George, A. (2007). Persistence of high maternal mortality in Karnataka, India. Reproductive Health Matters, 15(30), 91-102. http://doi.org/10.1016/S0968-8080(07)30318-2

[10] Glassman, A., Duran, D., Fleisher, L., et al. (2013). Impact of conditional cash transfers on maternal and newborn health. Journal of Health, Population and Nutrition, 31(4 Suppl 2), 48-66.

[11] Gupta, S. K., Pal, D. K., Tiwari, R., et al. (2012). Impact of Janani Suraksha Yojana on institutional delivery rate and maternal morbidity and mortality: An observational study in India. Journal of Health, Population and Nutrition, 30(4), 464-471. https://doi.org/10.3329/jhpn.v30i4.13416

[12] Hunter, W., & Sugiyama, N. B. (2014). Transforming subjects into citizens: Insights from Brazil’s Bolsa Família. Perspectives on Politics, 12(4), 829-845. http://doi.org/10.1017/s1537592714002151

[13] Jain, A., Singh, S., Choudhary, A., Jain, A., & Choudhary, A. (2017). Maternal health-care seeking behavior in North India. Journal of Family Medicine and Primary Care, 6(2), 265-269. https://doi.org/10.4103/2249-4863.219999

[14] Kapilashrami, A., & Hankivsky, O. (2018). Intersectionality and why it matters to global health. The Lancet, 391(10140), 2589-2591. http://doi.org/10.1016/s0140-6736(18)31431-4

[15] Kruk, M. E., Gage, A. D., Joseph, N. T., Danaei, G., García-Saisó S., & Salomon, J. A. (2018). Mortality due to low-quality health systems in the universal health coverage era: A systematic analysis of amenable deaths in 137 countries. The Lancet, 392(10160), 2203-2212. https://doi.org/10.1016/S0140-6736(18)31668-4

[16] Kumar, A. K. S., Chen, L. C., Choudhury, M., et al. (2011). Financing health care for all: challenges and opportunities. The Lancet, 377(9766), 668-679. https://doi.org/10.1016/S0140-6736(10)61884-3

[17] Lagarde, M., Haines, A., & Palmer, N. (2007). Conditional cash transfers for improving uptake of health interventions. JAMA, 298(16), 1900-1910. https://doi.org/10.1001/jama.298.16.1900

[18] Lim, S. S., Dandona, L., Hoisington, J. A., James, S. L., Hogan, M. C., & Gakidou, E. (2010). India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: An impact evaluation. The Lancet, 375(9730), 2009-2023. https://doi.org/10.1016/S0140-6736(10)60744-1

[19] Mahapatro, S. R., & Sethy, M. (2025). Maternal satisfaction in health facilities during childbirth and newborn survival in Bihar State of India. Discover Public Health, 22(1), 212. https://doi.org/10.1186/s12982-025-00574-x

[20] Ministry of Finance, Government of India. (2025). Economic survey 2025-2026. Government of India. Available from: https://www.indiabudget.gov.in/economicsurvey/

[21] Mohanan, M., Miller, G., Menon, P., & Tarozzi, A. (2019). Micro-evaluation of PMMVY program delivery in Madhya Pradesh. J-PAL. Available from: https://www.povertyactionlab.org/initiative-project/micro-evaluation-intervention-improve-implementation-pmmvy-program-delivery

[22] Mohanty, S. K., & Srivastava, A. (2013). Out-of-pocket expenditure on institutional delivery in India. Health Policy and Planning, 28(3), 247-262.https://doi.org/10.1093/heapol/czs057

[23] Paul, V. K., & Srivastava, A. (2016). Assessment of JSY implementation in high focus states. Ministry of Health and Family Welfare, Government of India.

[24] Peters, D. H., Garg, A., Bloom, G., et al. (2008). Poverty and Access to Health Care in Developing Countries. Annals of the New York Academy of Sciences, 1136(1), 161-171. http://doi.org/10.1196/annals.1425.011

[25] Powell-Jackson, T., Mazumdar, S., & Mills, A. (2015). Financial incentives in health: Evidence from JSY. Journal of Health Economics, 43, 154-169. http://doi.org/10.1016/j.jhealeco.2015.07.001

[26] Rasanathan, K., & Diaz, T. (2023). Research on health equity in the SDG era: the urgent need for greater focus on implementation. International Journal for Equity in Health, 15(1). http://doi.org/10.1186/s12939-016-0493-7

[27] Bano, N., Dahiya, R., & Kumari, A. (2020). A Review Critical: Impact Assessment of Janani Surakshya Yojana (JSY) in Terms of, Knowledge, Attitude and Service Utilization Pattern of Women Beneficiaries. International Journal of Current Microbiology and Applied Sciences, 9(12), 3553-3562. https://doi.org/10.20546/ijcmas.2020.912.422

[28] Ray, S., Chakrabarti, S., Pal, S., Nguyen, P. H., Scott, S., & Menon, P. (2025). Can Rights-Based Conditional Cash Transfers Improve Children’s Nutrition at scale? Evidence from India’s Maternity Benefit Program. medRxiv. https://doi.org/10.1101/2025.01.12.25320443

[29] Reddy, K. S., Patel, V., Jha, P., Paul, V. K., Kumar, A. S., & Dandona, L. (2011). Towards achievement of universal health care in India by 2020: a call to action. The Lancet, 377(9767), 760-768. http://doi.org/10.1016/s0140-6736(10)61960-5

[30] Sample Registration System. (2020). Special bulletin on maternal mortality in India 2016-2018. Office of the Registrar General, India. Available from: https://censusindia.gov.in/nada/index.php/catalog/34781/download/38469/SRS_MMR_Bulletin_2016_2018.pdf

[31] Sardar, S. S., Majee, B. K., Mandal, M., et al. (2025). Conditional cash transfer for safe delivery in India: utilisation and inequalities with reference to NFHS-5. BMC Public Health, 25(1). https://doi.org/10.1186/s12889-024-20952-5

[32] Sen, S., Chatterjee, S., Khan, P. K., & Mohanty, S. K. (2020). Unintended effects of Janani Suraksha Yojana on maternal care in India. SSM - Population Health, 11, 100619. https://doi.org/10.1016/j.ssmph.2020.100619

[33] Sethy, M. (2025). Beyond calories: Roots and tubers for health equity and sustainable development. Global Journal of Human-Social Science, 25(H2), 67-77. Available from: https://socialscienceresearch.org/index.php/GJHSS/article/view/104372

[34] Sethy, M., & Mahapatro, S. R. (2025). India’s Changing Diet: Millets, Processed Foods, and the Nutrition Crisis. Journal of Economic Development, Innovation and Policy, 1(1), 53-63. https://doi.org/10.55578/jedip.2508.004

[35] Sethy, M., & Mahapatro, S. R. (2026). Structural inequalities and dietary diversity in Odisha: Evidence from NSSO 68th and 79th rounds. Scientific Reports, 16, 2876. https://doi.org/10.1038/s41598-025-32743-y

[36] Sharma, B. B., Jones, L., Loxton, D. J., Booth, D., & Smith, R. (2018). Systematic review of community participation interventions to improve maternal health outcomes in rural South Asia. BMC Pregnancy and Childbirth, 18, 327. http://doi.org/10.1186/s12884-018-1964-1

[37] Sidney, K., Diwan, V., ElKhatib, Z., de Costa, A. (2012). India’s JSY cash transfer program for maternal health: Who participates and who doesn’t - a report from Ujjain district. Reprod Health, 9(1). https://doi.org/10.1186/1742-4755-9-2

[38] Srivastava, A., Gope, R., Nair, N., et al. (2015). Are village health sanitation and nutrition committees fulfilling their roles for decentralised health planning and action? A mixed methods study from rural eastern India. BMC Public Health, 16(1). https://doi.org/10.1186/s12889-016-2699-4

[39] Vellakkal, S., Gupta, A., Khan, Z., et al. (2016). Has India’s National Rural Health Mission reduced inequities in maternal health services? A pre-post repeated cross-sectional study. Health Policy and Planning, 32(1), 79-90. https://doi.org/10.1093/heapol/czw100

[40] Vora, K. S., Koblinsky, S. A., & Koblinsky, M. A. (2015). Predictors of maternal health services utilization by poor, rural women: a comparative study in Indian States of Gujarat and Tamil Nadu. Journal of Health, Population and Nutrition, 33(1). https://doi.org/10.1186/s41043-015-0025-x