DOI: 10.12688/f1000research.188237.1 ISSN: 2046-1402

Free on paper, paid at the bedside: closing the enforcement gap in India's zero-expense maternity entitlement

Shyamkumar Sriram
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Background India guarantees every woman delivering in a public health facility an absolutely free and zero-expense birth, including caesarean section, under the Janani Shishu Suraksha Karyakram. That guarantee sits alongside a conditional cash transfer and a national hospitalisation insurance scheme. Institutional delivery is now near universal, yet households still pay at the point of birth. Policy and implications The 2025 national household health survey records average out-of-pocket medical expenditure of 2,299 rupees per childbirth in a government facility, against 37,630 rupees in a private facility, a category that explicitly includes hospitals empanelled under the national insurance scheme. Reported insurance coverage more than doubled between the two most recent survey rounds while public-facility payment at birth rose in nominal terms. This brief argues that the failure is architectural. An enforceable guarantee requires four elements: a defined benefit, a price, a claim, and a published compliance rate. India’s maternity guarantee has the first only. No facility is paid for honouring it and none is measured against it, so the entitlement operates as an expectation rather than as a financing instrument. The cash transfer, on a rate card set two decades ago, no longer covers the average public-facility bill it was designed to offset. Recommendations Convert the entitlement into a purchased per-case product routed through the existing national claims platform; publish facility-level zero-bill compliance as a routine indicator with a dated national target; fix medicines and referral transport as the two dominant leak points; extend protection across the antenatal and postnatal episode rather than the inpatient admission; and impose zero balance billing on empanelled private obstetric care. Conclusions Because the entitlement promises zero expenditure, any positive figure represents a failure of delivery rather than a question of price inflation.

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