102531137 ppp-case-study-janani-express-madhya-pradesh

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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 available24 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
availabilityof any other option but in most of the cases, it is
followed
Having comprehensive
insurance
Some of the ambulance drivers donot have any comprehensive
insurance
ValidDriving 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
Securitydeposit –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 expressis beingusedmainly 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 womenfor deliveryand 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

Those entitled under Deen
Dayal Antyodyaya yojana
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 KalyanSamiti, 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 Roadtax, toll taxes and parking
charges
YES
Compensation to the clients in case of any
accident.
Salaryand overtime of driver having valid
driving license..
YES, but Drivers are grosslyunderpaidfor 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 Agencywill 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 publicityto mobile phone ofthe driver Not anydedicatedeffort seen, nonot displayedon 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.
Immediatelymake alternate arrangements
following breakdown of vehicle
Usuallyavailable 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 manipulationincase of Km based
payment
IEC Activities No IECguidelinesare being followed except labeling
the vehicle on back andfront glass as Janani express.
Wall paintings in some areas

First Aid Training to the Driver Conducting2-3dayfirst Aid training for the driver is
the responsibilityof 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 Policychanged fromKm basedto the Flat rate policyof
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
Administrative
expenses under
JSY or RKS.
Payment to
the
Rs 300/- to the A rural area woman
is paidRs 1400/-and
A rural area womanis
paidRs 1400/- andan
A rural area womanis paidRs
1400/- and an Urban area
Women were
being paid Rs

Beneficiary pregnant woman an Urban area
woman is paid Rs
1000/-on
Urban area womanis
paid Rs 1000/-on
woman is paid Rs 1000/-on
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-dutyMedical
officer or the staff
Nurse have the
moneyand give it to
the patient on
delivery
The on-dutyMedical
officer or the staff
Nurse have the
moneyand 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(
ASHA/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 theyusedJanani
Express to bring
pregnant woman else
theyused to get full
Rs 600/-
AsHA/DAI were given Rs 350
(Rs 600-Rs 250) in case they
usedJanani Express to bring
pregnant woman else they
used to get full Rs 600/
AWW are no
more
considered to
be motivator
as their being
involvedinthis
scheme used to
hamper their
duty in
Aanganwadi
In case of
Referral
The mother will
againget Rs 300/-
but motivator will
not get any extra
benefit over Rs
200/- alreadypaid
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 moneyis paideither
to Pregnant woman nor to
the motivator

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 dividedintotwo
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 fixedandvariable
component are
decided upon at local
level , basedon the
lowest bidreceivedin
response to anopen
tender advertisement
Policychanged fromKm
basedto 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
RKS by the 3rd of
every month and
RKS is supposedto
clear the payment
within a week ,
The contracted
agencyis 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
the payment within
a week, max by 10th
The contracted
agencyis supposedto
submit the log book
and allthe receipts to
the RKS bythe 3rd of
everymonth andRKS
is supposedto clear
the payment withina
week , max by10th of
everymonth
The contractedagencyis
supposedto submit the log
book and allthe receipts to
the RKS bythe 3rd of every
month and RKS is supposed
to clear the payment withina
week , max by10th of every
month

max by 10th of
every month
of every month
Role of RKS If RKS gets more
collectionthanthe
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
collectionthanthe
monthlycontract
amount, it willbe
treatedas its income.
And, if RKS gets less
collectionthan
monthlycontract
amount, the deficit
will be borne byRKS.
If RKS gets more collection
than the monthlycontract
amount, it willbe treatedas
its income. And, if RKS gets
less collectionthanmonthly
contract amount, the deficit
will be borne byRKS.
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
evenbefore the umbrellaProgramme, 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.
Thoughthe Prasav HetuParivahanYojnaand the thus evolvedJanani Expressare basedon 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
brainchildof Mr PS Madan Mohan,UNICEF.The state kepton runningPrasavParivahan Yojana with
an idea of providing benefit to those not entitled under JSY. A point of transition came with a

particulargovernmentorderwhichextendedthe benefitof JSYbeyond 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 atthe institutional Healthfacilitywillbe providedfinancial incentive underthese scheme,
withthe incentive amountbeingRs1400/- forthe 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
realizedthatsince the JSYwas providingthe universal coverage to all pregnant women irrespective
of APL/BPLdiscrimination,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
pilotedthe scheme inhisarea.The scheme was started in 2006. The Janani express was envisioned
to addressthe geographical inaccessibilityissue due tolackof transport facilitiesleavingpeople 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
utilizationof the Janani SurakshYojana.The Jananai expressscheme wasconceptualized based on a
deep-rootedthinkingandunderstandingof the socio-economic realities. The most of the people in
the rural area owna motor bike ora tractor (four-wheeler)andwiththe introductionof the financial
benefit/ incentive under JSY, the figures for the institutional delivery were rising. The pregnant
womenwouldcome 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 Expresswasintroducedbasedonthe 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 wasaddressedbylinkingJanani Expresstothe Janani surakshaYojana.As per the Janani
express,Rs250/- out of the motivatorsincentive isdeducted in case she utilized the Janani Express
vehicle tobring the lady to the health facility and she is paid Rs 350/- out of the Rs 600/- Which are
otherwise paidtothe motivatorandincludesthe incentive of the motivator plus the transportation

cost. The Pregnantwomenare paidthe full moneyshe isentitled 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 ofdistance etc) given
to reimburse Financial cost of transportation of
pregnanant ladyto the healthfacility plus some
money to themotivator.scheme aimed at
enhancinginstitutional delivery by incentivizing
the pregnant female and the motivator
Entitled Beneficiaries All SCs/ STs pregnant women not in the BPL
category
All SCs/STs/ general category pregnant women
not eligible for JSY
Anywomen benefittedunder JSY was ununtitled
A womenbenefittedunder JSY was not entitled
to the scheme but was entitled to any other
scheme eligible for
The target populationwere those not benefitted
under the Janani Express Yojana
All pregnant womenirrespective of being from
Rural or Urban area
Benefit on an
institutional Delivery
Rs 300/- to the pregnant womanand 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 tillsome time back but not anymore
as her involvement inthisscheme was found to
adversely affect functioning of Aanganwadi
In case of more than
motivator
the moneywould be givento onlyone 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
AnyPrivate Health facilityapprovedunder RCH /
JSY
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
The targets were distributed block –wise
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-dutyMedical officer or the staff Nurse
have the moneyandgive it to the patient during
admission
The on-dutyMedical officer or the staff Nurse
have the moneyandgive it to the patient during
admissionProof of eligibility SC/ST category card,
If from generalcategory-BPL card/ Rationcard or
a Declaration
All pregnant women delivering at public
institutional health care facility
IEC -Block MedicalOfficer 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
Seal of scheme on ANC registration cards
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 lackof clarityon whose responsibilityis
of getting prescribed IEC material painted on
Janani Express. There is discrepancy in the
guidelinesand the tender document prepared.
Monitoring and
Evaluation
CMHO/Civil surgeon/ chief Administrative officer
of the Hospital will visit min.3 Health
facilities/monthto checkimplementation of the
scheme
District Health officer and Nodal Officers
BMO will conduct meetings anddiscussions with
the Beneficiariesand the Health facility staff in
his area
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 deliveryinMadhyaPradeshwhere 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
reviewof the block medical officers by principal secretary (Health & FW) and senior officers of
the directorate was responsible for putting this scheme in to operation.
 Fairlywell definedprotocols andguidelinesforinitiationof the scheme have beendevelopedfor
hiring the vehicles and for implementation of the scheme, by utilizing transport cost available
under JSY scheme.
 Wide publicitytothe scheme withactive participationof highestlevelpolitical leadership in the
state has helped to create awareness about the scheme

ISSUES
Purpose ofthe scheme:
The Policy or the scheme document states that the Janani Express model was conceptualized and
implementedtoprovide pregnantmotherasafe transportationfacilitytothe healthcare facilityand
addressthe geographical accessibility issue, which is one of the main reason for women opting for
home deliveryinabsence of achoice,as highlighted as a key finding by various studies and surveys
conducted. The basic tenet behind introducing the Janani express is to promote institutional
deliveriesandthusimprove 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
emergencytransportationformotherandchildrenandotherMedical Emergencies.The mainAim of
the scheme inthe documenthasbeenstatedas ensuringa 24 hrs availability of a vehicle facility for
the transporting a pregnant woman to the health facility for institutional delivery. The list of
conditionsorsituationsunderwhichabeneficiaryisentitled have been laid down in the document
as per which Janani Express scheme is expected to provide transport services for institutional
delivery,emergencyduringpregnancyorafterdeliveryandforseekingpostabortion complications,
any illnessrelatedtoDeendayal Antyodaya Upchar Yojana, child illnesses and any medical/surgical
emergency.
In practical operation,the Janani Expressisbeingusedexclusivelyforproviding pregnant women, a
safe transport facility to the health institution for delivery.There are very rare cases, where the
vehicle wasusedforcarryingSickchildrenexcept 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).

Discussionswiththe communitymembers 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 .
Duringthe discussions,the CMHOsandthe BMOs expressedtheirlimitationsinpracticallyexecuting
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 whichisverylikelytooccur incase of a free service likeJanani Express and can defeat
the mainpurpose 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 isa lack of clarityof understandingthe real objectivesof the scheme andHOWit 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 forthe payment for cases other than the delivery. The payment in case of an
institutional deliverybroughtbyJanani Express is made from the JSY and the RKS funds but there is
no guideline onthe paymentmechanismincase of otherpurposes the Janani Express is availed for.
There are some other policy document which allow the funds under IMNCI to be used for the
transportationof the Janani Expressbutthe scheme documentdoesnotinclude orreferto 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 hasbeenused 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
transportationfordelivery,isrestrictedtothe extent of being nil in most of the blocks and Districts
Lack of IEC Activities

There isan evidentlackof the IEC activityinpromotingawarenessaboutthe scheme andthere 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
followthose normsexcept 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 wasa governmentorderonPublishingaboutthe scheme inlocal dailynewspapers which was
one time effort. The District Hospitals and the CHC have a wall painting on the scheme which is a
writtendescriptionof the scheme andalsothe Numberof the Driver has been put on public display
at few other sites in the hospital.
In one of the districts(Vidisha),asmall card hasbeenprintedwiththe numbersof the entire drivers
listedblockwise,whichisdistributedtothe womenandisgenerallyattachedto the ANC card of the
women.The practical problemobservedwiththiswasthatthe 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
everytime isquite atask.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 centreshave the Janani Expressdriver’sNumberdisplayedonawhite 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 communityfacilitatorsforbeingable to access the service. The mobile number of the
Janani expressisgenerallyavailable onlywiththe ASHA/DAIandnotwith 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
femalesare illiterateandcannotreadthe IEC material andit emphasizesthe needof using the word
of mouth and verbal means of communication for promotion.
There islack of separate designatedallocationforIECplusthere 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 IECmaterial hastobe preparedandhow the supplychainhas to be maintained.Inabsence
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 isa lotof confusionoverif the transportationfacilityhastobe providedTOandFRO or only to
the Healthfacility.The confusionismore sodue tofrequentchangesin the guidelines, wherein the
guidelinesare changedonpapersbutthe informationfailstopercolate 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 facilityhas to be provided only to the health facility and not back to their house but the lack of
clarityisso much that the scheme isbeingrundifferentlyindifferent 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
Expressandthe contracting agencyas thishelpedthemincreasethe 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
pregnancyas an emergencyandensure the safe arrival of the pregnantwomantothe healthfacility.
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 limitationdue toinaffordabilityissueisalsonotthere asa part of the JSY moneymaybe 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 communicatingthe MOsand the concernedofficialsdoesn’t necessarily lead to a change in the
mindsetof the general people.The mostof the people donot have higheducational standard or are
mostlyilliterate andthusItbecomesahassle forthe alreadyover-loadedanddoctorsandthe health
staff to make general public at an individual level, understand such changes especially in cases of
withdrawal of afacilityismade.The practical problemwasraised by one of the Medical officer who
said that area has a strong political hold, refusal of the transport facility back lead to multiple
instancesof conflictsandthe doctorwas eventhreatened.Thisis a practical case which emphasizes
that needof a far-sightedvisionandrigorousanalysis by the think tank while framing policy so that
the frequent changes are not required.
The discussionswiththe BMOsand MOs insome of the areas revealedthattheyprovide 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
caseswhere the Janani expressfacilityhad tobe refusedasthe ambulance wasbusyattendingsome
other cases. The transport facility is provided for return as a goodwill measure as the case was
refusedforarrival owingtobeingbusyattendingsome othercase. The intend though good, creates
a lack of uniformity in implementation of the scheme which is important.
Kilometres basedpolicy vs.flat rate policy of payment:
The policyon the paymentmechanismhasbeenrevisedandthe Kmbasiscriteriahasbeenscrapped
and replacedbythe newflatrate case basedpolicywhere the agencywould be paid Rs 250/- on per
case basis, irrespective of the distance
The problemobservedwiththe kmpolicywasthatthe mostof the blockswere actuallypaying close
to double the amountfixedforupto 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 newrevisioninthe policyof paymenttothe contractedagencyhas notreceivedan encouraging
response from the contracted partners or the potential bidders as they do not find the new rate
policyprofitablebyanymeasure.The confusionismore sobecause theyare not even clear on if the
facilityhastobe providedonlytothe healthfacilityandnotfroas itwas beingpracticedbefore. The

contracting agencies perceive this new guideline to lead to a reduction in their profits when
compared to the past.
There are prosand cons of both the policies. The Km based policy though encouraged drivers to go
to the far flungandremote areasto enhance the Km usage ,lefta lot of scope for manipulation as it
ispractically 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
nearbyareas thus defeatingthe 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.Asperthe Km policy,the paymentfordistance covered beyond 12000km was being made
through the administrative expenses of the RKS, which used to be really high and usually equal or
evenmore thanthe amount payable forcoveringupto1200kms. Major chunkof 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,
anotherthoughtprocessbehindthe flatrate policyisthatit wouldautomatically incentivise drivers
and contractors toput effortstowardsenhancingutilizationof 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,whichmeansitwouldbe performance basedpayment.The contractormaynot
feel secure in partnering with the government as their will be lack of surety on if at all any profit
wouldbe generatedatall whenmostof the areasin the MPare far –flungandthe state of the roads
is extremely poor.
No separate allocationofFund/ Financial sustainability
There isno separate allocationof fundtowardsthe scheme andit issustainable tillthe JSYscheme is
functioningbutpresentlynolong-termstrategyhasbeenevolvedforitscontinuity.Atpresent,there
isno financial contributionfromthe 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
understandhowpartof the scheme intermsof financial viability and sustainability once the NRHM
is rolled back.

Issues in payment of motivator
In cases,where there ismore thanone motivator, the payment is made as per the clause according
to whichthe paymentbe made to the one suggested/recommendedbythe beneficiary. In an ideal
case, the payment should be made to the one who came first and accompanied the patient but in
mostof the cases womenpreferDAItoaccompanythem as they can handle the case if the delivery
happensonthe way itself.The patientgenerallytendstorecommendthe name of the Dai as it is the
Dai and notthe ASHA whoprovidesthe care inthe post natal phase.The cleaningof 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
begunto share the moneyamongstthem, irrespective of whosename isrecordedinthe 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
driverwascalledbutthe family later refused to take the mother to the health facility. The cases of
the false pain,where the womanavailedthe Janani expressbutthe deliverydidnottake place when
onlythe JSY benefitcouldnotbe given.Inthese cases,there islackof 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 isnot guideline onwhathas to be the line of actionincase 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 heal th
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,Attimes,Neitherdoesthe name of the Janani Expressgets 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 isno guidelineorprotocol inplace,thusdifferentblocksanddistrictsfollow it subject to their
ownunderstandingbutthiswill become amajorissue withthe 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 RKShave reportedto be not workingwell. Monthly meetings are hardly convened.
The collectoristhe in-charge at the Districtlevel andthe SDMisthe in-charge atthe block level. The
distributionof 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
monthlypaymentstothe transporter.RKSisexpectedtocollecttransport 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 NRHMand the guidelines for utilization of
thisfunddoesnotspeakabout JES.Although.RKSisalsoexpectedto generate their own resources;

inall the blocksRKShas 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
Amongcommunitymembersthere islack of awareness of the brand name ‘Janani Express’. Mostly
the awarenessof communitymemberswaslimitedtothe 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 communityfacilitatorsforbeingable to access the service. The mobile number of the
Janani expressisgenerally 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
communityfacilitatorsseemtohave amonopolistic 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 directinterface betweenthe patientandthe Janani express driver, which reflects the lack of
IEC aboutthe scheme.The numbershouldalso be widely circulated amongst community members
and should not remain restricted to ASHA or DAI only so that in case of emergency the family
memberhimself canalsocall up the Janani expressdriverandrequestforthe 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 clientsavail JES,ASHA doesnotgetthismoney.Conflictof interest of ASHA is
also one of the reasons. It is a very common practice that the ASHAs of the near-by area generally
tendto misleadthe familyandpreferto take the pregnant woman by personal vehicle say a tractor
or a bike ownedbytheir husband.The explanationsofferedtothe familyare like the mobile phone
of driverwasnotreachable or The ambulance wasengagedin 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

usesJE, theyloose thisincentive. Thus,confrontationandclashof interestbetween ASHA and TBAs
resultinginacrimonyandmisleadingthe beneficiarywasobserved,whichcouldbe amajor 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
domainof workperceivedtobe interference orathreat.This isa major and botha specificaswell 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 driverscomplainedof the lackof rolling fund in their hand for maintainance and repair
or sometimesforfuel asthe paymentismade atthe endof the monthonly.Thisexhibitsnegligence
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 HealthFacilities: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 Districthospital Healthstaff complainedof the increasingnumber 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
Districthospital staff .Thisisanabuse of the Janai Expresscan alsoleadto increase inrefusal 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 Absenteeismishigh,especiallyincase of Doctors, with most of them staying
in the near by city and having their own private practice
 The most of the PHCs/SCsdonot workfull 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 healthfacilitieshave 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 DistricttHospital Vidishabuildingis in really old and in poor state. It is important to
lookat utilizationof the RKSfundsandchannelizethem 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 neededandthatbecomesapretext for excessive referrals and irregularity in
attendance on account of the lack of space
 It is importantto 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 DistrictHospital Vidisha building is in really old and in poor state. It is important to
lookat utilizationof the RKSfundsandchannelizethem 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
ObjectiveofSoftware
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
645
602 587
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 07
Total Beneficiaries of 2007- 08 : 5026
No.ofCasesTrasported
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. Thegeneral issueobserved 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 retrospectiveanalysis 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.
CONTRACTDOCUMENT
Penaltyclause:
 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 shouldpreferablybe 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.

 Needtohave a special separate designatedfundforrunningthe scheme inlongrun.An
innovative model forfundandresource generationmustalsobe exploredtoensure the
sustainabilityof 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 Hoshangabadas these DPMU s didnot getbiddersforthe tenderthistime as the model
isnot beingperceivedprofitablebythe contractors.On the otherhand,the Janani Express is
running smoothly and is running into profits even with this new Rs 250/- flat rate scheme
withthe servicesbeingrenderedonlyone-wayi.e.tothe healthfacilityasperthe guidelines.
This indicates that the contractors need of calling a meeting of the contractors and
reorientingthemonthe cost-benefitaspectandhow the cases get cross-subsidized in a flat
rate and the model could be a viable option.
The other importantnoteworthypointisthatbefore implementinganysuchpolicydecision,
it would be good to call a meeting with the contractors and take their feedbacks and
suggestionsasthey are the most important stake holders in the model. It is also important
to re-analyze the policydecision 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 analyzedasan issue of Moral Hazard versusthe rightto care especiallyin case of a
medical emergencyandthe guidelinesneedtobe speltoutmore clearly ondealingwiththis
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
monetarybenefitorincentive isinvolvedandinabsence of anyguideline spellingout clearly
the payment aspect in cases other than delivery, the other benefits the vehicle could be
availedforisneitherdisseminatednorencouragedandhaslimitedtothe scheme document
only.The paymentmechanismneedstobe explicitlydetailedinthe document as though it is
a social welfare measure fromthe publicprovider’sendbutthere isaprofitmotive 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 isneedof buildingmore clarityonif the nomenclature of the scheme shouldbe Janani
Express or should be changed as the nomenclature plays a big role in Image building and
perceptionthe communitybuildsof 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 anditsbenefits,includingestablishing 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 leavingthe motheronhome delivery,reflectsgapin 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 NRHMand its allied programme

 There needstobe a general awarenessbuilding amonst people that they should not only o
informor call the Janani Expresswell intime andprepare wellin advance instead of waiting
till the eleventhhourormakingthe driverwait.Buildinganunderstandingof the importance
of institutuionaldeliveryandtreatingdeliveryasanemergencywhich needs to be attended
at the earliest possible, will be a milestone achievement
ASHA/DAI
 The motivators,ASHA anddai shouldbe 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 , whereverthe 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 anddai shouldbe re-orientedtotheirrolesandthe componentof Rs
250/- be removedbecause otherwiseASHA/DAItendtouse personal vehicle
 It isrecommendedtohave furtherinteractionwith 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 conductedat a trainingcentre where theymaybe trainedonthe scheme andtheirrole in
it.. The driverbe orientedon 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 isnecessarytoinitiate systematicmappingof the block, which should include mapping of
healthinstitutionsforprovidingCEmOCand BEmOC services, geographical area attached to
these institutions,estimatednumberof 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 Expressservice has beenverbally reportedtohave stopped in Seahore, Raisen
and Hoshangabadas these DPMU s didnot getbiddersforthe tenderthistime as the model
isnot beingperceivedprofitablebythe contractors.On the otherhand,the Janani Express is
running smoothly and is running into profits even with this new Rs 250/- flat rate scheme
withthe servicesbeingrenderedonly one-wayie tothe healthfacilityas per the guidelines.
This indicates that the contractors need of calling a meeting of the contractors and
reorientingthemonthe cost-benefitaspectandhow 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 theirfeedbacksandsuggestions 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 reportingformatsbe preparedforJanani Expressanda columnbe addedto
the JSY or the Deliveryregistertosee if the vehicle wasevenusedbythe concernedperson
 Monthlyreportingandmonitoring 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
throughJanani Express,butactuallydidnotavail services, call for close monitoring to avoid
similar discrepancies in future
 The drivershouldbe givensome incentive onexceeding targets. Similarly targets be set for
the Blocks and the districts as well, and they should be linked to reward
 The incentivesanddisincentivesneedtobe 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 Deliveryregistertosee if the vehicle wasevenusedbythe concerned person.
 Monthlyreportingandmonitoring 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 controllingthe movementof the vehicleswillhelpinadequatemonitoringand 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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