A decade of conditional cash transfer programs for reproductive health in India: How did equality fare?

Since 2005, India has implemented conditional cash transfer [CCT] programs to promote the uptake of institutional delivery services [ID]. The study aims to assess changes in wealth-based inequality in the use of ID and other maternal health care services during the first decade of Janani Suraksha Yojana and related CCT programs. Data from two Demographic and Health Surveys were used to calculate changes in service inequality from 2005 to 2015-16 in the use of three or more antenatal care [ANC] visits, ID, and postnatal care [PNC]. The changes were assessed at the national level, within high and low performing states [HPS and LPS, respectively] and within urban and rural areas of each state category. Erreygers Index [EI] and Wagstaff Index [WI], superior to concentration index, were used to gain different insights into the nature of inequality. EI is an objective measure of inequality irrespective of prevalence while WI is a combined measure of inequality and the average distribution of an indicator that puts more weight on the poor. The results suggest that wealth-based inequalities decreased significantly at the national level. For ID, both indices showed a decline in both HPS and LPS though the change in WI in HPS was insignificant. For ANC, there was a significant decrease in inequality using both indices in HPS but not in LPS. For PNC, there was a significant decrease in inequality using both indices in HPS, and when using WI in LPS, but not when using EI in LPS. Overall, the first decade of India's CCT programs saw an impressive reduction in EI for ID but less so for WI suggesting that the benefit of CCTs did not go disproportionately to the poor, which suggests that there is a need to reduce or eliminate the evident leakages. The improvement in uptake and inequality in ANC and PNC was not at par with ID, stressing the need to place greater focus on the continuum of care. The urban rural difference in HPS versus LPS in the changes in inequality reveals that infrastructure is important for CCTs to be more effective.