Renewed focus on maternal and child care

On 31st December,2016, Prime Minister Narendra Modi committed his government implementing , the long-promised maternity entitlement commitment of National Food Security Act by extending a 53-district pilot to national scheme. It is expected that annually about 51.70 lakh beneficiaries would avail of the benefit.

Government of India is committed to ensure that every woman attains optimal nutritional status – especially from the most vulnerable communities as nutrition constitutes the foundation for human development.

This is all the more important during the period of pregnancy and lactation coupled with wage loss. A woman’s nutritional status has important implications for her health as well as the health and development of her children.

An under-nourished mother almost inevitably gives birth to a low birth weight baby. When poor nutrition starts in-utero, it extends throughout the life cycle, particularly in women. Owing to economic and social distress many women continue to work to earn a living for their family right upto the last days of their pregnancy.

Furthermore, they resume working soon after childbirth, even through their bodies might not permit it, thus preventing their bodies from fully recovering on one hand, and also impending their ability to exclusively breastfeed their young infant in the first six months.

To address the above issues, Ministry of Women and Child Development, in accordance with the provisions of Section 4(b) of National Food Security Act, formulated a scheme for pregnant and lactating mothers called Maternity Benefit Programme – a conditional cash transfer scheme. The Scheme provides cash incentives to pregnant and lactating women

(i) for the wage loss so that the woman can take adequate rest before and after delivery;
(ii) to improve her health and nutrition during the period of pregnancy and lactation; and
(iii) to breastfeed the child during the first six months of the birth, which is very vital for the development of the child.

Under the scheme, all Pregnant Women and Lactating Mothers (PW&LM), excluding the Pregnant Women and Lactating Mothers who are in regular employment with the Central Government or State Governments or Public Sector Undertakings or those who are in receipt of similar benefits under any law for the time being are eligible.

The cash incentive of Rs.6,000/- is payable in three instalments for the first two live births at the following stages:

• In an unexpected twist, PM made the pregnant women of India a surprise beneficiary of post demonetization sops, thereby taking steps towards championing the cause of maternal and child health (MCH) in India.
• The PM committed his government to implement the long-promised maternity entitlement commitment in NFSA by extending Indira Gandhi Matritva Sahyog Yojana, a 53 district pilot to a national scheme.
• Expansion of MBP will have huge impact on the PW&LM as it will not only provide them compensation for the wage loss but will also provide them adequate nutrition and rest before and after delivery. Mothers will have sufficient time to breastfeed the child during first six months of the birth. Resultantly, it is expected that it will reduce mother mortality rate, IMR, under-nutrition and its adverse effects.
• It is a Centrally Sponsored Scheme and the cost sharing between Centre and States is 60:40 for all the States and UTs (with legislature), 90:10 for NER and Himalayan States and 100% GoI share for UTs without legislatures. The total cost of the proposal for the balance period of 2016-17 and from 2017-18 to 2019-20 including Centre and State share is expected to be Rs. 12,661.00 crore. Out of this, Government of India’s share for the balance period of 2016-17 (Rs. 584 crore) and from 2017-18 to 2019-20 (Rs. 7348 crore) is expected to be Rs. 7932 crore.

Benefit Programme

• In last three years, the government’s track record on delivery in maternal and child health has been poor despite a dedicated section on maternal and child health in 2016 Economic Survey as well as NFSA’s provision for maternal and child health.
• Budget for nutrition flagship programme ICDS was decreased from Rs. 16,312 crore in 2013-14 to Rs. 14,000 crore in 2016-17. Even IGMSY had few resources, with allocation of Rs. 1294 crores between 2013-14 and 2016-17 and releasing only 63% of the allocated funds.
• Repeated calls have been given to address the challenges pertaining to implementation deficits, but hardly have they been addressed.
• However, a renewed focus on MCH is much needed with growing deficits in nutritional outcomes and high maternal and infant mortality rates in India.
• India’s maternal and infant mortality indicators are very poor. Every third woman is undernourished and every second woman is anaemic. Thus, an undernourished woman would likely give birth to a low-weight baby.
• Maternal mortality ratio: 174 deaths/100000 live births and Infant mortality ratio: 40 deaths/ 1000 live births.
• As per the UN Millennium Development Goals Report 2014, India recorded the highest number of maternal deaths in 2013 and accounted for 17% of global deaths due to pregnancy- and childbirth-related complications. In India, less than 40% of births in India are institutional deliveries.
• While women employed in the formal sector are entitled to maternity benefits like paid leave by their employers for 26 weeks (under Maternity Benefit Amendment Bill of 2016), such benefits are absent for women in the unorganised sector, which employs 90% of women.
• Hence, it was required that the government now universally implement Section 4 (b) of the National Food Security Act which states that every pregnant and lactating mother would be entitled to maternity benefit of not less than Rs. 6,000.

Delivery of Maternal Benefit Programme (MBP)

• MBP is a conditional cash transfer with money being given to beneficiaries in three instalments upon fulfilling conditions- antenatal checkups, institutional delivery and child vaccinations.
• The cash incentive of Rs.6000 is payable to pregnant and lactating women as compensation for the wage loss so that the woman can take adequate rest before and after delivery.
• The aim is to improve her health and nutrition during the period of pregnancy and lactation and to breastfeed the child during the first six months of the birth, which is very vital for the development of the child.
• Resultantly, it is expected that it will reduce mother mortality rate, IMR, under-nutrition and its adverse effects.

Looming challenges

• The anticipated beneficiaries under MBP are to be 5.17 million annually. However, the government data suggests that 7.5 million women received Janani Suraksha Yojna (JSY) benefits in 2015-16 and the ICDS supplementary nutrition programme beneficiaries is estimated to be 19.33 million.
• This means that existing + potential beneficiaries are higher than current calculation. In absence of clarity on 5.17 million numbers, the programme may have large exclusion errors.
• This might once again lead to spending of huge finances without reaping expected outcomes.

Conditions

• IGMSY pilot gave important lessons in this respect. The conditionality imposed might lead to exclusion of the truly vulnerable. This is because health services which fulfil certain conditions are not easily available in many parts of the country.
• Most maternity benefits schemes are targeted on the basis of income, age and number of children showing their patriarchal values.
• The findings related to repeated pregnancies suggest that women from the extremely marginalised groups are the ones who will get excluded from the scheme due to its eligibility condition, thereby deteriorating their health further in absence of counselling or information on family planning.
• A study by National Alliance for Maternal Health and Human Rights has shown that precondition such as eligibility excludes 60% of women in the 15-49 age group, most of whom are Dalits and tribal’s. They are the ones who have more than two children, are illiterate and devoid of financial inclusion.
• Conditions such as immunization, counselling session, ANCs and PNCs have a positive impact, but cash transfer on their strict adherence excludes the beneficiaries who are not able to fulfil them.
• 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.
• When these women are not given the cash transfer as expected, they are not encouraged for institutional deliveries. A 2016 study highlighted that fund flows to beneficiary bank accounts were slow because of complicated paperwork associated with fulfilling the conditionality’s.
• Conditionality’s related to utilising health and nutrition services are also meaningless in the absence of a service guarantee and the difficulties in accessing these schemes in the first place, as seen in most of the villages.
• Thus, the beneficiaries are more likely to be denied benefits due to government conditions rather than their own behavioural choices.

Financial hurdle

• The current programme is estimated to cost the government Rs. 16,000 crore a year, compared with the current estimate of Rs. 3,165 crore and entire WCD ministry allocation in budget 2016-17 of Rs. 17,408 crore.
• Also, change cannot be expected in the absence of significant changes in the incentives of health workers. While institutional deliveries have risen, partly driven by the JSY cash transferprogramme, it has not resulted in a significant impact on neo-natal mortality rates.
• Thus, the burden of finances may water down the intended outcomes.

Administrative challenges

• Along with financial concern, it is imperative for administrative reforms to take place.
• Most of the conditionality’s associated with the MBP are linked to programmes and schemes run by the health ministry. But MBP shall be under Ministry of Women and Child Development.
• Thus, presence of multiple ministries with different accountability systems will create roadblocks for the successful programme implementation.
• Administrative rigidities such as insisting on registration at the anganwadi centres (even if the woman was registered with the health department) and not including women in their natal homes add to the barriers in access to the scheme.

Implementation

• The Centre failed to implement universal maternity benefits as mandated by the NFSA for a long time.
• Only Tamil Nadu is prominently known to implement this scheme as ‘ Muthulakshmi Reddy Maternity Benefit Scheme’ where cash assistance of Rs. 12,000 is given in 3 instalments on conditional release and restricted for first two deliveries only.
• As per Registrar General of India, Tamil Nadu has the second lowest infant mortality rate (20 per 1,000 live births) among all states in India, only behind Kerala (12).
• In Odisha, the Mamata scheme is a universal maternity entitlement providing Rs 5,000 to all mothers. A found that although coverage was not universal, it was reasonably high.
• Hence, proper implementation along with regular monitoring is the key to success in decreasing maternal and child mortality rates as well as improving health status of India.

Nutrition constitutes the foundation for human development and becomes more important during the period of pregnancy and lactation coupled with wage loss.

If the government wants to prove that it is committed to the cause of providing optimal nutritional status, especially to the most vulnerable communities, it has to implement the programme effectively. India’s DPSP recognises the need for maternity benefits in

Article 39 (e)- “The State shall, in particular, direct its policy towards securing – that the health and strength of workers, men, women, and the tender age of children are not abused and that citizens are not forced by economic necessity to enter a vocation unsuited to their age or strength.”
Article 42 – “The State shall make provision for securing just and humane conditions of work and for maternity relief.”

The introduction of maternity entitlements in the National Food Security Act (NFSA) has been hailed as a recognition by the State that all women are workers. Apart from wage loss compensation, maternity entitlements are recognised as a medium to promote exclusive breastfeeding for first 6 months.

The conditional cash transfer scheme is to improve health behaviours, address the rights of all women as workers to have sufficient time for rest, recovery and child care during maternity. MBP is expected to deliver on these expectations.