A/HRC/14/20/Add.2 the programme can and should be improved, as signalled by a recent study.28 Nonetheless, the presence of medical officers trained under the programme enables some first referral units to function as comprehensive EmOC facilities. In short, the programme is helping to address one important part of the health workforce crisis gripping Rajasthan, Maharashtra and other Indian states. Everything possible should be done to promote the training of a sufficient number of medical officers in anaesthesia and to ensure that the necessary facilities and services are in place to permit them to use their life-saving skills. 46. Although the Special Rapporteur asked the Indian Society of Anaesthesiologists how many members they have, he did not receive a reply. However, he understands the problem is not a national shortage of, but inequitable access to, anaesthetists. While one way of enhancing access is by delegation or task-sharing, other measures can also be taken, some of which are signalled in later paragraphs. Janani Suraksha Yojana and institutional deliveries 47. A centrepiece of India’s maternal mortality strategy, the Janani Suraksha Yojana (JSY) initiative, aims to increase the number of institutional (i.e. facility-based) deliveries by providing cash incentives to pregnant women. The scheme is especially aimed at enhancing the access of women living in poverty and members of Dalit and tribal communities. Essentially, women who deliver in health facilities (government or accredited private facilities) are given greater financial assistance than women who deliver at home. The financial assistance is subject to fewer limitations (e.g. age of the woman and number of children) in designated low-performing states, such as Rajasthan (but not Maharashtra). 48. JSY depends on accredited social health activists (ASHAs) who are rural women appointed as community health aides. While their duties extend beyond maternal health, crucial responsibilities include providing information about family planning, facilitating antenatal and post-natal care, arranging transport and escorting pregnant women to preidentified health facilities for delivery. There is a cash incentive for ASHAs to ensure women deliver in a health facility. By mid-2009, nationwide there were nearly 50,000 ASHAs trained and in position with drug kits, a remarkable achievement. 49. The JSY and ASHA initiatives contribute to the four cornerstone interventions to reduce maternal mortality. Critically, they facilitate referrals from home to health facility and enhance access to skilled birth attendance and EmOC. There is overwhelming evidence that they have significantly increased the number of institutional deliveries. In Rajasthan, for example, the rates of institutional deliveries in 1998/99 were 15 per cent (rural), 48 per cent (urban) and 22 per cent (total). By the second year of the JSY implementation (2005/06), they were 23 per cent (rural), 68 per cent (urban) and 32 per cent (total).29 Note, however, that about 60 per cent of women in India continue to give birth at home, mostly with traditional birth attendants or family members, i.e., without a skilled birth attendant.30 For women living in poverty and members of Dalit and tribal communities, the percentage is substantially higher. 50. Nonetheless, the Government of India deserves much credit for its ambitious JSY initiative, fully funded by the central Government. However, there are problems with JSY. For example, the limitations on financial assistance penalize young women and women with more than two children. Also, in some cases the assistance depends upon a government card certifying the family is below the poverty line. The Special Rapporteur 28 29 30 12 Evans and others, “Where there is no obstetrician”. International Institute for Population Sciences, 2005–2006 National Family Health Survey, Fact Sheet: Rajasthan. NFHS-3, “Key indicators for India”. Available from www.nfhsindia.org/pdf/India.pdf. GE.10-12866