In an unexpected twist, demonetisation has spurred Prime Minister Modi into championing the cause of maternal and child health (MCH) in India. On 31 December, pregnant women in India were the surprise beneficiaries of post demonetisation sops as the PM committed his government to fulfilling one of the promises of the National Food Security Act (NFSA) by extending the Indira Gandhi Matritva Sahyog Yojna (IGMSY) from a 53-district pilot to a national programme.
Repackaged as the Maternity Benefits Programme (MBP), the PM’s renewed commitment to MCH is surprising. Despite a dedicated chapter to MCH in the 2016 Economic Survey, in the last three years, this government’s track record on delivery has been poor. Budgets for the key nutrition flagship, the Integrated Child Development Services (ICDS) programme were slashed from Rs16,312 crore in 2013-14 to Rs14,000 crore in 2016-17 and calls to address implementation deficits haven’t resulted in significant reform on the ground. The IGMSY pilot too received very few resources. Between 2013-14 and 2016-17, a total of Rs1,294 crore was allocated but only 63% was actually released till July 2016. With the pilot floundering, few had expected the IGMSY to be scaled up. But given the serious deficits in nutritional outcomes and the high infant and maternal mortality rates in India, this focus on MCH is a welcome first step.
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This is the good news. The bad news is that the MBP is unlikely to succeed in improving outcomes. In a press release issued in early January, details of the current proposal were unveiled. Like its predecessor, the programme is designed as a conditional cash transfer with money being given to beneficiaries in three tranches contingent upon fulfilling conditionalities including antenatal checkups, institutional delivery and child vaccinations. Between January 2017 and March 2019 the programme is expected to cost Rs12,661 crore. But here is the problem.
The first hurdle that MBP is likely to face is financial. In his 31 December speech, the PM announced that benefits will be provided to women who undergo institutional delivery and vaccinate their children. The subsequent press release anticipates the number of beneficiaries to be 5.17 million annually. The annual budget has been estimated accordingly. However, it is unclear how this has been calculated. According to government data, as many as 7.5 million women received Janani Suraksha Yojna (JSY) benefits in 2015-16. The number of reported beneficiaries of the ICDS supplementary nutrition programme was estimated at 19.33 million. This suggests that the number of potential beneficiaries is higher than the current calculation. And in the absence of clarity on this 5.17 million number, the programme is likely to result in severe rationing, leading to large exclusion errors.
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Second, the conditionalities attached to the MBP are likely to create an unwieldy implementation structure that will create multiple bottlenecks along the way. This was an important lesson from the IGMSY pilots. A 2016 study by Dipa Sinha and colleagues highlights that fund flows to beneficiary bank accounts were slow because of complicated paperwork associated with fulfilling the conditionalities. In 2014, the annual IGMSY budget for Bihar was released in September, halfway through the financial year, while Jharkhand was still awaiting its first tranche.
But perhaps the more important lesson from IGMSY is that the conditionalities imposed will lead to excluding the truly vulnerable. The fact is that health services are not easily available in many parts of the country. Data from the Rapid Survey on Children, 2014 highlights that less than half of pregnant women receive more than four antenatal care assessments or receive supplementary food during pregnancy, and less than a fourth report consuming iron-folic acid tablets. Thus women who are excluded from the IGMSY are most likely being denied benefits due to government failure rather than their own behavioural choices.
These problems can only be truly resolved by making the scheme universal. Estimates suggest that this would cost the government Rs16,000 crore a year, compared with the current estimate of Rs3,165 crore. It could be argued that fiscal constraints may prevent a universal approach. If that is the case, then administrative reforms will be critical. Most of the conditionalities associated with the MBP are linked to programmes and schemes run by the health ministry. The MBP, on the other hand, is to be housed in the Women and Child Development ministry. As anyone familiar with the workings of government will attest, the presence of multiple ministries with different accountability systems is a recipe for disaster. At the minimum, an effort will need to be made to converge the programme with relevant programmes being run by the health ministry. Another approach, keeping budget constraints in mind, is to present states with a basket of intervention strategies that they can pick from, depending on health infrastructure and health seeking behavioural patterns.
Finally, and to further reiterate the case for universality, if the goal of the MBP is to improve MCH then linking the cash transfer to institutional deliveries, in the absence of significant changes in the incentives of health workers, may not be the best strategy. As we have argued previously in this series, while institutional deliveries have risen, partly driven by the JSY cash transfer programme, this has not resulted in a significant impact on neo-natal mortality rates. Moreover, given the poor quality of care, the economic and psychological costs on women going to government hospitals outweigh the potential benefits of the programme. Thus, if the goal of improved MCH outcomes is to be achieved then universality may well be the only option.
The demonetisation sop is a unique opportunity for this government to take the MCH agenda forward. But getting the design right is critical. Lets hope that the PM realizes this, and restructures the current sop in to a universal MBP in this budget.
Yamini Aiyar is a senior fellow at the Centre for Policy Research (CPR) and director of the Accountability Initiative. Avani Kapur is a fellow at CPR and leads Accountability Initiative’s research in Public Finance.