Description
A report on evaluation of an ongoing conditional cash transfer scheme "IGMSY"
1
ACKNOWLEDGEMENT
The Development Internship Segment of IRMA was a great learning experience for me and I
take this opportunity to thank some of those people without whose help and support my study
would not have been possible.
I take this opportunity to thank Mrs Bandana Preyasi, Director ICDS and Ms Mahua Roy
Choudhary (Monitoring Officer, SAKSHAM) for their valuable guidance, closely
supervising this work over the past two months and providing helpful suggestions. Their
valuable advice and support, in spite of their busy schedule have really been an inspiration
and driving force for me. I am thankful to various dignitaries of the user agencies, DPOs,
CDPOs and whole of the ICDS department of district VAISHALI who helped and rendered
their valuable time, knowledge and information and whose suggestions and guidance has
enlightened on the subject. I thank them for extending all the help and cooperation during our
internship period.
I would also like to thank Prof. Hari K. Nagarajan, my faculty guide, who have constantly
enriched my raw ideas with his experience and knowledge.
I express my deepest regards to Mr. Pradeep Joseph (BTAST) without whom I could not have
completed this report. I thank him for guiding and facilitating me in esteemed organization
and also provided me with his valuable suggestions to complete my task.
The critical support to the project has come from the officials of sample districts and block
authorities who have directly and indirectly facilitated this study.
I also put across my sincere thanks to the government officials for allowing me to have access
to necessary data and documents relevant for the report to enable me to build state-specific
perspective.
Last but not the least I would like to thanks those who have not been mentioned here but
whose presence had made a big difference in compiling this report.
Neha Prakash (33091)
2
Abbreviations
ANC Antenatal Care
ANM Auxillary Nurse Midwife
APL Above Poverty Line
ASHA Accredited Social Health Activist
AWC Anganwadi Centre
AWH Anganwadi Helper
AWW Anganwadi Worker
BMI Body Mass Index
CCT Conditional cash transfer
CDPO Child Development Project Officer
DFID Department for International Development
DLHS District Level Household Survey
IGMSY Indira Gandhi Matritva Sahyog Yojana
MDG Millennium Development Goal
MMR Maternal Mortality Rate
MNH Maternal and New-born health
MO Medical Officer
NAMHHR National Alliance for Maternal Health and Human Rights
NFHS National Family Household Survey
PHC Primary Health Centre
TT Tetanus Toxoid
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
WHO World Health Organisation
3
ABSTRACT
The cash component of CCT programs could improve growth, health, and development
outcomes for children living in extreme poverty via two pathways. First, the additional
income could give parents greater purchasing power. They could use the additional cash to
purchase more or higher quality food or medicines, or books and other learning materials to
promote learning. The second pathway would be by improving the psychological wellbeing of
family members and thereby improving the care and support provided to the children in the
household. This paper provides an overview of the first conditional cash transfer scheme for
maternity benefit (IGMSY). It reviews the aims, rationale, implementation challenges, known
outcomes, potential and limitations of this scheme based on current available data. Increased
use of maternal health services has been reported since the scheme began, though evidence
of improvements in maternal health outcomes has not been established due to a lack of
controlled studies. Areas for improvement in these schemes, identified in this review, include
the need for more efficient operational management, clear guidelines, financial transparency,
plans for sustainability, evidence of equity and, above all, proven impact on quality of care
and maternal mortality and morbidity.
INTRODUCTION
Given the slow decline in maternal and new-born mortality since 1990, the achievement of
Millennium Development Goals 4 and 5 by 2015 is unlikely. Most of these deaths occur in
the intra-partum and immediate post-partum period largely from preventable causes.
Annually about 60 million women give birth outside of health facilities, mainly at home and
52 million without a skilled birth attendant. Family planning needs are satisfied for only
about 50% of women and fertility rates are still as high as 4 live births per woman in India.
Further, skilled birth attendance, use of antenatal care and satisfaction with family planning
are the most inequitably distributed of 12 key maternal, new-born and child health
interventions studied in low and middle income countries (LMIC) with poorer women facing
higher barriers to access. The reasons behind the limited use of health services by the poor
are myriad, and occur on both the supply (providers) and demand (households, women) sides.
On the demand side, poverty, poor health status, illiteracy, language, customs, lack of
information regarding the availability of health services and providers, and limited control
over household resources and decision-making all play a role in limiting access to care. On
the supply side, poor quality provision (both antenatal and obstetric care), mistreatment or
sociocultural insensitivity, absence of a trained attendant at delivery, inadequate referral
systems for emergency obstetric care, inadequate or lacks of transportation facilities and
absence of or poor linkages of health centres with communities are barriers to utilization.
Increasingly, maternal and new-born health (MNH) experts are exploring ways in which
demand-side barriers – the barriers women and their families face to seeking care – can be
overcome. Over the past decades, community-based programs to increase utilization of MNH
care have been piloted, most notably through community mobilization, behaviour change
communications, and volunteer outreach efforts, among others. These programs have in
general been small-scale and have not entirely solved the major barrier to care seeking: the
direct and indirect financial costs associated with seeking care.
4
Conditional cash transfers (CCT) are one type of demand-side program that has been used to
overcome cost barriers. CCT are social programs that condition regular cash payments to
poor households on use of certain health services and school attendance. CCT programs have
two main objectives: first, to provide a safety net to increase and smooth the consumption of
the extreme poor (alleviating short-term poverty), and second, to increase the human capital
investment of poor households (alleviating long-term poverty). Payments are usually
provided to women and compliance with conditions is verified by the program, and transfer
sizes are generally intended to close the gap between average consumption in the bottom
quintile of the income distribution and the extreme poverty line. Initially based in Latin
America, CCT programs now operate around the world, and are regarded as successful social
protection strategies.
Although few CCT programs have explicitly targeted the improvement of maternal and new
born health, many of the “broad” programs included conditionality, associated supply-side
strengthening and/or educational talks related to MNH, and many impact evaluations have
measured the effects of CCT on MNH interventions and outcomes. Further, as programs that
relax a household’s budget constraint, CCT can be expected to affect household spending
choices in general, including the potential to improve MNH. Other systematic reviews have
documented the effects of CCT on child health care utilization and nutritional status, yet no
paper has directly reviewed the evidence on CCT impact on MNH or use of appropriate
MNH services. To address this gap, we empirically explore the impacts of a maternity benefit
scheme IGMSY on maternal and new-born health. It has been hypothesized that the impact of
CCT on maternal and new-born health is channelled through one or more of the following
channels:
(i) Income effect: Household income increases as well as women’s control on income also
increases, thus there is more disposable income to spend on Health.
(ii) Conditioning cash specifically on the usage of maternal health services
(iii) Removal of costs associated with service utilization via subsidies for defined health
benefit plans that include maternal care
(iv) Knowledge effect that results from health or nutrition counselling
Specifically the questions we address are:
1) Does IGMSY improve health status of pregnant and lactating women and new-borns?
2) Are women of the household are empowered to take their own decisions on spending of
this cash incentive?
3) Are these women using this money in purchase of nutritional supplements or spending it
on other things?
4) If they are spending on nutritional supplements, are there any gender variegated
outcomes?
In Odisha, for example, cash incentives received under MAMTA scheme received by females
rather than males affected girls’ anthropometric status. Such relationships need not be limited
to contemporaneous outcomes but can include investment in human capital, health, or the
wealth of future generations.
5
Figure 1. Conceptual Framework of CCT Programs
These features of CCT programs are potentially associated with MNH outputs and outcomes
on both the demand- and supply- sides. On the demand-side, household-level outputs include
improved nutrition and feeding, as well as better new-born care, such as exclusive
breastfeeding, delayed bathing, warmth and cord care. At the health system level, demand-
side outputs involve care-seeking behaviour, such as use of antenatal care (ANC), use of
facilities for birth, and use of a skilled birth attendant. Increased demand for services may
also trigger improvements in the supply of services via greater and improved provider
responsiveness (e.g. less absenteeism). Together demand- and supply-side outputs –mediated
by contextual factors- are expected to jointly generate improved new-born outcomes such
higher birth weights and survival (both perinatal and neonatal), while maternal health
outcomes could include anaemia, fertility, survival and complications during pregnancy and
birth.
In view of the above, the Ministry of Women and Child Development (MWCD) formulated a
new Scheme for pregnant and lactating mothers called Indira Gandhi Matritva Sahyog
Yojana (IGMSY) – a Conditional Maternity Benefit Scheme. Under this Scheme, a cash
incentive of Rs4000 is provided directly to women 19 years and above for the first two live
births subject to the woman fulfilling specific conditions relating to maternal health, child
health and nutrition. Cash incentives are provided in three instalments, between the second
trimesters of pregnancy till the infant completes 6 months of age. The scheme has the broad
objective of Improving the health and nutrition status of Pregnant and Lactating women and
their young infants by:
1) Providing cash subsidy to Pregnant and Lactating women to enable them to acquire
nutritional supplements for their own health as well as for having healthier babies.
2) Enabling Anganwadi workers (AWWs) to impart better quality information about the
best practices to these pregnant and lactating women.
6
LITERATURE REVIEW
Most CCT programs are broad, aiming to alleviate poverty and increase human capital
through transfers that are conditioned on a combination of school attendance, use of well
child visits, vaccination, and/or use of nutritional supplements. Examples of “broad” CCT
include Mexico’s Oportunidades, Colombia’s Familias en Accion, Nigaragua’s Red de
ProteccionSocial, Honduras’ PRAF, Turkey’s SRMP, among others. However, “narrow”
CCT – programs that transfer cash only for the utilization of specific services- are becoming
more common; for example, India’s Janani Suraksha Yojana (JSY) and Nepal’s Safe
Delivery Incentive Program (SDIP) target MNH improvements specifically. However, unlike
the broad CCT, the “narrow” programs like JSY and SDIP do not always or only target low-
income groups. In JSY, a mix of geographical and income targeting is used to induce
pregnant women to seek care, while in Nepal, cash incentives are offered to all pregnant
women. India’s major problems affecting health care utilisation include a wide
socioeconomic gap between rich and poor and marked inequities in access to health care.
India as a whole has high numbers of maternal and neonatal deaths. Between 1992 and 2006,
two national surveys showed that the proportion of institutional deliveries overall showed
little increase, from 26% to 41%. Nevertheless, more recently India has driven the decline in
the maternal mortality ratio for South Asia as skilled birth attendance has increased in recent
years. Use of maternal health care services is limited despite increased inputs from
governments and international donors. Though use of antenatal care, skilled birth attendance
and emergency obstetric care are mediated by a range of factors, there is increasing evidence
that financial and other barriers are important in determining service uptake. Government and
donor investment in improvements in service availability, training, drugs and equipment are
offset by persisting difficulties with access to care experienced by poor women and their
families. The barriers that women face are usually multiple and overlapping. It includes lack
of information about where and when to seek care, distance to a facility, substantial direct
and indirect costs, age and gender-based norms concerning decision-making, the impact of
status and caste, the allocation of family resources for women’s health, and socio-cultural
norms favouring home births over institutional deliveries. India’s JSY is the largest CCT
program in the world and specifically targets MNH. Lim et al (2010), reports positive results
for service uptake as well as neonatal mortality. However, new studies challenge some of
these findings. An unpublished evaluation by Mazumdar, Mills and Powell-Jackson (2012)
finds similar results for JSY increases on facility deliveries, also reporting that the program
was more effective for less educated, poor and ethnically marginalized women. The study
also finds increases in breastfeeding and less use of private health providers. Going beyond
the positive impact on service uptake, however, the Mazumdar et al study finds that JSY
increases fertility and does not have an effect on antenatal care or neonatal mortality.
7
DATA AND ESTIMATION STRATEGY
Table 1. Comparative data on reproductive history of respondents
Total
no.
Total
no. of
live
births
Miscarriages Still
births
Child
deaths
Weight
of new
born
baby
Duration
of
exclusive
breast
feeding
Percentage
of women
knowing the
weight of
their child
Beneficiaries 30 23 3 1 5 2.8 kgs 4 months 80%
Non-
beneficiaries
30 24 5 2 8 2.1 kgs 1.5
months
55%
The above data shows that the reproductive history of women falling under the scheme is in a
better condition than the non-beneficiaries. Across the 2 sample blocks, it is observed that
even when government is leaving no stones unturned to improve maternal and child health of
the country, it still continues to suffer. However, IGMSY comes as a ray of hope in this as the
health status of the beneficiaries show small but significant improvement as compared to the
control group. Miscarriage rate is found to be lower in the beneficiaries. This can be related
to the fact that the scheme involves a lot of conditions to be fulfilled by them in order to avail
the cash incentive, thereby, indirectly compelling them to avail the health services. This can
be reflected in all the above observations. Still births and child deaths were also found to be
significantly low in the women covered under the scheme. 87% of the pregnant and lactating
women across all the two blocks knew that infants have to be exclusively breastfed for the
first few months of their lives. However, most of them lacked knowledge about the exact
duration for which the child needs to be exclusively breastfed. The common duration of
breastfeeding varies greatly ranging from 21 days to 6 months. About 60% women in the
chosen sample were aware that weight of the infant serves as one of the indicators for growth,
however, they are completely unaware of significance of growth charts. Awareness level was
still higher in the beneficiaries owing to the regular counselling held by the anganwadi
workers. More than 80% of the mothers knew the exact weight of her child.
Table 2: Description of the Respondent women (non-beneficiaries of IGMSY)
Block Name of
revenue village
Age
range
Caste Education Average no.
of children
per women
Range of no.
of
pregnancies
Lalganj Noorpur 16-32 SC,OBC 80% illiterate 3.6 6-3
Biddupur Dilawarpur S-E 22-30 Mostly
SC
90% illiterate 3.2 7-3
The characteristics of the women respondents of the in-depth interviews those who were
excluded from the scheme indicated that these women, who were already vulnerable in terms
8
of economic security, food security, social exclusion and large family size, a significant
proportion are not literate and they have all suffered from wastage of pregnancies (indicating
poor foetal or infant/child survival). Majority of those excluded had between 3-6 children.
73% of them aged between 18-25 years, and about 85% had never gone to school or studied
less than Class V. Husbands of 93% of these women worked in the unorganized sector.
About 58% of the women were in unpaid work, either household or family labour, with only
42% in paid work and most of them lived in joint families.
Table 3: showing Z-score of the children
Z – score
Weight for
length
Weight for age Height for age BMI for age
-1.79 -1.39 -2.64 -1.11
0 -2.08 -3.59 3.58
-1.45 -1.75 0 0
3.43 0 -3.86 3.46
-3.68 -3.18 -1.64 -3.72
0 -2.35 -2.75 2.37
1 -3.30 -1.87 7.30
-1.32 -3.08 -1.87 3.77
0 -2.15 -7.89 6.64
1 -1.15 -10.93 6.64
-2.33 -3.39 -2.23 6.45
3.54 -1.96 -2.15 -3.19
-2.33 -3.19 -0.91 -4.03
2 -4.97 -12.02 3.70
1.86 -3.16 -1.88 11.92
-1.57 -2.02 -8.64 -1.19
-2.33 -2.52 -5.86 6.80
2 -2.17 -1.36 -1.82
1.67 -3.15 -1.99 4.04
-1 -2.03 -2.26 2.05
2.66 -2.96 -3.91 1.97
-1.05 -2.03 -1.86 1.24
-2.28 0 2.24 2.03
1.84 -1.20 -2.43 -0.64
The above table shows the Z-score of the children under study on the basis of their recorded
height, weight and age. The data was analysed using “ANTHRO” software developed by
WHO to measure nutrition status of children. In the sample, 59 % of children were
moderately or severely stunted (Height-for-Age
A report on evaluation of an ongoing conditional cash transfer scheme "IGMSY"
1
ACKNOWLEDGEMENT
The Development Internship Segment of IRMA was a great learning experience for me and I
take this opportunity to thank some of those people without whose help and support my study
would not have been possible.
I take this opportunity to thank Mrs Bandana Preyasi, Director ICDS and Ms Mahua Roy
Choudhary (Monitoring Officer, SAKSHAM) for their valuable guidance, closely
supervising this work over the past two months and providing helpful suggestions. Their
valuable advice and support, in spite of their busy schedule have really been an inspiration
and driving force for me. I am thankful to various dignitaries of the user agencies, DPOs,
CDPOs and whole of the ICDS department of district VAISHALI who helped and rendered
their valuable time, knowledge and information and whose suggestions and guidance has
enlightened on the subject. I thank them for extending all the help and cooperation during our
internship period.
I would also like to thank Prof. Hari K. Nagarajan, my faculty guide, who have constantly
enriched my raw ideas with his experience and knowledge.
I express my deepest regards to Mr. Pradeep Joseph (BTAST) without whom I could not have
completed this report. I thank him for guiding and facilitating me in esteemed organization
and also provided me with his valuable suggestions to complete my task.
The critical support to the project has come from the officials of sample districts and block
authorities who have directly and indirectly facilitated this study.
I also put across my sincere thanks to the government officials for allowing me to have access
to necessary data and documents relevant for the report to enable me to build state-specific
perspective.
Last but not the least I would like to thanks those who have not been mentioned here but
whose presence had made a big difference in compiling this report.
Neha Prakash (33091)
2
Abbreviations
ANC Antenatal Care
ANM Auxillary Nurse Midwife
APL Above Poverty Line
ASHA Accredited Social Health Activist
AWC Anganwadi Centre
AWH Anganwadi Helper
AWW Anganwadi Worker
BMI Body Mass Index
CCT Conditional cash transfer
CDPO Child Development Project Officer
DFID Department for International Development
DLHS District Level Household Survey
IGMSY Indira Gandhi Matritva Sahyog Yojana
MDG Millennium Development Goal
MMR Maternal Mortality Rate
MNH Maternal and New-born health
MO Medical Officer
NAMHHR National Alliance for Maternal Health and Human Rights
NFHS National Family Household Survey
PHC Primary Health Centre
TT Tetanus Toxoid
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
WHO World Health Organisation
3
ABSTRACT
The cash component of CCT programs could improve growth, health, and development
outcomes for children living in extreme poverty via two pathways. First, the additional
income could give parents greater purchasing power. They could use the additional cash to
purchase more or higher quality food or medicines, or books and other learning materials to
promote learning. The second pathway would be by improving the psychological wellbeing of
family members and thereby improving the care and support provided to the children in the
household. This paper provides an overview of the first conditional cash transfer scheme for
maternity benefit (IGMSY). It reviews the aims, rationale, implementation challenges, known
outcomes, potential and limitations of this scheme based on current available data. Increased
use of maternal health services has been reported since the scheme began, though evidence
of improvements in maternal health outcomes has not been established due to a lack of
controlled studies. Areas for improvement in these schemes, identified in this review, include
the need for more efficient operational management, clear guidelines, financial transparency,
plans for sustainability, evidence of equity and, above all, proven impact on quality of care
and maternal mortality and morbidity.
INTRODUCTION
Given the slow decline in maternal and new-born mortality since 1990, the achievement of
Millennium Development Goals 4 and 5 by 2015 is unlikely. Most of these deaths occur in
the intra-partum and immediate post-partum period largely from preventable causes.
Annually about 60 million women give birth outside of health facilities, mainly at home and
52 million without a skilled birth attendant. Family planning needs are satisfied for only
about 50% of women and fertility rates are still as high as 4 live births per woman in India.
Further, skilled birth attendance, use of antenatal care and satisfaction with family planning
are the most inequitably distributed of 12 key maternal, new-born and child health
interventions studied in low and middle income countries (LMIC) with poorer women facing
higher barriers to access. The reasons behind the limited use of health services by the poor
are myriad, and occur on both the supply (providers) and demand (households, women) sides.
On the demand side, poverty, poor health status, illiteracy, language, customs, lack of
information regarding the availability of health services and providers, and limited control
over household resources and decision-making all play a role in limiting access to care. On
the supply side, poor quality provision (both antenatal and obstetric care), mistreatment or
sociocultural insensitivity, absence of a trained attendant at delivery, inadequate referral
systems for emergency obstetric care, inadequate or lacks of transportation facilities and
absence of or poor linkages of health centres with communities are barriers to utilization.
Increasingly, maternal and new-born health (MNH) experts are exploring ways in which
demand-side barriers – the barriers women and their families face to seeking care – can be
overcome. Over the past decades, community-based programs to increase utilization of MNH
care have been piloted, most notably through community mobilization, behaviour change
communications, and volunteer outreach efforts, among others. These programs have in
general been small-scale and have not entirely solved the major barrier to care seeking: the
direct and indirect financial costs associated with seeking care.
4
Conditional cash transfers (CCT) are one type of demand-side program that has been used to
overcome cost barriers. CCT are social programs that condition regular cash payments to
poor households on use of certain health services and school attendance. CCT programs have
two main objectives: first, to provide a safety net to increase and smooth the consumption of
the extreme poor (alleviating short-term poverty), and second, to increase the human capital
investment of poor households (alleviating long-term poverty). Payments are usually
provided to women and compliance with conditions is verified by the program, and transfer
sizes are generally intended to close the gap between average consumption in the bottom
quintile of the income distribution and the extreme poverty line. Initially based in Latin
America, CCT programs now operate around the world, and are regarded as successful social
protection strategies.
Although few CCT programs have explicitly targeted the improvement of maternal and new
born health, many of the “broad” programs included conditionality, associated supply-side
strengthening and/or educational talks related to MNH, and many impact evaluations have
measured the effects of CCT on MNH interventions and outcomes. Further, as programs that
relax a household’s budget constraint, CCT can be expected to affect household spending
choices in general, including the potential to improve MNH. Other systematic reviews have
documented the effects of CCT on child health care utilization and nutritional status, yet no
paper has directly reviewed the evidence on CCT impact on MNH or use of appropriate
MNH services. To address this gap, we empirically explore the impacts of a maternity benefit
scheme IGMSY on maternal and new-born health. It has been hypothesized that the impact of
CCT on maternal and new-born health is channelled through one or more of the following
channels:
(i) Income effect: Household income increases as well as women’s control on income also
increases, thus there is more disposable income to spend on Health.
(ii) Conditioning cash specifically on the usage of maternal health services
(iii) Removal of costs associated with service utilization via subsidies for defined health
benefit plans that include maternal care
(iv) Knowledge effect that results from health or nutrition counselling
Specifically the questions we address are:
1) Does IGMSY improve health status of pregnant and lactating women and new-borns?
2) Are women of the household are empowered to take their own decisions on spending of
this cash incentive?
3) Are these women using this money in purchase of nutritional supplements or spending it
on other things?
4) If they are spending on nutritional supplements, are there any gender variegated
outcomes?
In Odisha, for example, cash incentives received under MAMTA scheme received by females
rather than males affected girls’ anthropometric status. Such relationships need not be limited
to contemporaneous outcomes but can include investment in human capital, health, or the
wealth of future generations.
5
Figure 1. Conceptual Framework of CCT Programs
These features of CCT programs are potentially associated with MNH outputs and outcomes
on both the demand- and supply- sides. On the demand-side, household-level outputs include
improved nutrition and feeding, as well as better new-born care, such as exclusive
breastfeeding, delayed bathing, warmth and cord care. At the health system level, demand-
side outputs involve care-seeking behaviour, such as use of antenatal care (ANC), use of
facilities for birth, and use of a skilled birth attendant. Increased demand for services may
also trigger improvements in the supply of services via greater and improved provider
responsiveness (e.g. less absenteeism). Together demand- and supply-side outputs –mediated
by contextual factors- are expected to jointly generate improved new-born outcomes such
higher birth weights and survival (both perinatal and neonatal), while maternal health
outcomes could include anaemia, fertility, survival and complications during pregnancy and
birth.
In view of the above, the Ministry of Women and Child Development (MWCD) formulated a
new Scheme for pregnant and lactating mothers called Indira Gandhi Matritva Sahyog
Yojana (IGMSY) – a Conditional Maternity Benefit Scheme. Under this Scheme, a cash
incentive of Rs4000 is provided directly to women 19 years and above for the first two live
births subject to the woman fulfilling specific conditions relating to maternal health, child
health and nutrition. Cash incentives are provided in three instalments, between the second
trimesters of pregnancy till the infant completes 6 months of age. The scheme has the broad
objective of Improving the health and nutrition status of Pregnant and Lactating women and
their young infants by:
1) Providing cash subsidy to Pregnant and Lactating women to enable them to acquire
nutritional supplements for their own health as well as for having healthier babies.
2) Enabling Anganwadi workers (AWWs) to impart better quality information about the
best practices to these pregnant and lactating women.
6
LITERATURE REVIEW
Most CCT programs are broad, aiming to alleviate poverty and increase human capital
through transfers that are conditioned on a combination of school attendance, use of well
child visits, vaccination, and/or use of nutritional supplements. Examples of “broad” CCT
include Mexico’s Oportunidades, Colombia’s Familias en Accion, Nigaragua’s Red de
ProteccionSocial, Honduras’ PRAF, Turkey’s SRMP, among others. However, “narrow”
CCT – programs that transfer cash only for the utilization of specific services- are becoming
more common; for example, India’s Janani Suraksha Yojana (JSY) and Nepal’s Safe
Delivery Incentive Program (SDIP) target MNH improvements specifically. However, unlike
the broad CCT, the “narrow” programs like JSY and SDIP do not always or only target low-
income groups. In JSY, a mix of geographical and income targeting is used to induce
pregnant women to seek care, while in Nepal, cash incentives are offered to all pregnant
women. India’s major problems affecting health care utilisation include a wide
socioeconomic gap between rich and poor and marked inequities in access to health care.
India as a whole has high numbers of maternal and neonatal deaths. Between 1992 and 2006,
two national surveys showed that the proportion of institutional deliveries overall showed
little increase, from 26% to 41%. Nevertheless, more recently India has driven the decline in
the maternal mortality ratio for South Asia as skilled birth attendance has increased in recent
years. Use of maternal health care services is limited despite increased inputs from
governments and international donors. Though use of antenatal care, skilled birth attendance
and emergency obstetric care are mediated by a range of factors, there is increasing evidence
that financial and other barriers are important in determining service uptake. Government and
donor investment in improvements in service availability, training, drugs and equipment are
offset by persisting difficulties with access to care experienced by poor women and their
families. The barriers that women face are usually multiple and overlapping. It includes lack
of information about where and when to seek care, distance to a facility, substantial direct
and indirect costs, age and gender-based norms concerning decision-making, the impact of
status and caste, the allocation of family resources for women’s health, and socio-cultural
norms favouring home births over institutional deliveries. India’s JSY is the largest CCT
program in the world and specifically targets MNH. Lim et al (2010), reports positive results
for service uptake as well as neonatal mortality. However, new studies challenge some of
these findings. An unpublished evaluation by Mazumdar, Mills and Powell-Jackson (2012)
finds similar results for JSY increases on facility deliveries, also reporting that the program
was more effective for less educated, poor and ethnically marginalized women. The study
also finds increases in breastfeeding and less use of private health providers. Going beyond
the positive impact on service uptake, however, the Mazumdar et al study finds that JSY
increases fertility and does not have an effect on antenatal care or neonatal mortality.
7
DATA AND ESTIMATION STRATEGY
Table 1. Comparative data on reproductive history of respondents
Total
no.
Total
no. of
live
births
Miscarriages Still
births
Child
deaths
Weight
of new
born
baby
Duration
of
exclusive
breast
feeding
Percentage
of women
knowing the
weight of
their child
Beneficiaries 30 23 3 1 5 2.8 kgs 4 months 80%
Non-
beneficiaries
30 24 5 2 8 2.1 kgs 1.5
months
55%
The above data shows that the reproductive history of women falling under the scheme is in a
better condition than the non-beneficiaries. Across the 2 sample blocks, it is observed that
even when government is leaving no stones unturned to improve maternal and child health of
the country, it still continues to suffer. However, IGMSY comes as a ray of hope in this as the
health status of the beneficiaries show small but significant improvement as compared to the
control group. Miscarriage rate is found to be lower in the beneficiaries. This can be related
to the fact that the scheme involves a lot of conditions to be fulfilled by them in order to avail
the cash incentive, thereby, indirectly compelling them to avail the health services. This can
be reflected in all the above observations. Still births and child deaths were also found to be
significantly low in the women covered under the scheme. 87% of the pregnant and lactating
women across all the two blocks knew that infants have to be exclusively breastfed for the
first few months of their lives. However, most of them lacked knowledge about the exact
duration for which the child needs to be exclusively breastfed. The common duration of
breastfeeding varies greatly ranging from 21 days to 6 months. About 60% women in the
chosen sample were aware that weight of the infant serves as one of the indicators for growth,
however, they are completely unaware of significance of growth charts. Awareness level was
still higher in the beneficiaries owing to the regular counselling held by the anganwadi
workers. More than 80% of the mothers knew the exact weight of her child.
Table 2: Description of the Respondent women (non-beneficiaries of IGMSY)
Block Name of
revenue village
Age
range
Caste Education Average no.
of children
per women
Range of no.
of
pregnancies
Lalganj Noorpur 16-32 SC,OBC 80% illiterate 3.6 6-3
Biddupur Dilawarpur S-E 22-30 Mostly
SC
90% illiterate 3.2 7-3
The characteristics of the women respondents of the in-depth interviews those who were
excluded from the scheme indicated that these women, who were already vulnerable in terms
8
of economic security, food security, social exclusion and large family size, a significant
proportion are not literate and they have all suffered from wastage of pregnancies (indicating
poor foetal or infant/child survival). Majority of those excluded had between 3-6 children.
73% of them aged between 18-25 years, and about 85% had never gone to school or studied
less than Class V. Husbands of 93% of these women worked in the unorganized sector.
About 58% of the women were in unpaid work, either household or family labour, with only
42% in paid work and most of them lived in joint families.
Table 3: showing Z-score of the children
Z – score
Weight for
length
Weight for age Height for age BMI for age
-1.79 -1.39 -2.64 -1.11
0 -2.08 -3.59 3.58
-1.45 -1.75 0 0
3.43 0 -3.86 3.46
-3.68 -3.18 -1.64 -3.72
0 -2.35 -2.75 2.37
1 -3.30 -1.87 7.30
-1.32 -3.08 -1.87 3.77
0 -2.15 -7.89 6.64
1 -1.15 -10.93 6.64
-2.33 -3.39 -2.23 6.45
3.54 -1.96 -2.15 -3.19
-2.33 -3.19 -0.91 -4.03
2 -4.97 -12.02 3.70
1.86 -3.16 -1.88 11.92
-1.57 -2.02 -8.64 -1.19
-2.33 -2.52 -5.86 6.80
2 -2.17 -1.36 -1.82
1.67 -3.15 -1.99 4.04
-1 -2.03 -2.26 2.05
2.66 -2.96 -3.91 1.97
-1.05 -2.03 -1.86 1.24
-2.28 0 2.24 2.03
1.84 -1.20 -2.43 -0.64
The above table shows the Z-score of the children under study on the basis of their recorded
height, weight and age. The data was analysed using “ANTHRO” software developed by
WHO to measure nutrition status of children. In the sample, 59 % of children were
moderately or severely stunted (Height-for-Age