Over the years, India has implemented several programmes to overcome the issue of poor maternal and child health which can affect long-term physical and cognitive development. Using nationally representative data to study the impact of the current state maternity health benefits programme, this article shows that the programme has positive effects on infant health and immunisation rates and does not increase fertility rates unlike the previous programme. However, the results indicate that the programme’s effects are not sufficient to substantially improve health outcomes in children and mothers.
In January 2018, renowned economist Jean Drèze has been critical of the Modi government’s changes to India’s most recently proposed maternity benefit scheme, the Pradhan Mantri Matru Vandana Yojana (PMMVY)1 for cutting back on the benefit amount, registration being tied to biometric identification, and the programme’s benefits being restricted to only one child per woman. Are these changes merely a means to “save money”, as Drèze argues? Or are they the continuation of a series of successive reforms of Indian maternal cash transfer programmes that have the potential to improve maternal and child health and eliminate unintended negative effects of interventions?
India’s first maternal cash transfer scheme: Janani Suraksha Yojana
Despite rapid economic growth since the 1980s, India accounted for almost a third of global infant deaths and 40% of low-weight births by the beginning of the 21st century (World Bank, 2019, United Nations International Children's Emergency Fund (UNICEF) and World Health Organization (WHO), 2004). As a response, the UPA (United Progressive Alliance) government (2004-2014) started exploring conditional cash transfer programmes (CCTs) that incentivise health-promoting behaviours during the critical phase of pregnancy, childbirth, and lactation. The first such CCT, the Janani Suraksha Yojana (JSY), was rolled out in 2005. It pays a one-time cash transfer to mothers conditional on institutional delivery being assisted by a skilled birth attendant at a government health centre or an accredited private health institution. Notwithstanding this, five years later, India continued to show marked deficits in health service use around the time of birth, and in health markers among infants and young children, especially weight-related indicators (WHO, 2012).
Previous evaluations of JSY provide some insights into why it largely failed to redress the country’s dismal maternal and child health record. While it substantially increased deliveries in public health institutions, it did not reduce maternal and newborn mortality (Lim et al. 2010, Powell-Jackson et al. 2015, Rahman and Pallikadavath 2018). Moreover, the programme had several unintended effects, including an increase in fertility (Powell-Jackson et al. 2015, Nandi and Laxminarayan 2016). The programme features considered as responsible for JSY’s limited success and its unintended side effects are: first, its narrow focus on institutional delivery; second, the short time interval covered by the programme; third, cash incentives for all live births; and fourth, a lack of qualitatively adequate healthcare infrastructure (Powell-Jackson et al. 2015, Lahariya 2014).
How subsequent schemes might overcome JSY’s deficits
JSY has been complemented by an additional maternal CCT. The scheme, piloted in 2011 as the Indira Gandhi Matritva Sahyog Yojana (IGMSY), incentivises a broad range of healthy behaviours around the time of birth and features a number of trainings for the mother, including advice on child health, nutrition, and family planning. It covers a time interval of nine months around delivery and includes additional supply-side financing of health personnel (Ministry of Women and Child Development, 2011). In contrast to JSY, which covers all child births of a woman, during IGMSY’s five-year-long pilot phase, cash transfers were paid for only the first two live births of women aged 19 and older. Eligibility has been further restricted to the first live birth when the NDA (National Democratic Alliance) government expanded it to the entire country as PMMVY in 2017.
Based on existing research on other maternal CCTs, the programme design of IGMSY/PMMVY may be expected to improve upon JSY in the following ways. First, maternal and child health outcomes are more likely to improve as conditions for the receipt of cash transfers incentivise healthy behaviours – beyond just institutional delivery – that benefit the mother and child. In the case of IGMSY, programme conditions not only directly mandate vaccinations but also require repeated interactions with health workers. This raises the probability of prevention, early detection, and treatment of health deficiencies. Second, IGMSY may indirectly promote healthy behaviours and birth spacing through information conveyed in the incentivised educational sessions. Third, the cash transfer, which is larger and paid over a longer period around delivery than under JSY, is likely to be spent on additional healthcare and food during the critical phase of pregnancy, childbirth, and lactation. Fourth, the additional income may also contribute to maternal health by reducing the labour supply of beneficiary women during pregnancy. Lastly, the expansion of the supply of health-services, which has accompanied IGMSY, may remove barriers to healthcare access and thus increase the use of health services.
IGMSY also has the potential to mitigate or reverse the unintended effect on fertility documented for JSY. In principle, a monetary incentive for a second pregnancy also exists in IGMSY. However, trainings and frequent interactions with the public healthcare system, which strongly promotes family planning, might affect subsequent fertility choices and shift parents’ focus from having many children to child health and education.
Estimating intended and unintended effects of IGMSY/PMMVY
Have the innovative features in IGMSY’s programme design had the intended positive effects on child and maternal health nationwide while avoiding its predecessor’s undesired side effects on fertility?
So far, the effects of IGMSY have only been evaluated on a limited geographical scale by Ghosh and Kochar (2018), who focus on two districts of Bihar, where the programme had been rather poorly implemented. Our analysis covers most of India’s states and features a broad range of maternal and child health outcomes (Haaren and Klonner 2020). We employ nationally representative data from the National Family Health Survey (NFHS-4), 2015-16 and exploit the feature that IGMSY has been limited to 52 pilot districts based on district health scores, to identify for each pilot district one ‘control’2 district. We estimate IGMSY’s effects by comparing the intra-district difference in health outcomes between younger birth cohorts exposed to the programme and older cohorts not exposed to IGMSY, across pilot and control districts.
IGMSY shows positive impacts on health service use and immunisation
Consistent with the programme’s objectives, our results show an increase in the vaccinations incentivised by the programme as well as those not directly incentivised. The share of children who complete all four infant immunisations recommended for children under five years of age increases, from 59% to 64%. We also document two positive side effects of the programme – mothers of once eligible children report 14% more contacts with the public health system 3-4 years later. Moreover, there is a decline in fertility, and an increase in the interval between the first and second birth by around six months. The unintended increase in fertility due to JSY is thus reversed in IGMSY. On the other hand, similar to JSY, we find no robust evidence of gains in health outcomes, albeit some of our results suggest a reduction in child mortality and improved weight-related outcomes for both children and mothers.
Overall, IGMSY has increased the utilisation of health services and lengthened birth intervals. However, our results make clear that the programme’s effects are not sufficient to substantially improve health outcomes in children and mothers. Based on the analysis, we make three policy recommendations: (i) as IGMSY/PMMVY fails to reach almost every second eligible mother, the outreach of the scheme needs to be massively improved; (ii) additional policies need to identify and tackle underlying health risks; and (iii) the quality of health services need to be improved.
Therefore, our results support Jean Drèze’s criticisms of the changes to the PMMVY’s programme design in this essay – cuts in the programme budget decrease outreach, and biometric identification further restricts access to this programme. Moreover, eligibility restrictions to one child per woman cannot be justified on grounds of concerns of the programme’s adverse effects on fertility, which we have found to be absent in IGMSY with its two-child eligibility rule. On the bright side, our results show that the design of IGMSY/PMMVY has managed to avoid some of the negative side effects documented for JSY while improving newborn health – albeit to only a small extent.
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- Pradhan Mantri Matru Vandana Yojana is a government maternity benefit programme and is a conditional cash transfer scheme for pregnant and lactating women of age 19 or above for the first live birth conditional on completion of registration of pregnancy and birth, antenatal care and immunisation.
- A control district is a district which did not receive the programme and has comparable characteristics to a pilot district.
- Ghosh, Prabhat and Anjini Kochar (2018), "Do welfare programs work in weak states? Why? Evidence from a maternity support program in India", Journal of Development Economics, 134 (C): 191–208.
- Ghosh, P and A Kochar (2018), 'Expected income support and child health', Ideas for India, 17 August.
- Haaren, Paula von and Stefan Klonner (2020), 'Maternal cash for better child health? The impacts of India's IGMSY/PMMVY maternity benefit scheme. Heidelberg', AWI Discussion Paper No. 689.
- Lahariya, Chandrakant (2014), "A brief history of vaccines & vaccination in India", The Indian Journal of Medical Research, 139 (4): 491-511. Available here.
- Lim, Stephen S, Lalit Dandona, Joseph A Hoisington, Spencer L James, Margaret C Hogan and Emmanuela Gakidou (2010), "India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: An impact evaluation", The Lancet, 375 (9730): 2009–2023.
- Ministry of Women and Child Development (2011), 'Indira Gandhi Matritva Sahyog Yojana (IGMSY) - a Conditional Maternity Benefit Scheme (Implementation guidelines for state governments/UT administrations)', New Delhi.
- Nandi, Arindam and Ramanan Laxminarayan (2016), "The unintended effects of cash transfers on fertility: Evidence from the Safe Motherhood Scheme in India", Journal of Population Economics, 29 (2): 457–491.
- Powell-Jackson, Timothy, Sumit Mazumdar, Anne Mills (2015), "Financial incentives in health: New evidence from India's Janani Suraksha Yojana", Journal of Health Economics 43: 154–169.
- Rahman, Mohammad Mahbubur and Saseendran Pallikadavath (2018), "How much do conditional cash transfers increase the utilization of maternal and child health care services? New evidence from Janani Suraksha Yojana in India", Economics and Human Biology, 31: 164–183.
- UNICEF and WHO (2004), 'Low birthweight. Country, regional and global estimates', New York, US.
- WHO (2012), 'World Health Statistics 2012', Geneva, Switzerland.
- World Bank (2019), 'World Development Indicators (WDI)'.