More Evidence on the Impact of India's Conditional Cash Transfer Program, Janani Suraksha Yojana: Quasi-Experimental Evaluation of the Effects on Childhood Immunization and Other Reproductive and Child Health Outcomes

Background
In 2005, India established a conditional cash transfer program called Janani Suraksha Yojana (JSY), to increase institutional delivery and encourage the use of reproductive and child health-related services.
Objective
To assess the effect of maternal receipt of financial assistance from JSY on childhood immunizations, post-partum care, breastfeeding practices, and care-seeking behaviors.
Methods
We use data from the latest district-level household survey (2007–2008) to conduct a propensity score matching analysis with logistic regression. We conduct the analyses at the national level as well as separately across groups of states classified as high-focus and non-high-focus. We carry out several sensitivity analyses including a subgroup analysis stratified by possession of an immunization card.
Results
Receipt of financial assistance from JSY led to an increase in immunization rates ranging from 3.1 (95%CI 2.2–4.0) percentage points for one dose of polio vaccine to 9.1 (95%CI 7.5–10.7) percentage points in the proportion of fully vaccinated children. Our findings also indicate JSY led to increased post-partum check-up rates and healthy early breastfeeding practices around the time of childbirth. No effect of JSY was found on exclusive breastfeeding practices and care-seeking behaviors. Effect sizes were consistently larger in states identified as being a key focus for the program. In an analysis stratified by possession of an immunization card, there was little to no effect of JSY among those with vaccination cards, while the effect size was much larger than the base case results for those missing vaccination cards, across nearly all immunization outcomes.
Conclusions
Early results suggest the JSY program led to a significant increase in childhood immunization rates and some healthy reproductive health behaviors, but the structuring of financial incentives to pregnant women and health workers warrants further review. Causal interpretation of our results relies on the assumption that propensity scores balance unobservable characteristics.

背景
2005年，印度推出了一项名为贾尼尼安全计划（Janani Suraksha Yojana，JSY）的有条件现金转移支付项目（conditional cash transfer program），旨在提升机构分娩率，并推广生殖健康与儿童健康相关服务的使用。
研究目标
评估JSY向产妇提供的经济援助对儿童免疫接种、产后护理、母乳喂养行为以及就医行为的影响。
研究方法
本研究采用最新的地区级家庭调查（district-level household survey）数据（2007—2008年），开展倾向得分匹配（propensity score matching）结合逻辑回归（logistic regression）的分析。我们分别在全国层面以及按高关注州与非高关注州分组开展分析，并开展多项敏感性分析，包括按免疫接种卡持有情况进行分层的亚组分析（subgroup analysis）。
研究结果
获得JSY经济援助可使免疫接种率提升3.1个百分点（95%CI：2.2—4.0）至9.1个百分点（95%CI：7.5—10.7）不等，其中脊髓灰质炎疫苗1剂接种率提升3.1个百分点，完成全程免疫接种的儿童占比提升9.1个百分点。本研究结果还显示，JSY可提高产后检查率，并改善分娩前后的健康早期母乳喂养行为。未发现JSY对纯母乳喂养行为及就医行为存在影响。在被列为项目重点关注的州，其效应量始终更大。在按免疫接种卡持有情况进行的分层分析中，持有接种卡的群体中JSY的效应微乎其微甚至可忽略不计；而在未持有接种卡的群体中，JSY对几乎所有免疫接种结局的效应量均显著大于基准分析结果。
研究结论
初步结果表明，JSY项目可显著提升儿童免疫接种率及部分健康生殖健康行为，但针对孕妇与医护人员的经济激励机制仍有待进一步审视。本研究结果的因果解读依赖于‘倾向得分可平衡不可观测特征’这一假设。