The unintended positive consequences of India’s safe motherhood programme

India’s flagship maternal health intervention, Janani Suraksha Yojana, provided conditional cash transfers to women opting for institutional deliveries. In this study, Chatterjee and Poddar document large positive spillovers of this programme on children’s educational outcomes. They find that these spillovers accrue to the already born elder children in the household through increased investments in human capital and changes in fertility preferences among women beneficiaries of the programme.

The Government of India launched Janani Suraksha Yojana (JSY), its flagship safe motherhood programme, in April 2005 with a target of reducing maternal and neo-natal mortality rates. Under the JSY, pregnant women from poorer households in India would be eligible to receive a cash transfer conditional on opting for institutional delivery. The wide network of accredited social health activists (ASHAs) in India was used as the intermediary between the government and beneficiaries, with the expectation that ASHA workers would act as facilitators and counsellors for the pregnant women, eventually motivating them to choose institutional deliveries, in addition to having them undergo regular health check-ups and monitoring.

Considering that the government’s annual spending was around $200 million in 2008-09 and 2009-10, the JSY was one of the largest cash transfer programmes in the world, catering to approximately 7.7 million beneficiaries every year until 2012-13 (Lim at al. 2010; Sidney et al. 2012; Ng et al. 2014). Given the high costs incurred, it is important to account for the benefits of the programme in order to understand the efficacy of this massive intervention. In this connection, studies have estimated positive impacts of the programme on take-up of maternal health care at formal facilities, as well as on the incidence of institutional deliveries and neo-natal outcomes (Lim et al. 2010, Powell-Jackson et al. 2015, Rahman and Pallikadavath 2018). However, Joshi and Sivaram (2014) show that JSY’s impacts were actually limited if one focuses only on the targetted population. Nandi and Laxminarayan (2015) point out some unintended consequences of JSY, suggesting higher fertility rates in response to JSY, and Javadekar and Saxena (2019) show that the incidence of female births in India has also increased as a result of JSY.

Despite this mixed evidence on direct outcomes and unintended consequences, little is known about the spillover effects of JSY. This is relevant, because JSY was essentially a conditional cash transfer (CCT) programme which would have typically impacted household budget constraints by expanding the choices available for individuals. In our recent study (Chatterjee and Poddar 2021), we show that this expanded choice set potentially enables more investment in human capital by women on the other children in the household. Consequently, these children have better learning outcomes, as measured by higher test scores in reading, writing and math. As a result, we provide novel evidence of very large spillover effects of the JSY on education of children not directly impacted by the programme, suggesting that the CCT had positive and unintended consequences on not only intra-household, but also inter-generational outcomes.

Methodology

We use data from the India Human Development Survey (IHDS) – II from 2011-12 to carry out our analysis. Our primary outcomes of interest are standardised test scores of children. IHDS-II reports reading, writing and math test scores for children aged 8-11 years. To identify the causal effects of the JSY intervention, we employ a quasi-experimental design exploiting the institutional features of implementation of the programme. The JSY was implemented in the form of a graded assistance to states which were identified based on the prevailing average rates of institutional delivery. Accordingly, states like Uttar Pradesh, Bihar, Jharkhand, Rajasthan etc. were classified as “Low-Performing States” (LPS), while others were identified as “High-Performing States” (HPS). Additionally, while all pregnant women in LPS were eligible to receive benefits, only the women from historically disadvantaged sections of the society (such as scheduled castes (SCs) and scheduled tribes (STs)) were eligible in the HPS. Table 1 summarises the JSY eligibility based on these institutional norms.

Table 1. Matrix of JSY eligibility by category in low- and high-performing states

Eligibility based on category	Low-Performing States (LPS)	High-Performing States (HPS)
SCs and STs	Eligible	Eligible
All other households	Eligible	Not Eligible

Using this variation in exposure to the JSY based on eligibility norms, we employ a cross-sectional difference-in-difference strategy, wherein we compare the mean outcomes of various cross-sectional groups, conditional on controlling for covariates that may be correlated with these mean differences. Essentially, we look at the following differences:

i) Difference in mean test scores between children in the LPS and HPS households (D1)

ii) Difference in mean test scores between children in the SC/ST and other households (D2)

The causal effect of JSY is the difference between D1 and D2, after controlling for other observed covariates such as family size, age, family composition, household education levels, income of household head etc.

The assumption behind this econometric identification is that in the absence of the programme, this difference (D1 – D2) would not have been statistically different from zero. Since this is an assumption about the counterfactual, it is not testable. However, we use an earlier round of the survey, IHDS-I, conducted in 2004-05 before the implementation of the JSY and re-run this analysis. We show that for all our main test score outcomes, this difference is statistically insignificant using this pre-programme data. This provides confidence in our analysis that any significant differences estimated using IHDS-II can be attributed to the JSY intervention.

Findings

We find that the JSY led to an increase in reading test scores by approximately 0.2 standard deviations, math scores by 0.13 standard deviations and writing scores by 0.19 standard deviations¹. Interestingly, we also find that these effects are significant and large for girls, but are much more dampened for boys.

To explore potential channels through which a transfer payment received on account of JSY translates into learning gains for children in the household, we study two potential mechanisms. First, in the short run, the CCT should impact household budget constraints and could lead to changes in the composition of household expenditure. In line with this hypothesis, we estimate the positive impact that JSY had on investments in human capital for children already present in the household (not the newborn from the institutional delivery induced by JSY). Women seem to spend more on private tutoring and other expenses on the elder children of the household, which impacts their learning.

Second, as a long-term effect, we investigate whether the JSY also affects fertility preferences of women. We find evidence for this, as documented by a decrease in the reported number of ideal children that the woman would want to bear. Interestingly, this effect does not impact their preference for girls, but operates through a decrease in the preferred number of boys that women want to give birth to. These effects potentially suggest a change in fertility preferences without bias towards preference for a son, consistent with the idea that the CCT may have led to an increased bargaining power and empowerment of women. We rationalise these findings with the increased investment in human capital through the classic quantity-quality trade-off – it appears that women now prefer to have fewer, children but of a higher quality (that is, more educated).

Conclusion

Despite fiscal constraints imposed by CCT programmes due to their relatively high implementation costs, we show that benefits of these programmes are often underestimated because spillovers into other sectors are unaccounted for. In this case, JSY was meant to affect maternal and child health through higher incidence of institutional deliveries, which it succeeded in achieving as per existing literature. We show that it additionally led to huge learning increases for elder children in these households through productive investments made in human capital.

We provide empirical evidence of a maternal health CCT having a positive impact on education outcomes of elder children already present in the household, suggesting strong intra-household and inter-generational benefits of such programmes. India is faced with a learning crisis with less than 50% of enrolled children able to perform basic cognitive tasks (Annual Status of Education Report, 2019). In the wake of these problems, such large positive and unintended consequences of a maternal health program could rationalise spending on CCTs.

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