India's nutritional crisis: Red flags in cash flows

A disturbing scenario in India's paradoxical nutritional landscape — where obesity ails India’s ultra-rich upper-class cities and malnutrition makes those at the bottom of the pyramid suffer — has been evident from the pre-pandemic period as well.

Numbers from the 4th National Family Health Survey indicate how 53.1% of all women aged 15-49 are anaemic. An alarmingly high rate of undernourished mothers results in low-weight, poorly-nourished babies/infants, whose in-utero lack of nutrition can have lifelong consequences for them and their families. Almost 21% of all children under five years remain 'unproductive' or 'wasted' (due to low weight for height) as per India’s child wasting statistics.

In 2017, having recognised the critical importance to support maternal health and childcare, the Government of India launched the Pradhan Mantri Matru Vandana Yojana (PMMVY) — a centrally sponsored conditional cash transfer scheme.

Read more: Government extends Atmanirbhar Bharat Rozgar Yojana till March 2022

Under the scheme, pregnant women and lactating mothers are entitled to Rs 5,000 for their first live birth, subject to fulfilling certain conditions. The cash incentive is paid in three instalments with the first Rs 1,000 being awarded on early registration of the pregnancy at an anganwadi centre.

Once the beneficiary receives at least one ante-natal check-up (ANC), they become eligible for the second instalment (Rs 2,000). The Union government further complements this scheme with the Pradhan Mantri Surakshit Matritva Abhiyan that offers free, universal ante-natal care to all pregnant women. The final instalment (Rs 2,000) is paid after the birth and immunisation of the child. Between the fiscal years of 2018 and 2020, almost 1.75 crore eligible beneficiaries were paid Rs 5,931.95 crore.

By tying the cash transfer to 'conditions', the government hoped to incentivise mothers to engage in undertaking basic (self) maternal and childcare. Meanwhile, the money provided offers financial support for the soon-to-be-mothers to meet their nutritional requirements.

However, grassroots level implementation of such schemes has oft remained blemished with structural flaws. For a start, the efficiency of 'conditional cash transfers' has been brought into question given the high administrative cost (or ‘bureaucratic overload’) associated with factors like: identifying eligible beneficiaries, targeting and monitoring the disbursements made to them, and ensuring that intended goals are met with a given scheme’s actual implementation. Moreover, complaints regarding delayed payments of ‘assigned transfers’ have aggravated, especially since the pandemic.

What’s startling is how, even after a year and a half since the pandemic affected the nation’s citizenry, particularly the poor, the government’s fiscal priority in allocating more funds to existing schemes still remains woefully low. The focus is only on providing PDS supported foodgrains to the very poor as against supporting that with more funding for existing nutrition-focused welfare programmes.

In a rhetorical pitch to allocate most government resources towards the pandemic, budgetary outlays show how the Union government has abdicated its social and financial responsibility towards other equally serious health issues.

Pre-existing Union-sponsored schemes were allocated around Rs 2,500 crore every year for the last two fiscal years. But, in the financial year 2021-22, PMMVY has been clubbed with other programmes under Mission Shakti (Samarthya Subgroup). By pooling in the budget of Rs 2,500 crore with other schemes, the effective allocation of PMMVY significantly reduced.

Further, in recognising the nature of logistical and administrative challenges posed by the pandemic, a recent study undertaken in Rajasthan by IPE Global brings out micro-snapshots of poor health and nutritional programme implementation scenarios in places like Baran, Jhunjhunu, Jodhpur and Udaipur during the 2020 lockdown period.

Covid disruptions to services

Observed ethnographic findings from the IPE report suggest how Maternal Child Health and Nutrition (MCHN) day was suspended, terminating regular health services like ante-natal check-ups, immunisation, and child-growth monitoring for respondents across the state (much like what was seen across the nation).

Meanwhile, reproductive healthcare workers (ASHAs, ANMs) struggled to deliver adequate services to the public. Due to mobility restrictions, most reproductive healthcare workers were forced to work from home due to which physical tests and examinations were not conducted.

ASHA workers, anganwadi workers, and nurse midwives conducted counselling sessions online and provided supplementary tablets and contraceptive devices during house visits, but their services, too, were constrained due to administrative delays and shortage of tech-abled resources (most workers didn’t even have a smartphone).

Hospitals and government health facilities were overburdened by Covid-19 patients and were not able to provide adequate delivery services for non-Covid related treatment (including for high-risk pregnant women).

With limited capabilities to afford the high fees of private hospitals, many rural women were compelled to opt for ‘private’ delivery options that proved to be economically burdensome — and medically dangerous, for their families.

Amidst falling incomes and a burdened state healthcare infrastructure, a robust functioning of PMMVY was supposed to be critical during a public health emergency. As per the IPE’s report, only 27% of the registered beneficiaries received their three instalments in 2020.

Conditionalities associated with each transfer made it difficult for most beneficiaries to get their entitlements on time. Pregnant and lactating mothers struggled with access to nutrition when they needed it the most. Further, the IPE’s findings from Rajasthan also reported that despite the meeting of conditions imposed on each entitled cash transfer, maximum beneficiaries still didn’t receive their instalment for months after the documents were submitted. The lack of direction and purpose marks a major red flag in evaluating the success of such condition-based social programmes.

Going forward, there is a lot for the Union government and state governments to work on. Findings from districts of Rajasthan and Uttar Pradesh, as microcosmic case reflections, show how conditional cash transfers have limited effectiveness during times of crisis. It is also about time that a renewed focus on improving community healthcare access through tech-abled, decentralised processes translates into an actual vision and action plan to include (and ensure) the well-being of all engaged key stakeholders, including community health workers (ASHAs, ANMs) to recognise and treat their invaluable work and contributions on the ground with dignity.

(Deepanshu Mohan is Associate Professor and Director, Centre for New Economics Studies (CNES), Jindal School of Liberal Arts and Humanities, O P Jindal Global University. Vanshika Shah and Advaita Singh are both Senior Research Analysts with CNES)