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JANANI EXPRESS: A practical solution

INTRODUCTION:

The Janani express scheme launched by the Health department of the MP government on

15th August 2006 is a strong and innovative measure in the stride of reducing the MMR and

the IMR as envisioned by the National Rural Health Mission. The scheme was launched with

an idea that it would help in a big way to bring down the performance of the state in terms

of RCH indicators , the state has had been performing badly at. There was an astute

understanding behind it, as the MP is not only the largest state in terms of area but is

predominated by tribal areas with poor connectivity and inaccessibility to the cities/ towns

and still follow those traditional practices like home delivery etc.

Initially it was planned that the scheme would be implemented in the two blocks of each of

the 10 selected districts in the first stage. The districts selected for initiation of Janani

Express scheme included Dindori, Morena, Raisen, Hoshangabad, Damoh, Panna, Jabalpur,

Rajgarh, Shivpuri, and Ratlam.

The other 38 districts also received directives to initially start Janani Express in at least one

block in their district. Presently the Janani Express Scheme has been functioning for more

than 2 years in all the districts with a guideline of atleast one JSE per block which would

eventually be increased to two JSE per block.

NEED OF THE STUDY:

MP has different models of JES - the hi-tech Guna Model to NGO partnership based

model in Dewas and the simplified original version of the model. Thus MP can serve as a

good filed to carry out a comparative analysis and gain learning lessons from the

process. It is important to be able to devise a cost effective, generally replicable model

Analysing the performance and costing of the model is important to understand the

sustainability of Janani Express. It is sustainable till the JSY scheme is functioning but

presently no long-term strategy has been evolved for its continuity. At present, there is

no financial contribution from the state fund. Transport cost under JSY scheme is the

main source of financing the scheme.

As per the data upto March ’08, 12, 96,740 women have availd the benefit of the Janani

Express scheme and it is operational in 298 blocks with a total of 371 vehicles.The

current utlilization rate in terms of the state average is around 25% of institutional

deliveries conducted in government health facilitiesb ,making it imperative to analyse

the factors acting as barriers to access and leading to under-utilization

The MP govt is now planning to collaborate with EMRI and in this context it is important

to understand if the current model can be made self sustainable /profitable and more

efficient or does the state need to go for more resource intensive model like EMRI. Or if

a mix of these models can be devised to find a custom based model with necessary

contextualization.

METHODOLOGY:

The Janani Express scheme has been poorly documented on the web and on the

Government of Madhya Pradesh website and the information available is superficial. A

broad framework was developed to gain an insight into the scheme and critically analyse it

to gain learning lessons from the scheme and understand its viabilility and replicability. The

study involved capturing the views of all the stake holders and practically observes the

functioning of the scheme. One of the most important components of the analysis being the

costing and financials of the model.

The first phase involved meeting the key persons at the state level who were involved in the

policy making. A series of the meetings were held with the health commissioner, the Joint

Director, the Deputy Director dealing with the scheme, the State Programme manager, the

maternal health consultant, Child health consultant and consultants of some of the other

organizations who have been working in MP in alliance with the Govt of MP. The discussions

were also held with the MIS managers and the finance unit of the state health office. The

documents and data pertaining to the scheme were collected in the first phase.

The second phase of the study involved going to the districts and the block level to

understand the ground realities and practical implementation of the scheme. The districts

were selected based on few criteria and the selection was made in consensus with the Joint

Director and the SPMU. The three districts were chosen for the field visit. The selection of

each district was based on a rational and selection-mix was created.

The one thought process was to create a mix by choosing one proximal and the one an

extremely distant area. The district Vidisha was chosen one, because the Janani express was

never discontinued in Vidisha and the proximity was the other factor.

Amongst the proximal areas, the Janani express had stopped in Seahore, Hoshangabad and

Raisen etc after introduction of the new flat rate policy while it was still continuing in

Vidisha, thus it felt important to analyse it also in terms of the factors responsible for

ensuring continuity of the scheme. The District Vidisha is a strong political base of BJP and

there is a strong political influence in the area.

The Distt Balaghat on the one hand, is a remote and an extremely tribal and naxalite area,

with extreme accessibility issues and thus very much in need of a scheme like Janani Express

and but has still performed extremely well on the health indicators, as reported by the latest

DLHS survey. It was also thought important to see the availability and functionality of the

health facilities in such a remote area and understand the role of the Janani Express in the

success of the district. The Janani Express has been operating on a different call centre

based model in Guna and has gained popularity over the years, thus it was felt necessary to

study and document this model and see if this could be a workable solution to cover the

gaps, if any , existent in the standard Janani Express Model.

Nearly three to four days were spent per district which involved the discussions with the

CMHO, Civil Surgeon, District Programme Manager, District Accounts Manager, members of

the RKS and Collector of the District (wherever possible). The District Hospitals were visited

and the discussions were held with the RKS accountant, the Gynaecologists, Staff Nurses. A

detailed interview of the Janani Express driver was taken and the log books were seen. The

rounds of the Maternity wards and Labour rooms were taken and Discussions were held

with the women admitted in those wards. The idea was to understand that in practice how

many women actually knew about this service and have used it. The experiences of the

beneficiaries were captured in Detail and the discussions were also held with the

motivators, ASHA/ Dai etc. The JSY registers were also compared with the log books.

The 2 blocks per district were visited and the selection was made so as to cover one CHC,

one PHC and a Sub centre .The visit to the sub centre level were made to see the utilization

of the scheme at the bottom of the pyramid, in the remotest of areas where there is no

facility for institutional delivery and the dependence on the Janani Express is high. The

meetings were also held with the Block Medical officers.

The areas visited in Vidisha were-Pipal kheda, Pipal Dhar, Shamshabad and Barkheda

Jagar and Ganj Basoda.

The areas visited in Balaghat were-Lalburgha, Lanji, Bahiyar and Risewa

The areas visited in Distt Guna were -Bamori, Jhagad and Rahogar

At the CHC level, discussions were again held with the BMO, gynaecologists, Staff Nurses,

RCH accounts Manager, the RKS accounts Manager and the Janani express driver and the

contractor. The maternity wards and the labour room of the hospital were visited, the

experiences of the beneficiaries were captured and discussions were held with the Dais and

Aanganwadi workers.

At the PHC and the Sub centre level, the health facility was visited and discussions were held

with the health staff and the JES driver wherever possible.

FGD with village people were conducted in some villages falling on the way to understand

the reach and awareness of the scheme to a common man.

The third phase of the study involved analysing the scheme documents and the physical and

financial reports collected from various levels and analyse the qualitative aspects of the data

and documenting it into a report.

SCHEME DOCUMENT ANALYSIS

The Janani Express scheme is a Public –Private partnership model based on contracting-out,

where the contract is signed between the Government and the private vehicle provider who

is generally a local transporter. The JANANI EXPRESS is basically a vehicle (four wheeler

jeep/ Tata Sumo / Mahindra types, running with diesel) hired locally for periods of one year

on the basis of outsource criteria to ensure provisioning of 24 hrs transport availability at

the field level (Block level) in order to bring the pregnant women to the health institutions.

Though the state Health society frames the standard contract document and lays down

certain guidelines on specifications and sharing of responsible, the actual contract is signed

between the District level authorities with the private contacting agency. The invitations are

called for by releasing an open tender as per the guidelines laid by the state health society

and accordingly the contracting agency is selected.

The term Ambulance has purposely not been used and the term Janani Express has

purposely been coined for the vehicle so as avoid general people confusing it for an

ambulance as it is doesn’t have all the facilities a typical ambulance is ought to have. The

primary aim is to provide a means for safe transportation. Also, the primary purpose of the

scheme is to promote institutional deliveries and in case of need, it may be used for other

purposes listed in the guidelines.

Guidelines and Salient features of the scheme as lay down by the state Government:

Observation

Nature of the model PPP(Outsourcing)

Coverage Overall state

Ownership of vehicle Private

Availability of vehicle 24 hrs Usually, The vehicles are available 24 hrs, except in some cases

when vehicle is out of order at times or is engaged attending

other cases.

Duration of contract One year

Type of vehicle Jeep/Maruti van/Ambulance YES

Specifications for

vehicle:

Not older than 24 months This specification is not followed in all cases, in case of non

availability of any other option but in most of the cases, it is

followed

Having comprehensive

insurance

Some of the ambulance drivers do not have any comprehensive

insurance

Valid Driving license with driver Available with almost all the drivers met

Having valid registration and

vehicle fitness certificate

Available with almost all the cases but most of the drivers do not

keep the registration papers in the car

Security deposit –Rs 1000/-DD

submitted to the RKS

In 100% of cases

Purpose of the vehicle:

Provide transportation

for

All pregnant women for

institutional delivery

In practice, Janani express is being used mainly for this purpose

only. Also only records and reporting for this purpose are

maintained and not for others.

The scheme is usually propagated for providing facility to the

pregnant women for delivery and not for other purposes as laid

down in guideline

Any complication during

Antenatal/ post natal phase

Not used, no records kept

Sick children to public health

facility

Rarely used, no records kept

Any Medical Emergency Not used, no records kept

2nd and 3rd ANC or MTP

(Institutional ) for BPL women

Not used, no records kept

Those entitled under Deen

Dayal Antyodyaya yojana

Not used, no records kept

Facilities in the vehicle Not more than 24 months old Lack of options , so not always followed

A long back seat for lying down Available

Folding stairs Not available

Portable drinking water and

forced lightning facility

Not available

A folding stretcher Not available

A curtain between the driver

seat and the back seat/rear of

the vehicle

Available in some cases

Disposable Dai kit Not available, was provided but not replenished

Cotton, bandage,savlon, sanitary

napkins etc

Not available, was provided but not replenished

Funding Transport money available

under JSY. Funds from RKS

Monitoring &

Implementation

Rogi Kalyan Samiti, RCH - State

and District Program

management Units

SHARING OF RESPONSIBILITIES: PUBLIC VS PRIVATE

Responsibility of the contracted Agency Responsibility of the

Government

Observations

POL & Maintenance: Provide petrol, oil and

lubricants (POL)

YES

Preventive maintenance of the vehicle and

repairs

YES

Payment of Road tax, toll taxes and parking

charges

YES

Compensation to the clients in case of any

accident.

Salary and overtime of driver having valid

driving license..

YES, but Drivers are grossly underpaid for the job, plus

job is difficult for just one driver

Availability of alternate vehicle in case of

breakdown of the vehicle

Not followed in all the cases. Provided only in few

instances by the contractors

The Agency will provide mobile phone to the

driver and district society will make a

payment of Rs. 200 per month to the driver

for outgoing charges

The drivers are usually using only personal mobile

phones and the numbers keep on changing with

change in driver

Wide publicity to mobile phone of the driver Not any dedicated effort seen, no not displayed on the

vehicle as well

Deposit Rs. 10000 as security with RKS Yes

Provide uniform and name badge to the

driver

Not seen in case of even a single drive

Ensure 24 hours availability of vehicle in

designated health institution's premises.

Immediately make alternate arrangements

following breakdown of vehicle

Usually available 24 hrs in case not out of order or

engaged attending some other case

Submit all vouchers, copy of the updated

vehicle logbook and cash collected to

respective RKS by 3rd of each month.

Done but log books are incomplete, not properly

maintained and no standard format is followed,

leaving the scope for manipulation in case of Km based

payment

IEC Activities No IEC guidelines are being followed except labeling

the vehicle on back and front glass as Janani express.

Wall paintings in some areas

First Aid Training to the Driver Conducting 2-3day first Aid training for the driver is the

responsibility of the civil surgeon but was not seen

even in a single case.

Disposable TBA/ Dai kits, Cotton

bandage, Dettol, soap, first Aid kit

Was made available but not replenished. Not found in

even a single vehicle out of those seen

Payment of cases Policy changed from Km based to the Flat rate policy of

Rs 250/- per case

PAYMENT MECHANISM

Prasoota

Parivahan

yojana

Janani Express:

Old guidelines

Janani Express:

Old guidelines

Janani Express:

New guidelines

Remarks

Funding Separate

Budget

allocated but

separate

Departmental

Budget for

treatment and

investigation

may be used

Transport money

available under

JSY. Funds from

RKS

Transport money

available under

JSY. Funds from

RKS

Transport money

available under JSY. Funds

from RKS

There is

confusion

over if the

variable

component

of payment is

to be

managed

from

Administrativ

e expenses

under JSY or

RKS.

Payment

to the

Beneficiary

Rs 300/- to the

pregnant

woman

A rural area

woman is paid Rs

1400/-and an

Urban area

woman is paid Rs

1000/-on

institutional

delivery

A rural area

woman is paid Rs

1400/- and an

Urban area woman

is paid Rs 1000/-on

institutional

delivery

A rural area woman is

paid Rs 1400/- and an

Urban area woman is paid

Rs 1000/-on institutional

delivery

Women were

being paid Rs

500 on home

delivery by a

trained

personnel

till……….and

No money is

paid on

home

delivery now

Transfer of

money to

the

beneficiary

The on-duty

Medical officer

or the staff

Nurse have the

money and give

it to the patient

during

admission

The on-duty

Medical officer or

the staff Nurse

have the money

and give it to the

patient on

delivery

The on-duty

Medical officer or

the staff Nurse

have the money

and give it to the

patient on delivery

The on-duty Medical

officer or the staff Nurse

have the money and give

it to the patient on

delivery

Payment

to the

Motivator

Rs 200/- to the

motivator( ASH

A/DAI/ AWW

AsHA/DAI were

given Rs 350

(Rs 600-Rs 250) in

case they used

Janani Express to

bring pregnant

woman else they

used to get full Rs

600/-

AsHA/DAI/ AWW

were given Rs 350

(Rs 600-Rs 250) in

case they used

Janani Express to

bring pregnant

woman else they

used to get full Rs

600/-

AsHA/DAI were given Rs

350

(Rs 600-Rs 250) in case

they used Janani Express

to bring pregnant woman

else they used to get full

Rs 600/

AWW are no

more

considered to

be motivator

as their being

involved in

this scheme

used to

hamper their

duty in

Aanganwadi

In case of

Referral

The mother will

again get Rs

300/- but

motivator will

not get any

extra benefit

over Rs 200/-

No extra money is

paid either to

Pregnant woman

nor to the

motivator

No extra

money is paid

either to

Pregnant

woman nor to

the motivator

No extra money is paid

either to Pregnant

woman nor to the

motivator

already paid

Payment

to the

contracted

Agency

Flat payment

structure

irrespective of

distance

Daily minimum 40

Kms travel or

minimum 1200

Kms travel per

month. If the

travel is more

than 1200 kms

per month, the

vehicle owner will

be entitled for

incentive:

Up to 25% more

of minimum Kms

per month (up to

1500 Kms per

month) -- No

incentive

25 to 50% more

of minimum Kms

per month (1500

to 18000 Kms per

month) -- 25% of

monthly contract

50 to 100% more

of minimum Kms

per month (1800

to 2400 Kms per

month) -- 35% of

monthly contract.

The payment has

been divided into

two components:

Fixed: : upto 1200

Kms amount of

payment to be

made is fixed

Variable

component: above

1200 Kms, the

payment is made

on Kms basis

Both the figures

for the fixed and

variable

component are

decided upon at

local level , based

on the lowest bid

received in

response to an

open tender

advertisement

Policy changed from Km

based to the Flat rate

policy of Rs 250/- per case

No

incentive

was paid to

the driver

and /or the

agency

Transfer of

payment

to the

contracted

Agency

The contracted

agency is

supposed to

submit the log

book and all the

receipts to the

The contracted

agency is

supposed to

submit the log

book and all the

receipts to the

The contracted

agency is supposed

to submit the log

book and all the

receipts to the RKS

by the 3rd of every

The contracted agency is

supposed to submit the

log book and all the

receipts to the RKS by the

3rd of every month and

RKS is supposed to clear

RKS by the 3rd

of every month

and RKS is

supposed to

clear the

payment within

a week , max by

10th of every

month

RKS by the 3rd of

every month and

RKS is supposed

to clear the

payment within a

week , max by

10th of every

month

month and RKS is

supposed to clear

the payment

within a week ,

max by 10th of

every month

the payment within a

week , max by 10th of

every month

Role of RKS If RKS gets

more collection

than the

monthly

contract

amount, it will

be treated as its

income. And, if

RKS gets less

collection than

monthly

contract

amount, the

deficit will be

borne by RKS.

If RKS gets more

collection than

the monthly

contract amount,

it will be treated

as its income.

And, if RKS gets

less collection

than monthly

contract amount,

the deficit will be

borne by RKS.

If RKS gets more

collection than the

monthly contract

amount, it will be

treated as its

income. And, if

RKS gets less

collection than

monthly contract

amount, the deficit

will be borne by

RKS.

If RKS gets more

collection than the

monthly contract amount,

it will be treated as its

income. And, if RKS gets

less collection than

monthly contract amount,

the deficit will be borne

by RKS.

EVOLUTION OF THE SCHEME

The present day scheme Janani express is a modified version of a scheme known as Prasav Hetu

Parivahan Yojna which was conceptualized and implemented by the Madhya Pradesh government

even before the umbrella Programme, National Rural Health Mission came into being. The Madhya

Pradesh Government can rightly claim of having been the first state government to have put into

practice an innovative solution of providing emergency transportation to women for delivery.

Though the Prasav Hetu Parivahan Yojna and the thus evolved Janani Express are based on the same

idea, but in practice, they are variants of each other when the policy structure and guidelines are

compared.

The Prasav Parivahan Yojana came into force from Sept 2004 and the Janani Suraksha yojana came

in to Presence in 2005 with the rolling out of the NRHM. The PRASOOTI Parivahan Yojana was the

brain child of Mr PS Madan Mohan, UNICEF.The state kept on running Prasav Parivahan Yojana with

an idea of providing benefit to those not entitled under JSY. A point of transition came with a

particular government order which extended the benefit of JSY beyond BPLs and provided universal

coverage to all pregnant women only in the EAG states, with the Madhya Pradesh being one of

them. This new change in the Janani Suraksha scheme ensured that all the pregnant women

delivering at the institutional Health facility will be provided financial incentive under these scheme,

with the incentive amount being Rs 1400/- for the tribal and rural area woman and Rs 1000/- for the

woman staying in urban area.

The Prasav Parivan Yojama was running for quite sometime in parallel to the JSY but it was later

realized that since the JSY was providing the universal coverage to all pregnant women irrespective

of APL/BPL discrimination, the Prasav Parivan Yojama could be rolled back.The interviews with the

various concerned officials at the state and the district level revealed that the innovative Jananai

Express Scheme d is the brain child of` Sh. Uma kant, the then collector of the Chattarpur who

piloted the scheme in his area. The scheme was started in 2006. The Janani express was envisioned

to address the geographical inaccessibility issue due to lack of transport facilities leaving people with

no choice but to go in for the home delivery. The scheme was also envisioned to act as a support

scheme to the already running JSY as a facility of safe and timely transport to the health facility in

case of delivery was presumed to enhance the institutional deliveries and even optimize the

utilization of the Janani Suraksh Yojana. The Jananai express scheme was conceptualized based on a

deep-rooted thinking and understanding of the socio-economic realities. The most of the people in

the rural area own a motor bike or a tractor (four-wheeler) and with the introduction of the financial

benefit/ incentive under JSY, the figures for the institutional delivery were rising. The pregnant

women would come on a bike or a tractor to get her delivery conducted at the health acility, which

was not only risky but could also lead to complications. The risk of bleeding on the way or the

delivery on the way with no paramedical personnel or medical help could increase the IMR and

MMR and thus defeat the very purpose of theJSY.

The Janani Express was introduced based on the felt need of providing a safe transportation facility

to the pregnant women to ensure the right to a safe delivery. The issue of the financial viability of

the scheme was addressed by linking Janani Express to the Janani suraksha Yojana. As per the Janani

express, Rs 250/- out of the motivators incentive is deducted in case she utilized the Janani Express

vehicle to bring the lady to the health facility and she is paid Rs 350/- out of the Rs 600/- Which are

otherwise paid to the motivator and includes the incentive of the motivator plus the transportation

cost. The Pregnant women are paid the full money she is entitled to, Rs 1400/- in case of being from

tribal /rural area or Rs 1000/- If from urban area.

COMPARATIVE ANALYSIS OF PRASAV HETU PARIVAHAN YOJNA & JANANI EXPRES SCHEME

Parameters Prasav Hetu Parivahan Yojna Janani Express scheme

Year of the

Implementation

Sept 25, 2004 2006

Catchment area All parts of Madhya Pradesh All parts of Madhya Pradesh

Nature of Scheme A flat amount (irrespective of distance etc) given

to reimburse Financial cost of transportation of

pregnanant lady to the health facility plus some Entitled Beneficiaries All SCs/ STs pregnant women not in the BPL

category

All pregnant women irrespective of being from

Rural or Urban area

Benefit on an

institutional Delivery

Rs 300/- to the pregnant woman and Rs 200/- to

the motivator( ASHA/DAI/ AWW)

Rs 1400/- to a woman from rural area and Rs

1000/- to a woman from urban area

Who can be a

motivator

ASHA/DAI/ AWW ASHA/ DAI but AWW used to be considered

motivator till some time back but not anymore

as her involvement in this scheme was found to In case of more than

motivator

the money would be given to only one suggested

and approved by the mother

the money would be given to only one

suggested and approved by the mother

In case of Referral The mother will again get Rs 300/- but motivator

will not get any extra benefit over Rs 200/-

already paid

No money is paid again either to the pregnant

woman or the motivator

Variability in amount

of Benefit

A flat rate scheme , No discrepancy on basis of

distance, Urban/ Rural etc

The policy has now been changed from variable

to a flat rate scheme

Designated Health

facility

A health facility where 24 hrs deliveries are

conducted- PHC/ CHC/ FRU/ Distt Hospital Or

A government health facility where 24 hrs

deliveries are conducted- PHC/ CHC/ FRU/ Distt

HospitalPost-Delivery stay in

Hospital

3 days 2 days

Target for the scheme 20% of the estimated deliveries in the district No targets set

Source of Budget

Funding

Separate Budget allocated but separate

Departmental Budget for treatment and

investigation may be used

Transportation cost under JSY given to

motivator and extra expenses from

Administrative head of RKSTransfer of money to

the beneficiary

The on-duty Medical officer or the staff Nurse

have the money and give it to the patient during

admission

The on-duty Medical officer or the staff Nurse

have the money and give it to the patient during

admissionProof of eligibility SC/ST category card, All pregnant women delivering at public

institutional health care facility

IEC -Block Medical Officer has to get it done though

Filed workers

- Urban set-up : Prabhari /CMHO

-Distt/ Block level: Women and child

Development, Education Dept,Panchyart

Scheme put on Public display at entrance of

hospital, Outside the ANC clinic

The pamphlets and IEC material has to be

prepared by government (state level) plus

making wall paintings is Govts responsibility but

whose exactly, is not clear. There is lack of

accountability due to lack of clarity

There is lack of clarity on whose responsibility is

of getting prescribed IEC material painted on

Janani Express. There is discrepancy in the

guidelines and the tender document prepared. Monitoring and

Evaluation

CMHO/Civil surgeon/ chief Administrative officer

of the Hospital will visit min.3 Health

facilities/month to check implementation of the

CMHO,BMO,RKS at grass root level AND state

health society under NRHM

STRENGTHS

The JES intervention is an innovative effort for complementing JSY scheme for promoting

institutional delivery in Madhya Pradesh where poverty, distances and transportation are major

problems.

Commitments of highest state level policy makers and administrators were responsible for

conceptualization and initiation of scheme in few blocks in the first stage. Regular and close

review of the block medical officers by principal secretary (Health & FW) and senior officers of

the directorate was responsible for putting this scheme in to operation.

Fairly well defined protocols and guidelines for initiation of the scheme have been developed for

hiring the vehicles and for implementation of the scheme, by utilizing transport cost available

under JSY scheme.

Wide publicity to the scheme with active participation of highest level political leadership in the

state has helped to create awareness about the scheme

ISSUES

Purpose of the scheme:

The Policy or the scheme document states that the Janani Express model was conceptualized and

implemented to provide pregnant mother a safe transportation facility to the health care facility and

address the geographical accessibility issue, which is one of the main reason for women opting for

home delivery in absence of a choice, as highlighted as a key finding by various studies and surveys

conducted. The basic tenet behind introducing the Janani express is to promote institutional

deliveries and thus improve the performance of the state on the MMR and IMR indicators the state

of Madhya Pradesh has been performing badly at.

The policy document states that the purpose of the scheme would be to provide a means for

emergency transportation for mother and children and other Medical Emergencies. The main Aim of

the scheme in the document has been stated as ensuring a 24 hrs availability of a vehicle facility for

the transporting a pregnant woman to the health facility for institutional delivery. The list of

conditions or situations under which a beneficiary is entitled have been laid down in the document

as per which Janani Express scheme is expected to provide transport services for institutional

delivery, emergency during pregnancy or after delivery and for seeking post abortion complications,

any illness related to Deendayal Antyodaya Upchar Yojana, child illnesses and any medical/surgical

emergency.

In practical operation, the Janani Express is being used exclusively for providing pregnant women, a

safe transport facility to the health institution for delivery.There are very rare cases, where the

vehicle was used for carrying Sick children except in Guna Where it has been linked to the Sick new

born care unit attached to the hospital. There was not record available for any client availing

transport facilities for post abortion complications (important causes of maternal mortality).

Discussions with the community members revealed that Very few people know that it can be used

for afore mentioned purposes other than delivery and there is a general understanding that the

Janani Express is a vehicle which can be called over phone in case of the need of taking a pregnant

woman to the health centre for delivery .

During the discussions, the CMHOs and the BMOs expressed their limitations in practically executing

the scheme as per the laid down guideline. The Medical officers and BMOs admitted to not

propagating about the other purposes of Janani Express so as to avoid a situation of Demand side

Moral Hazard which is very likely to occur in case of a free service like Janani Express and can defeat

the main purpose of the scheme. The doctors have left it to their discretion to call Janani Express if

required for transporting case other than a delivery case.

Thus there is a lack of clarity of understanding the real objectives of the scheme and HOW it must be

executed in context of ground realities and practical issues faced in process of implementation.

It has been reported that the major chunk of the RCH and even RKS funds are going towards

supporting the JSY.

Non Payment in cases other than Delivery

The other reason for the non-utilization of the scheme for purposes other than the delivery is

absence of any clause for the payment for cases other than the delivery. The payment in case of an

institutional delivery brought by Janani Express is made from the JSY and the RKS funds but there is

no guideline on the payment mechanism in case of other purposes the Janani Express is availed for.

There are some other policy document which allow the funds under IMNCI to be used for the

transportation of the Janani Express but the scheme document does not include or refer to any such

funds even if available .

Nomenclature Vs Image Building

Discussions with the Directorate officials also revealed that the nomenclature of the vehicle as

Janani Express has been used to avoid any confusion in the mind of the community of perceiving it

as a general ambulance service but due to the lack of IEC and awareness building measures on the

other purposes the Janani Express can be availed for, the use for the purposes other than

transportation for delivery, is restricted to the extent of being nil in most of the blocks and Districts

Lack of IEC Activities

There is an evident lack of the IEC activity in promoting awareness about the scheme and there is no

clause on sharing of responsibility in this regard, making it primarily a responsibility of the

Government. The scheme document has clearly spelt out the IEC material that must be painted on

the Janani Express vehicle but not even in a single area was any Janani Express found to comply or

follow those norms except the labelling of the vehicle on the front and back as Janani Express. The

reason could be cost cutting to callousness but the lack of IEC has severe repercussions on the

effective utilization of the scheme and generating a public demand for the same. No strong IEC

measure or material prepared by the state IEC bureau could be seen at the state level and most of

the IEC activities are being carried out at the local level.

There was a government order on Publishing about the scheme in local daily newspapers which was

one time effort. The District Hospitals and the CHC have a wall painting on the scheme which is a

written description of the scheme and also the Number of the Driver has been put on public display

at few other sites in the hospital.

In one of the districts (Vidisha), a small card has been printed with the numbers of the entire drivers

listed block wise, which is distributed to the women and is generally attached to the ANC card of the

women. The practical problem observed with this was that the some of the numbers printed on the

card had got changed and the cards could not be printed again and again as the change of the

mobile numbers of the drivers is quite a regular phenomenon which happens every time the

contracting agency / the hired driver of the contracted agency / the mobile number of the driver

changes and the card once printed can not be re-printed every time and updating those numbers

every time is quite a task. The non-updated cards when circulated cause not only non-utilization of

the scheme but also build mistrust on the service and the public health dept. Which can lead to

negative image building amongst masses through the word of mouth?

The PHCs and the Sub centres have the Janani Express driver’s Number displayed on a white piece of

paper pasted in the OPD area etc but no where an elaborate description was found put on public

display.

The FGDs with the village people revealed that that there is a gross dependence on the Heath

workers/ the community facilitators for being able to access the service. The mobile number of the

Janani express is generally available only with the ASHA/ DAI and not with the public in general. The

ASHA/ Dai are the contact points and act as a mediator which indicates the need to ensure a

widespread circulation of the number

Though the posters have been put up in all the health facilities, the village population especially

females are illiterate and cannot read the IEC material and it emphasizes the need of using the word

of mouth and verbal means of communication for promotion.

There is lack of separate designated allocation for IEC plus there is lack of accountability on who the

public or the private partner is responsible and at which level-the state, the District ,or the block

level the IEC material has to be prepared and how the supply chain has to be maintained. In absence

of awareness building measures, there is under-utilization of the scheme leading to the cost-

ineffective of the scheme when a cost benefit analysis is done

Lack of clarity

There is a lot of confusion over if the transportation facility has to be provided TO and FRO or only to

the Health facility. The confusion is more so due to frequent changes in the guidelines, wherein the

guidelines are changed on papers but the information fails to percolate down to the grass root level

to the people directly involved in the implementation of the scheme. Discussions with the CMHO

and the BMOs also revealed the lack of clarity on the issue. Though, as per the revised guidelines,

the facility has to be provided only to the health facility and not back to their house but the lack of

clarity is so much that the scheme is being run differently in different districts of MP. In Vidisha, the

Janani express even goes back to drop the patients whereas Balaghat is following the revised

guidelines and is maintaining its financial and physical records accordingly.

The to and Fro practice was also being encouraged and promoted by the drivers of the Janani

Express and the contracting agency as this helped them increase the Kms , the distance travelled by

the Janani Express as the payment made was directly proportional to the Kms covered beyond

1200km , which is the min desired per month.

The scheme has been revised as the idea behind the scheme was to address Labour during

pregnancy as an emergency and ensure the safe arrival of the pregnant woman to the health facility.

Thus, once the mother has had a safe delivery and has stayed in the hospital for the prescribed 48

hrs, this is no more an emergency and her family can arrange for transportation back to the home.

The limitation due to in affordability issue is also not there as a part of the JSY money may be utilized

for safe transportation back home. The idea is basically to address emergency during arrival and

providing return facility defeats the very purpose and would be practically very difficult as the

utilization is likely to increase proportionately with the passage of the time with the growing

awareness.

There are practical problems as reported by some of the MOs like the policy change on the papers

and communicating the MOs and the concerned officials doesn’t necessarily lead to a change in the

mind set of the general people. The most of the people donot have high educational standard or are

mostly illiterate and thus It becomes a hassle for the already over-loaded and doctors and the health

staff to make general public at an individual level, understand such changes especially in cases of

withdrawal of a facility is made. The practical problem was raised by one of the Medical officer who

said that area has a strong political hold, refusal of the transport facility back lead to multiple

instances of conflicts and the doctor was even threatened. This is a practical case which emphasizes

that need of a far-sighted vision and rigorous analysis by the think tank while framing policy so that

the frequent changes are not required.

The discussions with the BMOs and MOs in some of the areas revealed that they provide a transport

facility back to the home in case woman could not or did not avail the Janani express facility for

coming to the health facility. This is a common practice in some blocks and is seen more often in

cases where the Janani express facility had to be refused as the ambulance was busy attending some

other cases. The transport facility is provided for return as a goodwill measure as the case was

refused for arrival owing to being busy attending some other case. The intend though good, creates

a lack of uniformity in implementation of the scheme which is important.

Kilometres based policy vs. flat rate policy of payment:

The policy on the payment mechanism has been revised and the Km basis criteria has been scrapped

and replaced by the new flat rate case based policy where the agency would be paid Rs 250/- on per

case basis, irrespective of the distance

The problem observed with the km policy was that the most of the blocks were actually paying close

to double the amount fixed for up to the 12000 km as the kilometres were calculated mainly by the

log book maintained by the driver and was easily subject to manipulation where already the

monitoring system is so weak.

The new revision in the policy of payment to the contracted agency has not received an encouraging

response from the contracted partners or the potential bidders as they do not find the new rate

policy profitable by any measure. The confusion is more so because they are not even clear on if the

facility has to be provided only to the health facility and not fro as it was being practiced before. The

contracting agencies perceive this new guideline to lead to a reduction in their profits when

compared to the past.

There are pros and cons of both the policies. The Km based policy though encouraged drivers to go

to the far flung and remote areas to enhance the Km usage , left a lot of scope for manipulation as it

is practically not possible that every time the doctor /nurse goes and verifies the reading from the

milometer. The rampant manipulation being done was very much obvious from the payment

cheques issued to the contracted agencies. The issue with the flat rate policy is that the drivers

would have no incentive to go to the far flung areas and would thus bring women only from the

nearby areas thus defeating the aim of the reaching out to those actually in need because patients

from near by areas can anyways come on their own, plus the ASHAs or Dais of proximal villages

anyway prefer not using Janani express.

Another important reason behind introducing the flat rate scheme is that over the years since the

inception of the JSY and JSE, the maximum funds of the RKS get diverted towards supporting the

schemes. As per the Km policy, the payment for distance covered beyond 12000km was being made

through the administrative expenses of the RKS, which used to be really high and usually equal or

even more than the amount payable for covering upto 1200kms. Major chunk of the RKS money was

going into the scheme which made it imperative to relook at the policy.

The flat rate policy, even if not would be a no profit no loss scheme for the government. Also,

another thought process behind the flat rate policy is that it would automatically incentivise drivers

and contractors to put efforts towards enhancing utilization of the scheme and up-scaling it as their

profit would directly be proportional to the number of cases brought by the Janani Express for the

institutional delivery, which means it would be performance based payment. The contractor may not

feel secure in partnering with the government as their will be lack of surety on if at all any profit

would be generated at all when most of the areas in the MPare far –flung and the state of the roads

is extremely poor.

No separate allocation of Fund/ Financial sustainability

There is no separate allocation of fund towards the scheme and it is sustainable till the JSY scheme is

functioning but presently no long-term strategy has been evolved for its continuity. At present, there

is no financial contribution from the state fund. Transport cost under JSY scheme is the main source

of financing the scheme and some part of it is managed through RKS funds. It is important to

understand how part of the scheme in terms of financial viability and sustainability once the NRHM

is rolled back.

Issues in payment of motivator

In cases, where there is more than one motivator, the payment is made as per the clause according

to which the payment be made to the one suggested / recommended by the beneficiary. In an ideal

case, the payment should be made to the one who came first and accompanied the patient but in

most of the cases women prefer DAI to accompany them as they can handle the case if the delivery

happens on the way itself. The patient generally tends to recommend the name of the Dai as it is the

Dai and not the ASHA who provides the care in the post natal phase. The cleaning of the mother, the

care of the baby and the daily massage which is a common practice followed during the post natal

phase is taken care of by Dai. These cases are common but now with time the ASHA and DAI have

begun to share the money amongst them, irrespective of whose name is recorded in the motivator’s

column in the register.

Cases of Non- Payment

There are some cases of non-payment recorded every few months. These are the cases where the

policy guidelines do not permit giving any monetary benefit to the patient. The cases of home

delivery, where the delivery occurs at home before the driver could reach .The cases where the

driver was called but the family later refused to take the mother to the health facility. The cases of

the false pain, where the woman availed the Janani express but the delivery did not take place when

only the JSY benefit could not be given. In these cases, there is lack of clarity in minds of these cases

on if they can avail the janani express facility, if required when true labour pains occur.

The cases where the delivery has taken place in the Janani express vehicle itself are mostly

considered to be the institutional delivery and are paid in such cases

On an average 8-9 cases of nonpayment occur which mean a loss to the contracted agency, which

they try and cover for by other wrong practices like manipulating the log book etc

Cases of Referral

There is not guideline on what has to be the line of action in case of a referral and how the payment

has to be made in such cases . The referrral rate is high from PHCs to CHCs and CHC to the District

Hospitals and in absence of clarity on this, a number of delivery cases fail to get the due adequate

care needed. The payment under JSY is made at the health facility the mother delivers at and the

payment of the Janani Express is linked to the JSY.

The Janani Express is supposed to carry a patient from her house to the nearest public health

facility institutionalized for carrying out deliveries , but in case , the patient has to be further

referred to a higher level of health facility, which usually happens after the patient has been

dropped at the health centre, the confusion occurs over if the Janani Express only or the hospital

ambulance should be used for the said for the further transportation but in case the general

ambulance is not available, the issue becomes of ethics Vs profitability of the private partner.

In absence of a clear guideline on this and no separate record –maintenance for the Janani

Express,At times , Neither does the name of the Janani Express gets registered in the health facility

the patient was brought to because they lady was refererred nor does it get registered in the

hospital records of the hospital where the lady delivered because patient availed the general

ambulance and not the janani Express for the same. In such cases also, the payment to the Janani

Express becomes an issue and he also shirks from giving Janani Express facility as he is not sure of

being paid for the same

There is no guideline or protocol in place, thus different blocks and districts follow it subject to their

own understanding but this will become a major issue with the introduction of the new flat Rs 250/-

policy as the drivers do not periceve it to be insufficient in case he has to travel more Kms for no

extra benefit and in most of cases Rs 250/- do not suffice for the Kms driven. In such a case, the

patient is likely to suffer due to the unnecessary delay and lack of understanding of Emergency of

the case.

Role of the RKS

The most of the RKS have reported to be not working well. Monthly meetings are hardly convened.

The collector is the in-charge at the District level and the SDM is the in-charge at the block level. The

distribution of power is such that the collector has more fiannacial powers whereas the CMHO has

more administrative power.

RKS is responsible for maintenance of financial and other transport related records and make

monthly payments to the transporter. RKS is expected to collect transport and send the same to the

block medical officer for claiming this amount from JSY funds. If RKS makes more payment per

month than JSY claims and deposits received from transport of other clients, RKS has to bear this

expenditure. At present RKS gets a fixed amount under NRHM and the guidelines for utilization of

this fund does not speak about JES. Although. RKS is also expected to generate their own resources;

in all the blocks RKS has not generated any additional funds. Maintenance of too many records and

all these complicated issues is an important reason for delayed payments to the transporter.

Role of the ASHA/ DAI as community facilitators

Among community members there is lack of awareness of the brand name ‘Janani Express’. Mostly

the awareness of community members was limited to the knowledge about availability of a vehicle

provided by hospital for transportation of women. They knew that vehicle can be called by

telephone or by informing grassroots functionaries to do so.

The FGDs with the village people revealed that that there is a gross dependence on the Heath

workers/ the community facilitators for being able to access the service. The mobile number of the

Janani express is generally available only with the ASHA/ DAI and not with the public in general. In

The maximum cases, the calls were also made by the ASHA/ DAI .The ASHA or DAI though

community facilitators seem to have a monopolistic attitude as the family members generally have

to approach them and ask them to call the Janani Express. There is a general dependency on the

ASHA/ DAI as they are in the possession of the number and there are hardly any cases where the

family members themselves called the Janani express, which hints at multiple gaps in

implementation.

There is lack of General awareness amongst community about the scheme in details plus there is

lack of direct interface between the patient and the Janani express driver, which reflects the lack of

IEC about the scheme. The number should also be widely circulated amongst community members

and should not remain restricted to ASHA or DAI only so that in case of emergency the family

member himself can also call up the Janani express driver and request for the vehicle instead of first

rushing to the house of the DAI/AWW.

If ASHA brings the client for institutional delivery, she gets Rs. 250 as transportation charges from JSY

scheme, but, if the clients avail JES, ASHA does not get this money. Conflict of interest of ASHA is

also one of the reasons. It is a very common practice that the ASHAs of the near-by area generally

tend to mislead the family and prefer to take the pregnant woman by personal vehicle say a tractor

or a bike owned by their husband .The explanations offered to the family are like the mobile phone

of driver was not reachable or The ambulance was engaged in attending some other case or may be

the number has got changed etc.

ASHA/AWW/ or TBA have not properly understood the scheme, as they felt that, if they take the

clients for institutional delivery, they get transport cost as motivational money, and, if the clients

uses JE, they loose this incentive. Thus, confrontation and clash of interest between ASHA and TBAs

resulting in acrimony and misleading the beneficiary was observed, which could be a major hurdle in

promoting Janani Express service by community facilitators. There are villages where only either

ASHA or DAI functions in practice as irrespective of this scheme as well there are clashes in their

domain of work perceived to be interference or a threat. This is a major and both a specific as well as

a generalized issue which needs to be addressed.

ASHA, AWW, TBA are mainly interested in monetary benefits of JSY scheme and are therefore

apprehensive about this scheme as observed in focused group interviews . They need to be

reoriented on their roles and functions and on benefits of the scheme to seek their active

participation.

ASHA versus DAI

The Janani Express model when compared to the EMRI or the other such model is more

cost-effective, more apt and more suitable in contextualized .The major chunk of the cost

for running a model like EMRI is borne on trainings and capacity building to develop a

cadare of paramedics as Emergency response technicians to handle emergencies. The Janani

Express model is primarily for carrying a pregnant woman to the health facility for delivery,

and though no where mentioned in the guideline,the component of motivator’s incentive

involved in the scheme by default ensures that a Dai or an ASHA, accompanies the patient in

the JANAI EXPRESS. DAI is a certified SBA and is a trained personnel and can carry out

delivery, if it occurs on the way. The presence of DAI rules out the necessity of having a

special trained personnel and bearing training costs on the same, thus makes the model

more cost effective.

This perspective only holds true in case the government is clear on its objective and

perspective of the Janani Express it has dedicated for ensuring that the Driver is trained in

the first Aid would also give more confidence when transport is used for emergency cases

other than delivery.

The motivator is usually ASHA or DAI and either of the two can accompany the patient but

the noteworthy point is that though ASHA is a SBA, while ASHA is not. ASHA is trained in

ANC and PNC but her training doesn’t involve or equip her with an ability to carry out a

delivery and this was not considered important as the government aims to discourage

home deliveries and promote institutional delivery. Even though the cases of delivery on the

way are not rare but they are also not very common as well. There are intricate details

which need to be looked into:

There are cases when ASHA despite being well aware that an emergency could occur on the

way, choose not to call Dai for accompanying so as to avoid losing out on incentive. In

certain cases, ASHAs called DAIs but they had to settle on a mutual agreement of sharing

the incentive received

Specifically, in context of the Janani Express, the following Questions need to be answered?

Who should accompany the patient, ASHA or DAI?

Who should decide which case is an emergency or a complicated case and would

necessarily require a SBA to accompany the patient?

The most of the people calling the vehicle at the eleventh hour not only shows callousness

in attitude but also points the weak linkage between the Driver and the ASHA/DAI/ANM, the

field levels Staff and the Medical officer. The Driver has no prior intimation of the cases

which are anticipating delivery and the EDD, the driver is supposed to just respond to the

call and take the vehicle immediately.

The most of the women in the village are illiterate and are generally not able to tell the

exact date of their LMP, thus the EDD can not be calculated precisely. This becomes even

more important in case of a multi-para as unlike in case of a primi, the delivery takes place

really fast in case of a multi gravida. The delay in calling the vehicle at the eleventh hour or

reaching of the vehicle is so much that the delivery take place at home only before the

vehicle reaches. In such a case, the delivery occurs at home, in not so aseptic condition, the

pregnant women looses out on the JSY benefit and in absence of any clause for settlement

of payment in such cases, the driver doesn’t get any payment and does not take the patient

to the health facility.

In such cases, the driver decides not to take the patient to the health facility orthe family

members themselves refuse to take the lady to the health facility as they know that the no

more remain eligible for the incentive linked to JSY. This observation raises a big question –

Is the programme being able to achieve what it intends to? Is it merely the incentive linked

to the JSY which is the pull factor for people to prefer institutional delivery? The underlying

intent is to develop a rational understanding of the benefits of the ANC, institutional

delivery and PNC in the minds of the community so that even after the withdrawal of the

NRHM, the preference for the institutional delivery remains.

Role of the Driver

Since, the vehicle has got a private ownership; the profit is the main driving force for the

private partner. The most of the Janani express are manned by only driver who is expected

to be on duty 24 hrs which is humanly quite a difficult task. The nature of his duty requires

the driver to be available even at night and in fact most of the calls are received at night as

reported by the drivers. Thus, in lack of a consistent controlled monitoring and supervision,

the operations of the Janani Express model is largely dependent on the driver’s discretion as

he is the one in direct interface with the caller and there are instances reported where in

the mobile phone of the driver was found to be switched off. The driver can offer multiple

explanations like the network was not available or the vehicle was busy or out of order are

not subject to verification easily as such issues and the driver has to be given the benefit of

doubt in cases of abuse as well. The other important noteworthy point is that the drivers are

basically the employees of the Vehicle provider and there is no regulation or standard set

for his remuneration. Most of the drivers are grossly underpaid ranging from Rs2000pm to

Rs3000Pm which is not commensurate to the job.

The driver is required to maintain entries of clients (for JSY claims), maintaining log book,

receipt book, depositing cash to RKS, and then claiming monthly contract amount needs to

be simplified, as in all cases the transporters received contract amount after 1-3 months of

submission of desired records

Some of the drivers complained of the lack of rolling fund in their hand for maintainance and repair

or sometimes for fuel as the payment is made at the end of the month only. This exhibits negligence

on the part of the contracted agency.

Community Attitude

ASHA is a holistic concept under NRHM and she has been trained in Antenatal and Post

Natal care and ensures compliance of the lady to medication, ANC,PNC, immunization etc.

They consistently remain in direct interface with the beneficiary and establish a good

rapport with the pregnant women. People generally prefer to call DAI because it is usually

Dai who takes care of massage, bathing, diet, asepsis etc in post natal phase. This is rooted

in socio-cultural factors. There were cases reported wherein though the ASHA took care of

the pregnant woman during Antenatal phase but the pregnant woman and her family

preferred to be accompanied with the DAI or recommended DAIs name for the incentive in

case of a conflict between the ASHA and DAI wherein both reached the health facility and

claimed for the incentive.

This is a small but an important observation and unless resolved, can act as a deterrent to

the functioning of ASHA, the main carrier or linkage of the Programme to the people it is

meant for.

A common observation in a number of villages is that though both Dais and ASHA are there

on papers, only either of them practically works /operates in the village. The major issue is

with the common tendency observed and reported by the Drivers and Doctors is that

instead of calling the vehicle well in advance, people generally tend to call the Janani

Express at the Eleventh hour. They drivers have reported instances of the family members

of the beneficiary refusing to even bring the patient to a convenient point on the road and

insisting the driver on bringing the vehicle through the bad kachha uneven temporary field

routes to their doorstep, which may not be necessary in that particular case. Drivers have

also reported that people tend to make them wait , usually from 15 min to 4o min while

they prepare for taking the patient to the health facility , which not only exhibits a lack of

understanding of the emergency of the case but also an attitude of callousness a sense of

emergency. This becomes an issue especially when driver happens to receive other calls

which he has to refuse or delay and this would become a major issue when the scheme gets

scaled up

The practice of leaving the mother on home delivery, reflects gap in understanding in minds

of community as the most of the complications normally tend to occur in the post natal

phase, which is a critical period ideally requiring at least 2-3 days stay in a health facility.

Addressing this gap is imperative to the success of the NRHM and its allied programme

Absence of any Penalty clause: Partner agency not complying with

norms

Minimum facilities required to be provided by the transporter in a vehicle were not closely

monitored (first aid kit - 4 vehicles, folding stretcher - 2 vehicles, drinking water facilities - 4

vehicles, comfortable long seat for transportation of clients - 5 vehicles). Although as per the

guidelines, it is responsibility of the transport agency for insurance coverage, in two cases,

the vehicles did not have valid insurance. The drivers never received first aid training.

For easy communication, it was expected that the transporter would provide mobile phone

to the driver and district RCH society would sanction Rs. 200 per month for mobile charges

for incoming calls, and mobile numbers would receive wide publicity. This was not observed

in a single case. There also took place a change in the guideline on this and as per the

revised guideline it is now the duty of the contracting agency and not the District RCH

society to Pay Rs 200/-pm towards mobile expenses of the Janani Express driver. There is

confusion over this as at some places the RKS is paying for the mobile expenses while at

others they are not.

The most of the centres have put the Janani Express driver’s number on the public display at

one or two sites in the PHC or the Sub centre and have distributed the number to the ASHA/

ANM. There is lack of widespread circulation of the number due to lack of IEC initiatives to

promote utilization of the facility. The drivers had their personal mobiles, and with frequent

turn over of drivers, their mobile number changed adversely affecting communication.

This was also observed in case of vidisha where they had printed cards with a list of area

wise mobile nos of the Janani express driver but on verifying it was found that the numbers

of 2 drivers had already changed and the cards had been circulating with the previous

numbers only, which obviously hinders utilization.

Janani Express scheme is expected to provide transport services for institutional delivery,

emergency during pregnancy or after delivery and for seeking post abortion complications,

any illness related to Deendayal Antyodaya Upchar Yojana, child illnesses and any

medical/surgical emergency. However, important function of the scheme is to complement

JSY scheme for enhancing institutional deliveries by providing transport facilities and also to

provide emergency transport services for management of obstetric complications and post

abortion complications (important causes of maternal mortality). However, the scheme has

not addressed these issues with same priority .There was not record available for any client

availing transport facilities for post abortion complications. Delay in reaching to the health

institution for EOC services being an important factor contributing to high maternal deaths,

this issue needs to be considered seriously in planning, management and monitoring of the

scheme.

Even amongst the community members there is a general understanding that this is a

vehicle which can be called over phone in case of the need of taking a pregnant woman to

the health centre for delivery. Very few people know that it can be used for afore

mentioned purposes other than delivery plus no such records are kept. This indicates that

the utilization in delivery case is demand driven as there is a financial incentive / component

involved and in absence of any clause for the payment for cases other than the delivery, the

drivers also do not feel inclined / interested in either disseminating any information to

masses regarding the purposes of Janani express beyond delivery.

The discussions with the BMOs and MOs etc also revealed that though such criteria for

entitlements have been incorporated in the guidelines, they are practically difficult to

execute, say transportation of the sick new born child in case of emergency. In practice it

will be very difficult to define what an emergency is? For a layman even fever to his child

may be an emergency and when a free transport facility is easily available, it would lead to

demand sided moral hazard, defeating the very essence of the scheme. Thus the BMOs also

said that they prefer not to propagate about such benefits which can be availed and instead

of leaving such cases to the discretion of public, the doctors at the PHC or the ANM etc at

the sub-centre themselves call the Janani Express in case of an emergency.

The poor framing of the contract document with the guidelines not spelt clearly has left

scope for ambiguity and subjective interpretation. The absence of penalty clause leaves no

way an action could be taken against the party at fault even if held responsible. The contract

Management is poor and poor monitoring and supervision further weakens the

implementation aspect. The communication linkages both horizontal and especially vertical

are weak due to which the scheme is not being implemented in the way it was intended to,

when conceptualized. There are minor gaps which if covered following a 360 degree

approach, can help make the scheme a big success.

Maintenance of records

Log book:

The driver is supposed to fill a log book in which he is supposed to enter the Date, the name

of the patient , her husband, the name of the motivator, the pick-up point and the health

facility he drops the patient at along with the initial and the final reading of Kms driven and

this has to be verified the doctor or Staff nurse present at the health facility. The most of the

Drivers could not produce the log book as they normally don’t carry even though its

mandatory. The log books were incomplete, they were not signed by the doctor or the staff

nurse as they are supposed to be , generally the BMO signs the log book in the end. This

indicators a loophole in monitoring , there is no check on the milometer and doctors already

grappling with the overload of patients find it practically somewhat infeasible to check km

readings every time. There are no patient signatures also, anywhere in the log book.

The entries in log book are verifiable from the JSY /delivery register but due to lack of

orientation or understanding on how to record, the name of the patient gets registered

both in the PHC and the health facility where the delivery takes place but there is no

separate register for Janani Express and the details on referral TO/FROM need to be

recorded at both the levels.

Lack of monitoring and supervision

The important noteworthy point is that data is not being analyzed at the state level. The

discussions with the Dy Director dealing with the scheme have revealed that the time

constraint and over-load of work does not permit enough time to keep a track of the

performance of the scheme and consistent monitoring generally does not happen.There is

no column in the JSY register to record how many women availing JSY benefit availed the

Jananai express facility.

At the grass root level, there is no consistency in the format of the log book the drivers are

supposed to maintain .The interactions with the drivers have revealed that most of the

drivers do not keep the log book with themselves in the Janani express which is mandatory

and the logbooks seen have been found to have been filled later on at a time. The log book

entries were in complete in most of the cases and they had not been verified and signed by

the BMO or any Doctor or staff Nurse on duty at that particular time to confirm the case was

delivered at the health facility. The BMOs or The incomplete details made it difficult to trace

the case.

E.g. The log book of the driver of a block Peepal kheda, Vidisha is stationed at the District

Hospital, Vidisha as the Peepal kheda PHC is under construction and is being run in a

temporary building with no compound to station the vehicle. Due to the incomplete log

book, wherein entries were missing in the columns of where from and where to, it was

difficult to cross check the entries from the JSY register and confirm if the delivery had even

occurred. The some of the entries also revealed discrepancy in the entries. No separate

Audit/ Inspection is carried out for the Janani Express scheme per say and thus there is lack

of supervision .Some of the cases reported that the driver had asked the patient and his family to

get the fuel tank refilled for transporting patient to the health facility which indicates that some

drivers, instead of taking cash make the beneficiary pay in kind.

Lack of preparedness of the Health Facilities: LACK OF MANPOWER

The introduction of the Janani Suraksha Yojana and the Janani Express has enhanced the

load on the already poorly performing Public health facilities. The load of deliveries has

increased manifold with the financial incentive linked to the scheme and the Janani Express

is further supplementing the scheme in MP. In this context, it is imperative to analyze the

shortcomings and lack of preparedness of the public health system.

The scenario is even worse in MP with the major shortage of the Human resource in the

Hospitals and the health centers which was evident in the hospitals and the health facilities

visited. Most of the Doctors are on the verge of retirement and within the next few months,

nearly 40% of the positions for the Doctors would be vacant in MP.

There are more than one, usually upto 2 PHCs allotted per Medical officer and the most of

the PHCs are being run by the ANM and the MPWs. Some of the PHCs are there with

Medical officer but no paramedical or class –IV staff. The extreme shortage of staff has

overburdened the existant staff, adversely affecting the quality of care and the job

satisfaction level of the staff

The Accounts departments are extremely loaded with work and the Accounts Asst managing

the payment of cheques and disbursement of the JSY payments is extrememely overloaded,

especially at the Distt hospital level

The coordination needs to be established with the banks so as to facilitate the timely

clearance of JSY cheques so that the benefeciaries do not have to come repeatedly for the

same.

Trend of Increasing Referrals

The District hospital Health staff complained of the increasing number of referrals from the Primary

health centres and CHCs. The problem of understaffing is at all the level of care but the PHCs and

CHCs tend to refer a major chunk of cases to the District Hospital. This has further overloaded the

District hospital staff .This is an abuse of the Janai Express can also lead to increase in refusal rate to

even the priority cases

The most of the Health facilities are understaffed .Some of the PHC s have been upgraded to the status of the CHC or FRU without recruiting more staff which has extremely burdened the existant staff.

The rate of Absenteeism is high, especially in case of Doctors, with most of them staying in the near by city and having their own private practice

The most of the PHCs /SCsdo not work full time and the OPD which is usually run by the ANMs also runs in the first half of the morning and not in the evenings

The Data and the figures collected and recorded in the prescribed register have to be

relied upon in absence of adequate monitoring and verification

The most of the health facilities have irregular supply of electricity and power cuts is a

regular feature, especially at night which makes carrying out delivery really difficult

The most of the wards do not have electricity and staying in the hospital wards is

pericieved to be more uncomfortable than at home

The most of the health facilities have poor in hygiene, especially the labour rooms. The

most of the doctors and the staff Nurses etc complained about the callousness of the

class-IV staff due to which it is not possible to maintain asepsis in the labour room

Some of the Delivery tables were found rusted and the rooms were unhygienic

There are usually no bed sheets or bed covers on the patient bed in the wards and the

explanation given for the same is to avoid the unscrupulous practice of stealing of the

bedsheets by the patients or their relatives which is quite common

The Districtt Hospital Vidisha building is in really old and in poor state. It is important to

look at utilization of the RKS funds and channelize them towards revamping the state of

the hospital building

There are few PHCs/SCs which are currently running in rented accommodation, while

the new building under construction, which has exceeded much beyond the time

otherwise needed and that becomes a pretext for excessive referrals and irregularity in

attendance on account of the lack of space

It is important to give a defined timeline to the Medical officer and the BMO till which

the construction should get complete and the centre must be fully operationalised

The District Hospital Vidisha building is in really old and in poor state. It is important to

look at utilization of the RKS funds and channelize them towards revamping the state of

the hospital building

The most of the Health facilities are understaffed .Some of the PHC s have been

upgraded to the status of the CHC or FRU without recruiting more staff which has

extremely burdened the existent staff.

THE GUNA MODEL:

The Guna is a UNICEF adopted districts and a number of projects and initiatives are being

piloted in the district. One such initiative is the Guna call centre which is one of its kinds

when seen both on parameters of efficiency as well as cost –effectiveness. Call Center was

Started on 9th Sep 07 by district Health Society, Guna with support of Unicef .The total cost

of setting up ranges from max. 1.5lakh to 2 Lakh. The fixed infrastructure of the call centre

was provided by the MP government and the technical support and the salary support to

the staff was provided by the UNICEF. However the call centre was set-up by the UNICEF, it

was taken over by the MP government under NRHM programme .There is a fleet of 22

ambulances/ vehicles, owned by the government and the most of them are donated by

trusts or some international NGOs or are the old government ambulances. There is a toll

free number of 102 and 07542-251560 linking the community to the call centre to which the

call is made in case of need. The call centre is manned by the three support staff and is

managed by a call centre Manager who had developed an in-house software and MIS for

record maintenance and keeping a track of the performance of the scheme. The call centre

support executive calls up and transfers in information pertaining to the patient and the

location to the driver of the concerned area. After having informed the driver, the call

centre support executive, calls back the family and tell them an estimate time in which the

Janani Express will reach them and asks them to be ready. The support executive also calls

up the Health facility as well and intimates them of the delivery case coming to the centre

which allows them some time to be prepared in advance to immediately attend the case

leaving no room for any further delay The driver therefore picks the pregnant woman safely

transports the lady to the health faculty and informs back the call centre. The total 5026

women availed the benefit of the model in the year 2007-08 which further rose to 9421 in

2008-09 tremendously boosting the figures of women going for institutional delivery. So far

nearly 15000 benfeciaries have availed the Janai Express service in GunaThe other

noteworthy thing in the Guna model is that the ownership of the ambulance is Public,

owned by the MP government but most of them have been donated by international NGOs

and PSUs like SAIL or some charitable trust while few other are the old ambulance which

have been deputed from elsewhere in the district for serving as Janani express. This exhibits

the high level of entrepreneurship and commitment of the district health officials and the

collector towards making the model really cost effective. The most of the drivers are the

government drivers while 2-3 drivers have been hired locally. The drivers generally give a

miss call to the call centre and the call centre support executive calls him back whenever,

there is a need to communicate .The vehicle are usually stationed at the designated health

facility but in case the driver has to go and take rest in his house, usually in close proximity

of the hospital, he is supposed to take the vehicle along with himself so that it is ensured

that the Janani express is always with the driver and is available as and when required. The

details of all the visits are monitored simultaneously into the software and are closely

tracked and monitored. The ideal time which must be taken to a particular site is usually

known and thus the working of the vehicle can easily be tracked against timelines.

The Guna Janai express call centre model has also been linked to the SCNU set up by the

joint effort of the UNICEF and NRHM and both the general ambulance and the Janani

Express are controlled and monitored by the call center. The cost of transporting the sick

new borns is manged from the IMNCI funds provided and the Cost per transportation is

around Rs 200 per case.

Call Center was established Under Janani Suraksha Yojana to provide free of Cost round the

clock (24 Hrs.)Transport Facility to Pregnant Mother’s and severely sick children below the

age of 6 years.

- To optimize and regulate the use of 24 Delivery Van’s stationed at District Health

Center’s (Delivery Centers).

- To establish a system of coordination among health workers from Village to District

Level.

- To monitor the progress of No. Of Institutional Deliveries month wise in District

Health Center’s (Delivery Centers).

- To accumulate the ANC List for all the blocks in the District

Objective of Software

Call Center Software is developed to automate and monitor the working of Call Center.

The sole objective is to accumulate the free transportation details and generate following

reports:

1. Monthly Free transportation report for the District.

2. Monthly Free transportation report for the Block’s.

3. Monthly Free transportation statistics for the Sector’s.

4. Monthly transportation report for each van Driver.

5. Monthly transportation report for each van Driver.

No system is perfect and some of the flaws observed in the model were:

- The IEC material was not painted on the Janani express as prescribed in the guideline

- The locally hired drivers are paid Rs 2000-3000 which is extremely less especially

when the driver has to relocate and stay away from his family and it is not

commensurate to the nature of the Job

- The call centre support staffs are also under paid, Rs 2000 for a 9 hrs shift per day

with no holiday. The salary is same for the support executive working at night. Also

the call centre is under-staffed as there is no back up support available.

- Though the posters have been put up in all the health facilities, the village

population especially females are illiterate and cannot read the IEC material and it is

basically the word of mouth and verbal means of promotion which must be used.

- Few FGDs with the village people also highlighted that though people know about

availability of a vehicle called Janani, but they do not have the number and for

availing the facility the ASHA/ Dai are the contact points and act as a mediator which

indicates the need to ensure a widespread circulation of the number.

MONTH WISE JSY FREE TRANSPORTATION CHART 2007-08 Call Center,Guna (M.P)

128 125

234

292

386

771

546

645602 587

648

62

0

100

200

300

400

500

600

700

800

900

April may june july August september October November December January February March

Call Center was established on 09 sep 07Total Beneficiaries of 2007- 08 : 5026

No. o

f Cas

es T

rasp

orte

d

2007-08

NGO / SELF HELP GROUP MODEL:

The MP government had experimented with the NGO model similar to the one

in West Bengal. The Distt of Bhopal had collaborated with an NGO which had

set-up a call centre and was running the Janani Express vehicles but the model

the contract was terminated on the doubt of scrupulous practices by the NGO

which escalated the costs due to which government was bering losses.

The other model in Dewas was different where the government tied up with a

self help group instead of an NGO but though this model took off well initially,

there were conflicts and issues over Non payment due to which the model

stopped working and currently the Janani Express is running on the standard

model in Dewas. The general issue observed with the Self Help group models is

the issue of sustainability in terms of volume of investment, ability to wait for

the long gestation period ,risk taking ability and Management once the

initative gets scaled up.

An in-depth retrospective analysis of the NGO these models may be carried out

in detail but by and large it is the standard model with less stake holders

involved, which is more viable to manage and sustain.

Benefits of the SHG Model

- Long term sustainability , can charge after 2-3 YRS

- Better utilization

- Community Moniotring

- Livelihood Generation

RECOMMENDATIONS

More clarity in terms of guidelines for selection of transport agency, for having a contract

with them, their physical and financial reporting mechanism, and for monitoring their

performance is required. In context to the observations and challenges, there is a need to review

implementation guidelines of the scheme and circulate revised guidelines.

CONTRACT DOCUMENT

Penalty clause:

The penalty clause be introduced like deduction in payment etc on not adhering to the

guidelines laid down

Certain clauses like the vehicle must be under the taxi quota and should not be more than

24 Months old are practically difficult to adhere to, especially in areas where getting a

vehicle for the said purpose is already difficult.

The contract should preferably be signed with a contractor who has more than one Vehicle

and an arrangement of substitute driver in case of need

FINANCIAL MANAGEMENT OF SCHEME

Financial component, financial modalities, role of RKS and payment procedures need

to be simplified.

At present the scheme is functioning mainly out of financial support of JSY scheme.

For sustainability of the scheme, regular budgetary resources are required to be

tapped.

Need to have a special separate designated fund for running the scheme in long run. An

innovative model for fund and resource generation must also be explored to ensure the

sustainability of the scheme

The contract should preferably be signed with a contractor who has more than one

Vehicle and an arrangement of substitute driver in case of need

The flat Rs 250/-case based policy is better but for vehicles operating in tribal areas

and hilly areas or difficult areas as told by the block level officials some additional

payment or charges must be paid to the contractor

The Janani Express service has been verbally reported to have stopped in Seahore, Raisen

and Hoshangabad as these DPMU s did not get bidders for the tender this time as the model

is not being perceived profitable by the contractors. On the other hand, the Janani Express is

running smoothly and is running into profits even with this new Rs 250/- flat rate scheme

with the services being rendered only one-way i.e. to the health facility as per the guidelines.

This indicates that the contractors need of calling a meeting of the contractors and

reorienting them on the cost-benefit aspect and how the cases get cross-subsidized in a flat

rate and the model could be a viable option.

The other important noteworthy point is that before implementing any such policy decision,

it would be good to call a meeting with the contractors and take their feedbacks and

suggestions as they are the most important stake holders in the model. It is also important

to re-analyze the policy decision from their perspective that if the model will be profitable

for them

The non utilization of the scheme for purposes other than for carrying women for delivery

has to be analyzed as an issue of Moral Hazard versus the right to care especially in case of a

medical emergency and the guidelines need to be spelt out more clearly on dealing with this

practical issue.The Janani Express model is a Public Private Partnership model where the

Driver or the contracting agency would not be interested in providing service unless any

monetary benefit or incentive is involved and in absence of any guideline spelling out clearly

the payment aspect in cases other than delivery, the other benefits the vehicle could be

availed for is neither disseminated nor encouraged and has limited to the scheme document

only.The payment mechanism needs to be explicitly detailed in the document as though it is

a social welfare measure from the public provider’s end but there is a profit motive from the

other partner’s end who is an equal partner in running the scheme and ensuring that it

meets the desired objectives

IEC AND AWARENESS BUILDNG

There is need of building more clarity on if the nomenclature of the scheme should be Janani

Express or should be changed as the nomenclature plays a big role in Image building and

perception the community builds of the service. It seems the nomenclature is in some way

restricting the optimal utilization of the scheme.

Development and implementation of comprehensive IEC plan for popularizing about the

scheme and its benefits, including establishing a toll free call center for monitoring calls for

request of a vehicle for transportation of a client

General Awareness amongst community needs to be increased by using some media like

street play using folk media or the word of mouth. The Number be put up on strategic

locations in the village, like at PCOs etc, Ration shops etc to bring a wide circulation of the

number.

The practice of leaving the mother on home delivery, reflects gap in understanding in minds

of community as the most of the complications normally tend to occur in the post natal

phase, which is a critical period ideally requiring at least 2-3 days stay in a health facility.

Addressing this gap is imperative to the success of the NRHM and its allied programme

There needs to be a general awareness building amonst people that they should not only o

inform or call the Janani Express well in time and prepare well in advance instead of waiting

till the eleventh hour or making the driver wait. Building an understanding of the importance

of institutuional delivery and treating delivery as an emergency which needs to be attended

at the earliest possible, will be a milestone achievement

ASHA/DAI

The motivators, ASHA and dai should be re-oriented to their roles and the component of Rs

250/- be removed because otherwise ASHA/DAI tend to use personal vehicle It is

recommended to have further interaction with village level functionaries (AWW, TBAs,

ASHA) to understand their issues and concerns and to evolve appropriate strategic plan so

that they become strong advocates in the village for this scheme.

There needs to be a strategically planned series of efforts to develop systemic linkage

between the ASHA and DAI and some orientation session on the need of cooperation and

coexistence and supporting each other in view of realizing their limited capability of

addressing the huge population in their catchment area.

There needs to be a strong linkage between the ASHA/DAI and the Medical officer of the

PHC or the CHC , wherever the woman attends the ANC clinic. An arrangement where a list

of cases detected as complicated ones,should be made available to the ASHA/ DAI . This

would help plan for transportation well in advance and both ASHA/DAI would also know

cases which necessarily need to be accompanied by DAI

The motivators, ASHA and dai should be re-oriented to their roles and the component of Rs

250/- be removed because otherwise ASHA/DAI tend to use personal vehicle

It is recommended to have further interaction with village level functionaries (AWW, TBAs,

ASHA) to understand their issues and concerns and to evolve appropriate strategic plan so

that they become strong advocates in the village for this scheme.

DRIVER

The driver should be given some incentive on exceeding targets. Similarly targets be

set for the Blocks and the districts as well, and they should be linked to reward

The penalty clause be introduced like deduction in payment etc on not adhering to

the guidelines laid down

The driver be oriented on his role and a training session on the maintainance of the

log book and other aspects etc

Certain clauses like the vehicle must be under the taxi quota and should not be more

than 24 Months old are practically difficult to adhere to, especially in areas where

getting a vehicle for the said purpose is already difficult

A training session for all the drivers be conducted at a training centre where they

may be trained on the scheme and their role in it. A training session for all the drivers

be conducted at a training centre where they may be trained on the scheme and their role in

it. . The driver be oriented on his role and a training session on the maintenance of the log

book and other aspects etc

Ensuring that the Driver is trained in the first Aid would also give more confidence when

transport is used for emergency cases other than delivery.

UPGRADATION OF HEALTH FACILITIES

It is necessary to initiate systematic mapping of the block, which should include mapping of

health institutions for providing CEmOC and BEmOC services, geographical area attached to

these institutions, estimated number of institutional deliveries, obstetric emergencies and

other clients. This would help program managers to arrive at a decision of optimum client

load for transportation per month, number of vehicles required to cover all geographical

areas, and institutions where these vehicles would be located. It is recommended to take

simultaneous steps for Operationalization of CEmOC and BEmOC institutions for meeting

unmet needs of management of obstetric complications

Local linkages need to be established with the locally practicing private doctors as its

important to realize the limited capability of the Public health facilities

REPORTING

The Janani Express service has been verbally reported to have stopped in Seahore, Raisen

and Hoshangabad as these DPMU s did not get bidders for the tender this time as the model

is not being perceived profitable by the contractors. On the other hand, the Janani Express is

running smoothly and is running into profits even with this new Rs 250/- flat rate scheme

with the services being rendered only one-way ie to the health facility as per the guidelines.

This indicates that the contractors need of calling a meeting of the contractors and

reorienting them on the cost-benefit aspect and how the cases get cross-subsidized in a flat

rate and the model could be a viable option. The other important noteworthy point is that

before implementing any such policy decision , it would be good to call a meeting with the

contractors and take their feedbacks and suggestions as they are the most important stake

holders in the model. It is also important to re-analyze the policy decision from their

perspective that if the model will be profitable for them

The standard reporting formats be prepared for Janani Express and a column be added to

the JSY or the Delivery register to see if the vehicle was even used by the concerned person

Monthly reporting and monitoring tools need to be developed and monitoring mechanism

need to put in to place for successful implementation of the scheme

MONITORING

Clients whose names were recorded in health institutions of availing transport services

through Janani Express, but actually did not avail services, call for close monitoring to avoid

similar discrepancies in future

The driver should be given some incentive on exceeding targets. Similarly targets be set for

the Blocks and the districts as well, and they should be linked to reward

The incentives and disincentives need to be introduced in to the Performance appraisal and

it be linked to the payment mechanism

The standard reporting formats be prepared for Janani Express and a column be added to

the JSY or the Delivery register to see if the vehicle was even used by the concerned person.

Monthly reporting and monitoring tools need to be developed and monitoring mechanism

need to put in to place for successful implementation of the scheme

Reporting compliance- Timeliness, Completeness, Reliability

MIS must keep a track of:

- No of ambulances / district

- Average no of trips /day

- Case Mix - The No of APLs served

- No of BPLS served

- No of women availing service for delivery

- No of women availing service for Antenatal care

- No of women availing service for post natal care

- No of sick new borns transported

- No of Deendayal Antodaya yojana cases availing service

Patient Feedback complaints and grievance Redressal

THE GUNA CALL CENTRE MODEL: ONE NUMBER, ONE NODAL CENTRE

The Guna call centre model is a sacrosanct model with one Number and once nodal centre

for controlling the movement of the vehicles will help in adequate monitoring and efficiency

in operations of the Scheme. Propagating one number of the call centre would be much

easier than spread around the number of the driver, which keeps on changing every time.

Thus a call centre be set up at the level of the District Hospital on the similar lines

The Guna call centre model with one Number and once Nodal centre for controlling

the mocement of the vehicles will help in adequate monitoring and efficiency in

operations of the Scheme.

Propagating one number of the call centre would be much easier than spread

around the number of the driver, which keeps on changing everytime.

Thus a call centre be set up at the level of the District Hospital on the similar lines

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