Date of Award

August 2016

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Administration

Advisor(s)

John P. McPeak

Keywords

JSSK, JSY, Maternal Health in India, Melghat, Mobile Phones, Policy Implementation

Subject Categories

Social and Behavioral Sciences

Abstract

Fifty thousand women died during childbirth in India in 2013, the highest total in the world; that is, one maternal death every 10 minutes. India and Nigeria account for almost one-third of total global maternal deaths. In pursuit of the Millennium Development Goals, the government of India directed efforts to improve maternal health and was able to reduce maternal mortality rate from 437 per 100,000 live births in 1990 to 140 per 100,000 in 2015, albeit missing the target of 109. Moreover, estimates for maternal morbidity are three to four times that of the mortality rates with even more pronounced regional disparities. Universal access to free public healthcare for maternal health has been a national goal since 2005, but its quality of service and utilization rate of maternal healthcare remains an elusive dream for many of the rural women even after a decade of substantial efforts.

In a stark contrast, mobile technology has become more pervasive than the most basic infrastructure across the world. There are over 7 billion mobile phones subscriptions worldwide, but only 4.5 billion people have access to basic sanitation facilities, implying more people have access to mobile phones than toilets in the world, including India. The ubiquity of mobile phones can no longer be ignored. According to the 2011 census of India, 47 percent of the rural households owned mobile phones, and mobile phone network coverage spanned over 99 percent of the rural landscape, but only 31 percent of these rural households had a toilet.

This exponential growth in mobile phone ownerships and adaptation has captured the imagination of academic scholars, public administration and the private sector to push for mobile based solutions and services in almost every aspect of public, social and personal life. M-governance has gained prominence too, aimed at improving service delivery, transparency, policy monitoring, public engagement, combatting corruption and poverty, especially in the developing world, leap-frogging poor-resource and low-income constraints. Today there is a mobile app for everything and the solution to any problem is a mobile app, including maternal health.

However, amidst this optimism, it is surprising that the potential of mobile phones to improve social policy awareness is yet to be fully exploited. There are initiatives toward health literacy and mobile based cash transfers but few initiatives are geared toward improving awareness of social welfare policies, informing people about eligibility, enrollment and entitlements. Here lies the uniqueness of this research. Motivated to find solutions to actual policy implementation problems in practice, this research lies at the intersection of information communication technology, maternal health benefit policies and public management. In India, low maternal health benefits policy awareness imposes an administrative burden on rural women and leads to uptake of cash and public health service benefits. This research explores if mobile phones can be used as an effective medium to increase maternal health benefit awareness; thereby increasing the claiming of benefits.

Using mixed methods of research, insights are drawn from a longitudinal case study in Melghat, a tribal belt of Amravati District in Maharashtra, India; a region that suffers from high maternal morbidity and high infant mortality rate. Forty-two percent of total childbirths take place in the home despite four different maternal benefit policies promoting institutional delivery and safe motherhood. In this dissertation, customized audio messages about maternal healthcare benefit policies were designed and broadcasted to 82 pregnant tribal women and followed up with qualitative interviews to examine any improvements in claiming of the policy benefits in 2013. The research provided an in-depth view of how information was disseminated through mobiles phones, and what factors and trade-offs, beyond information, were actually considered by the households in claiming the policy benefits.

This research offers four contributions. First, it provides a deeper understanding of maternal health policies, how incentives work and the impact of conditions attached to these incentives, providing a plausible explanation for why the policies remain only partially effective. Second, in an era of m-governance, it illuminates the potential and limitations of the mobile phones in policy implementation and civic engagement, through a gendered lens. Third, it yields a caution to the technological optimistic use of mobile phones. By evaluating the causal mechanism of whether and how information awareness led to greater claiming of benefits, the findings revealed that information awareness alone was insufficient to improve claims when there were structural and systemic deficiencies in the policy design and management. Fourth, it advances the theory of administrative burden, by using mobile phones to reduce learning costs and by expanding the concepts of compliance costs and psychological costs, and highlights the relative interaction and trade-offs between components of administrative burden in an international context. The research concludes that although mobile phones have the potential to trigger demand for policy benefits and public engagement, and reduce learning cost, they are not the “silver bullet” because they cannot bypass the fundamental challenges of other administrative burdens, policy design deficiencies and bureaucratic processes.

Access

Open Access

Download

Share

COinS