The case for going universal

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.