What Are Some Stumbling Blocks In India’s Quest To Improve Maternal Health?

YLAC

4 years ago

The authors are students of the Young Researchers for Social Impact (YRSI) Program conducted by Young Leaders for Active Citizenship (YLAC). YRSI identifies promising high schoolers and builds their capacity as critical thinkers and problem solvers to produce thought-provoking solutions to pressing issues that affect our societies today. This article was written as part of the July 2020 edition of the program. The views expressed in this study are solely those of the authors, and do not represent the views of YLAC as an organisation.

Maternal health has long been seen as a key indicator of the competency of a country’s healthcare system, and as a crucial determinant in the overall health of a community. Malnourished pregnant women almost inevitably give birth to underweight children, and the resulting lifelong health complications can severely impact an individual’s earnings and financial stability.

The enduring social and economic impact that inadequate maternal health and nutrition can have on a community means that it is crucial to sustainable development, and thus holds particular significance for developing countries such as India.

India has registered drastic improvements in the state of maternal health over the last three decades – a fact that was recently recognised internationally^[1] – but for a country of over 1.3 billion, even a Maternal Mortality Ratio (MMR) of 122 per 100,000 live births^[2] represents an unacceptable number of women at risk.

A nationwide maternity benefits programme called the Pradhan Mantri Vayu Vandana Yojana (PMMVY) was introduced in 2017 to help deal with this situation. The scheme is a conditional cash transfer programme, meaning that upon fulfilment of certain conditions (such as one antenatal check-up, registration of birth, vaccinations) the beneficiary receives cash transfers.

Beneficiaries can receive up to ₹5,000 in three instalments and the cash is meant in part to help women meet enhanced nutritional needs and in part to compensate for wage loss. However, the scheme has been plagued by a number of issues.

Low Coverage

For one thing, coverage of the scheme is dismally low. While the National Food Security Act, 2013 (NFSA) states that all pregnant woman and lactating mothers (excluding government employees) are entitled to minimum ₹6,000 in maternity benefits, a comparison of the number of PMMVY beneficiaries with the estimated number of births in India indicates that in 2019 only 22% of all pregnant women received any PMMVY money at all.^[3]

In part this is a result of strict criteria – the scheme only applies to the firstborn child, and to women above 18. Both these criteria, especially the former, mean the scheme excludes many women from poorer socioeconomic areas.

Lengthy documentation presents another problem. Requirements of the 23-page long paperwork include the woman’s Aadhaar card, the husband’s Aadhaar card, and an Aadhaar-seeded bank account belonging to the beneficiary. All of these even separately are barriers. Using Aadhaar to implement welfare schemes has proven exclusionary^[4] in the past; requiring a husband’s details leaves out unwed mothers and widows; and a woman-owned bank account (let alone an Aadhaar-seeded one) is, again, unlikeliest in precisely those underdeveloped areas where the scheme is most needed.

The network of AWW and ASHA workers responsible for enrolment and data collection is stretched thin and tends to be overworked and undertrained, and underpaid. This means that workers often lack either the incentive or the capacity to effectively deliver these schemes. Development consultant Priyambada Seal comments that on-ground there is a lack of frontline workers and that often they simply lack the capacity and incentive to “go knocking on every door.”

Further complications arise because of mismatches in data. Names, ages, and addresses on the Aadhaar card must match all other documents, to the extent that even a typographical error could result in an application being relegated to the correction queue. Neither does the system account for common cultural practices such as women changing their names after marriage, or returning home for the birth of the first child.

A lack of training for AWW/ASHA workers and for data entry officers responsible for digitising and feeding applications, combined with the extensive documentation requirements, means that there is an even greater chance of a data mismatch – be it last names, current addresses, or just a typo.

The network of AWW and ASHA workers responsible for enrolment and data collection is stretched thin and tends to be overworked and undertrained, and underpaid.

Delayed Payments

Even for those women who are eligible and successfully apply for the scheme, actually receiving payments is not guaranteed. A NITI Aayog progress report from 2019 found that one in three payments under the PMMVY are credited to the wrong bank account. Often, payments are received months or years after childbirth, which defeats the purpose of the scheme.

In a 2019 survey, called the Jachcha-Bachcha Survey (JABS), conducted by prominent noted economists Reetika Khera and Jean Drèze, only 39% of respondents had received the first instalment due before the end of their pregnancy.^[5] In part this can be attributed to all the reasons listed above, compounded by the lack of an efficient redressal system. Once an application finds its way to the correction queue, it is up to the ASHA/AWW to communicate the necessary changes to applicants, and then have them resubmit their forms. However, field workers are often the weak link in this chain of information.

“The field supervisor reads out the name and reason for correction queue of beneficiaries at periodic meetings of anganwadi workers. We often fail to take notes on paper when the announcements are being made,” said Netam, an anganwadi worker from Rajpur, speaking with IndiaSpend^[6]. “We in turn fail to convey this to the applicant or fail to obtain the requisite information from them.”

Laxity on the part of AWW/ASHA workers can cause problems elsewhere too. A qualitative study in 2019 conducted in Latehar, Jharkhand found that the general practice amongst Anganwadi workers there is to simultaneously submit the forms for all three instalments once the final condition has been filled (the child receiving the first round of immunizations) in violation of official implementation guidelines. They justified this practice by stating that it is inconsequential whether the forms are submitted in sequence or simultaneously since payments are delayed anyway.

Adequacy Of Provisions

The cash amount available under the scheme has also been debated. The NFSA, as mentioned, guarantees ₹6,000 to all pregnant women and lactating mothers – the PMMVY, however, makes only Rs. 5,000 available. The government has responded to this by pointing to a separate scheme called the Janani Suraksha Yojana, under which ₹1,000 are available on the condition of institutional childbirth – the idea is that the PMMVY and JSY together mean that women will receive an “average” of ₹6,000. However, given the various restrictions of both schemes, the only women actually eligible for the mandated ₹6,000 are those who are above 18, pregnant with their first child, married, and below the poverty line – the latter being an eligibility requirement of the JSY.

There are more than just financial barriers to adequate maternal nutrition and health-seeking behaviour, and thus solutions must extend beyond just financial assistance. Representational image.

Efficacy Of Cash Transfers Alone

While the PMMVY aims at improving health-seeking behaviour, simply incentivising certain practices may not be enough – several unhealthy cultural norms can and have fallen through the gaps in the PMMVY safety net. A simple example of this is the fact that the cash grants – which are meant partly to compensate for wage loss – may not translate to adequate rest because of the cultural reality of women being responsible for housework.

Almost all the respondents of the JABS had done household work regularly during their last pregnancy, with two-thirds of respondents saying they had worked right until the day of delivery. “More work helps an easy delivery as there are fewer complications and pains. Work helps the veins to get loose and the body is able to relax better during labour,” said a community elder.^[7] There are more than just financial barriers to adequate maternal nutrition and health-seeking behaviour, and thus solutions must extend beyond just financial assistance.

The Way Forward

First and foremost, the scheme should be made fully compliant with the NFSA. The eligibility criteria should be loosened significantly so that all pregnant women and lactating mothers are eligible, and the cash amount should be increased to or above the mandated ₹6,000 (alternatively, the eligibility criteria of the JSY should be expanded to include all pregnant women and lactating mothers.) To this end, the allocated budget should be increased from the current less than ₹5,000 crores ^[8] to the recommended minimum ₹8,000 crores.^[9]

Maternal health has long been seen as a key indicator of the competency of a country’s healthcare system, and as a crucial determinant in the overall health of a community. Representational image.

Next, the documentation process should be streamlined, and made more accessible and women-centric. This would mean making the Aadhaar card and Aadhaar-seeded bank account optional, as well as not requiring any details relating to a husband. Odisha’s MAMATA scheme and Tamil Nadu’s MRMBS (Muthulakshmi Reddy Maternity Benefit Scheme) should be emulated in this aspect.

Thirdly, the network of ASHA/AWWs and other relevant workers responsible for the implementation of the scheme should be strengthened. This would mean encouraging states to provide incentives for enrolment of beneficiaries, as well as strengthening training for ASHA/AWWs and also data entry operators to ensure accurate data collection and entry, and proper knowledge of the recommended guidelines (e.g. filing applications in sequence instead of simultaneously.) This could also include training on how to handle applications in the correction queue – alternatively, a different system for effective redressal could be instituted.

Authors: Aditri Joshi, Anushka Verma, Kriti Malik, Manya Kocchar, and Trisha Lodha.

Also read: COVID-19 Will Worsen The Already Abysmal State Of Nutrition Among Women