Let’s start with some good news. According to world bank statistics, between 2005 and 2015, India has seen significant reductions in indicators of maternal and infant death rates including a 38% reduction in the maternal mortality rate (MMR), a 35% reduction in infant mortality rate (IMR) and a 32% reduction in neonatal mortality rates (NMR).
One of the factors that these positive trends can be attributed to is the Janani Suraksha Yojana or JSY, a conditional cash transfer programs launched by the central government in 2005, with an aim to reduce maternal and neonatal mortality by promoting institutionalized delivery of children.
A large number of reports and academic papers confirm the impact of this scheme.
Yet, we see reductions in the JSY budget by the current central government. This includes a reduction of about 4% in the budgetary allocation for the scheme from Rs. 2040 crores in 2014–2015 to Rs 1963 crores in 2015–2016.
Not surprisingly, the number of JSY beneficiaries per year has also reduced significantly since 2014. There has also been talk of a ‘rollback’ of the scheme or subsuming it within the central government’s new Maternity Benefits Program or MBP.
Since the rollout of JSY, institutional deliveries have seen a sharp uptake from 39% in 2005-06 to 79% in 2015-16. The MMR has fallen from 280 women out of every 100,000 live-births in 2005 to 174 women out of every 100,000 live-births in 2015. The IMR has fallen from 56 infant deaths out of every 1000 live-births in 2005 to 34 per 1000 live-births in 2016.
While these improvements may also be associated with other factors such as improvements in infrastructure and increased awareness, the causal impact of the scheme has also received rigorous testing in a number of peers reviewed academic journals.
Most authors agree that JSY has had a causal impact on (in other words, the scheme has been responsible for) improved health and behavioural outcomes. This body of academic research finds that along with a decrease in NMR and IMR, the scheme has led to better healthcare practices including significant increases in institutional births, antenatal and postnatal care and child immunization.
With so much evidence on the positive impact of the scheme, what can explain the reduction in budget allocation and speculation about a possible rollback of JSY? Two reasons come to mind.
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First, the MBP is poised to take centre stage regarding maternal welfare programs, with a four-fold increase in its budgetary allocation in 2017-18. The MBP aims to compensate first-time mothers for wages lost during the pregnancy and lactation period. Although a targeted version of the scheme was launched in 2010, a universal version of the scheme has become a policy priority this year, particularly after the Prime Minister’s mention of it in a post-demonetization speech.
While the MBP scheme is a welcome addition to government measures to ensure safe and healthy motherhood, it is essential that the introduction of the scheme does not lead to disbanding of JSY. JSY specifically incentivises institutional deliveries whereas MBP incentivises registration of pregnancy, antenatal care and child immunisation. As a result of its sharper focus JSY has a significantly smaller payout of around Rs 1000 per birth compared to the Rs 5000 payout from MBP.
This makes JSY more affordable for governments in terms of universal benefits. Further, MBP is restricted to first -time mothers only. In comparison, at least the first two births are eligible for JSY. Since first births account for less than half (about 43%) of the total number of births in India, JSY impacts a much more significant proportion of mothers and infants and is thus a critical scheme for India to catch up with the rest of the world regarding child and maternal health indicators.
Finally, unlike JSY, MBP has not yet received rigorous academic testing or analysis. Thus the gap between the intention and impact of the scheme remains to be measured.
Second, such budgetary reductions are consistent with the trend in social welfare spending reductions in real terms in recent years, perhaps to keep fiscal deficits low amidst slowing economic growth. Consider for instance that while the total receipts are estimated to go up by about 10%, total, there has been an estimated 2.1% reduction in allocation to National Health Mission (under which JSY falls).
Ironically, even the allocation for MBP in the 2018-19 budget has come down to Rs 2400 crores from Rs 2700 crores in the previous year.
In fact, in the first year of implementation, MBP has missed proposed targets by a large margin – less than 1 lakh women of the 51 lakh annual target (in other words less than 2% of the target) received maternity benefits from the scheme since its rollout in January 2017.
To be fair, the overall allocation to the health sector has gone up by 2.7% in the 2018-19 budget. The 2017-18 budget too saw some increases in social sector spending — healthcare allocations, in particular, saw a 22% increase compared to the previous years. However, most of these increases are towards secondary and tertiary sectors, with the primary care sector being left behind.
Assuming the aim of any government is long-run and stable economic development, cutting down on primary health care is a misguided approach. Many studies have found that better maternal and child health leads to better long-run economic outcomes.
Maternal deaths especially have a large detrimental impact at the household level, leading to loss of income, lower educational levels of children, the earlier marriage of girl children and poorer financial management within the household.
For the long run stability and development of our nation, achieving maternal and child health targets should be as much a policy priority for us as lower fiscal deficits and higher economic growth.
It would be foolhardy if JSY is diluted or rolled back at this critical juncture, especially to make way for a costlier, more restrictive scheme which has not received the same level of rigorous testing and analysis.
About The Author: Nandana Sengupta is an Assistant Professor at the School of Policy and Governance, Azim Premji University.