Maternity entitlements are an
important policy tool for encouraging better maternal health. This is
why we need to do away with conditionality in cash transfer schemes
Since
the National Food Security Act (NFSA) was passed in 2013, policy
circles have been buzzing with talk of reforms in the public
distribution system (PDS). Less well appreciated is the NFSA’s potential
to call attention to, and help address, poor maternal nutrition — an
aspect of food security that is extremely important for health,
well-being, and productivity.
Indian women are unhealthily thin
when they begin pregnancy — the 2013-2014 Rapid Survey on Children finds
that a little less than half of the women aged 15-18 are underweight.
Further, women gain too little weight during pregnancy to nurture
healthy babies. Maternal nutrition is so poor that Indian women actually
weigh less at the end of pregnancy than sub-Saharan African women do at
the beginning. As a result, India’s neonatal mortality rate is high,
birth weight is low, and far too many children suffer the consequences
of being undernourished in the womb.
The NFSA legislates a
“maternity benefit of not less than Rs. 6,000” to “every pregnant and
lactating mother.” Unfortunately, except for laudable efforts in Odisha
and Tamil Nadu, and a small pilot programme called the Indira Gandhi
Matritva Sahyog Yojana (IGMSY) which is active in only 53 of India’s 676
districts, maternity entitlements have not been implemented.
Government’s role
Maternity
entitlements would be a good idea even if they weren’t already written
into law. The health of future Indians depends on women gaining more
weight during pregnancy. Maternity entitlements could be used to
purchase vegetables, fruits, dairy products, eggs, or meat, which are
essential for healthy pregnancies but are not distributed through
existing programmes.
The government should put new emphasis on
educating women and their families about weight gain during pregnancy.
It should combat the common, though false, notion that women should eat
less, not more, during pregnancy. It should talk to people about the
fact that pregnant women are often treated poorly by their own families;
they are expected to work hard and eat little. Despite clear
difficulties of addressing entrenched gender and age hierarchies with
government action, maternity entitlements are a good way to signal to
families just how important a time pregnancy really is.
Last
September, the Supreme Court issued a notice to the Centre about
non-implementation of maternity entitlements. A representative of the
Ministry of Women and Child Development (MWCD) responded in late
October. The response suggests that if the Finance Ministry allocates
funds for maternity entitlements (the Finance Ministry has, at present,
allocated funding only for the 53 IGMSY districts), the MWCD would
expand IGSMY in its current form. There are several reasons why this is a
bad idea.
IGMSY is a conditional cash transfer, which means that
mothers only receive benefits if they meet certain requirements.
Recipients must register pregnancies with a village health worker,
receive ante-natal check-ups, take iron-folic acid supplements, receive
immunisation, attend infant-feeding counselling sessions,breastfeed for
six months, and begin complementary foods at six months. These are
steps to raising healthy children, but making them conditions for
receiving benefits makes little sense.
Conditional cash transfers
have been successful in Latin America, where health systems are
well-developed. In India, though, major deficiencies in the provision of
health services mean that conditional transfers will not work
similarly. Conditional transfers solve demand problems, but India
chiefly faces supply problems. Conditions that have to do with mothers’
behaviour rather than participation in services are nearly impossible to
verify. Verifying behaviour which occurs in private, at home,
constitutes an undue burden on health workers. Further, the need to
document the fact that conditions have been met invites corruption: many
health workers demand to be paid for producing paperwork that
“verifies” the unverifiable.
Universalise entitlements
Although
the NFSA clearly legislates a universal entitlement, IGSMY, which MWCD
proposes to expand, restricts benefits to the first two births. This
position appears to be based on the ill-conceived notion that universal
transfers increase fertility.
Certainly, people respond to
incentives. But a Rs. 6,000 transfer is not large enough to persuade
parents to raise a child they don’t want. Children are expensive: the
2011 India Human Development Survey found that parents spend an average
of Rs. 4,207 per year educating each 5-18-year-old child, not to mention
what they spend on food, clothing, and medicines.
Some recent
research, casually cited in media reports, claims that Janani Suraksha
Yojana (JSY) incentives for institutional birth have slowed fertility
decline. The basis of this claim is that between 2001 and 2008,
fertility decline was slower in States with high JSY incentives than in
those with low incentives. This argument, however, overlooks the fact
that NFHS data show that this pattern was applicable even before JSY was
launched.
No social-scientific evidence supports the idea that
families would be motivated to raise another child by JSY incentives of
Rs. 1,400, or maternity entitlements of Rs. 6,000. Regrettably, social
biases may be at play when government officials baulk at universal
entitlements: the Centre for Equity Studies finds that restricting
participation to the first two births would disproportionately exclude
mothers from poor and minority backgrounds.
Maternity
entitlements are an important policy tool for encouraging better
maternal health. But a well-designed programme would not merely scale up
the IGMSY. It would be, as the law already requires, a universal
programme, and it would do away with conditionality in favour of
educating families about the importance of investing in healthy
pregnancies.
(Diane Coffey is a visiting researcher at the
Indian Statistical Institute, and Payal Hathi is managing director of
the Research Institute for Compassionate Economics, New Delhi.)