A/HRC/14/20/Add.2 was informed that sometimes the poorest women do not have such a card. He was also informed that the actual costs incurred by women accessing institutional delivery often exceed the financial assistance provided by JSY, requiring them to take loans. These and other issues are cause for concern. However, JSY gives rise to one especially grave problem. 51. When visiting India, the Special Rapporteur found some facilities to be inspirational: community-supported, well-equipped and staffed by dedicated teams of health and other workers. But the record is extremely uneven. Some health facilities are grossly inadequate: dilapidated, ill-equipped, understaffed, and offering extremely poor services. JSY and other measures have increased the number of women delivering in health facilities: they have increased the demand side. But, in many cases, the range and quality of services in those facilities has been seriously neglected: the supply side has received too little attention. The reforms are seriously out of sequence. Crucially, the focus in India is on increasing institutional delivery, but institutional delivery is not a proxy for access to skilled birth attendance or life-saving care. While cash incentives are not necessarily inconsistent with human rights, a scheme that gives incentives to pregnant women to use facilities which do not have the services the women need is offensive, unethical and in violation of their right to the highest attainable standard of health. Much more effort must be devoted to ensuring that health facilities are not only adequate in number and accessible to all, but also functional and of good quality. “Informal fees”: corruption and barrier to equitable access 52. Access has several dimensions, including financial access or affordability. There is only space to mention briefly one aspect of financial access in the present context. In some health facilities, there is a widespread practice of staff asking for money for services (e.g. transport, medicines and tests) that the Government has mandated are free.31 “Informal fees” undermine the JSY scheme and sometimes compel women and their families to take out loans at high interest rates. These corrupt practices disproportionately affect those living in poverty and are a barrier to equitable access. In relation to each health facility, the Special Rapporteur strongly recommends the strengthening of transparency, as well as community and patient participation in monitoring and accountability. Mandatory pre-qualification service in underserved areas 53. One way of addressing profoundly inequitable access to health professionals is to make it mandatory for them to work in underserved areas, for a limited period, immediately prior to qualification. While this might not be appropriate in relation to all categories of health professionals, there is a strong case that it should apply to India’s general practitioners (MBBS doctors). Understood as part of professional development, such an arrangement needs to be very carefully discussed, prepared, supported, supervised and managed. The Special Rapporteur strongly recommends that steps be taken to put in place such arrangements as a matter of urgency in relation to appropriate categories of health professionals. Incentives for post-qualification service in underserved areas 54. This is another way of addressing deeply inequitable access to health professionals. The incentives need not only be financial. In some contexts, they might relate to accommodation, transport, opportunities for professional development, promotion, extra leave, among other things. 31 GE.10-12866 Iyengar, Iyengar and Gupta, “Maternal health”, p. 284. 13