Data collated from a recent paper—studying the impact of the Covid19 lockdown in 2020—by Jean Dreze and Anmol Somanchi reflect the grim state of affairs in India’s colossal (mal)nutrition crisis.
In an essay co-authored around April 2020, I had then argued how the ‘hidden costs of this pandemic’ (and the administrative response to it) is likely to be most evident in:
a) the psycho-social costs emerging from the decline in incomes, rising unemployment for India’s most vulnerable population, and
b) the nutritional distribution chart amongst the low social, economic groups (worst impacting women and children).
It seems Dreze and Somanchi’s work, alongside other recent empirical findings, provide evidence for both these ‘hidden costs’ now, more or so for the latter.
Malnutrition Travels From Mothers to Offspring
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 age 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.
21% of all children under 5 years remain ‘unproductive’ or ‘wasted’ (due to low weight-for-height) as per India’s child wasting statistics.
Flaws in Central Schemes for Improving Maternal Health
In 2017, having recognized the critical importance needed 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.
Under the scheme, pregnant women and lactating mothers are entitled to Rs 5000 for their first live birth subject to fulfilling certain conditions. The cash incentive is paid in three instalments with the first Rs 1000 being awarded on early registration of the pregnancy at an Anganwadi Center (often with the help of an ASHA worker).
Once the beneficiary receives at least one ante-natal check-up (ANC), they become eligible for the second instalment (Rs 2000). The Union Government further complements this scheme with the Pradhan Mantri Surakshit Matritva Abhiyan that offers free, universal antenatal care to all pregnant women. The final instalment (Rs 2000) is paid after the birth and immunization of the child. Between the fiscal years of 2018 and 2020, almost 1.75 core eligible beneficiaries were paid Rs 5,931.95 crores.
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, the grassroot 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.
How the Pandemic Upended Such Welfare Schemes
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 food grains to the very poor as against supporting that with more funding for existing ‘nutrition-focused’ welfare programs.
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 (see here for a discussion on the poor implementation of existing family planning measures during the pandemic).
Pre-existing Union sponsored schemes were allocated around Rs 2500 crores every year for the last two fiscal years. But, in financial year of 2021-22 PMMVY has been clubbed with other programs under ‘Mission Shakti’ (Samarthya Subgroup). By pooling in the budget of Rs 2500 crores with other schemes, the effective allocation of PMMVY has, therefore, significantly reduced.
Further, in recognizing the nature of logistical and administrative challenges posed by the pandemic, a recent study undertaken in the state of Rajasthan by IPE Global bring out micro-snapshots of poor health and nutritional program implementation scenarios in places like Baran, Jhunjhunu, Jodhpur, and Udaipur during the 2020 lockdown period. The focus of the study was primarily on assessing the state of maternal and childcare scenarios in Rajasthan during the pandemic.
Deterioration of Healthcare Services During Covid-19
Observed ethnographic findings from the report suggest how Maternal Child Health and Nutrition (MCHN) day was suspended, terminating regular health services like antenatal check-ups, immunization, 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 smart phone for use).
On-ground health workers were not provided enough PPE equipment so, most respondent families refused to avail themselves of any physical help from these workers. We saw similar observations from our own Centre’s field work in Lucknow, UP.
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.
Real Life Experiences During the COVID Crisis
“My friend who went to the Government hospital for delivery was put alongside other COVID-19 patients. I felt very uncomfortable, so decided to go to a private hospital. I spoke to the AWW (Anganwadi workers), she supported my decision,” said an anonymous respondent from Udaipur.
An ASHA worker, Rekha from Lucknow (UP) provided details of her challenging experience at Balrampur district hospital (UP). She said: “Sometimes, they (hospital guards) didn’t even let us enter with our patient, saying ‘So what if you are an ASHA! Get lost from here’… It was as if we have no respect or right to be treated with dignity any-where we would go; neither outside, nor in the hospitals… Why would our patients or their community trust us?”
Further findings from surveyed districts across Rajasthan indicate how (state) government services eventually made up for the time and services lost in the initial phases.
Towards the end of 2020, indicators of maternal health were nearly the same as it was in 2019, both state and district wise. Still, childcare took a more serious hit with the percentage of new-borns weighing less than 2.5 kg rising in 3 out of the 4 districts surveyed.
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 IPE’s report, only 27% of the registered beneficiaries received their 3 instalments in year 2020.
A woman in Jhunjhunu (Rajasthan) said, “It has been more than 8 months since I submitted my documents. I have even had my child, but yet to get even the first PMMVY payment.”
Barriers to Accessing Schemes
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, 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 programs.
Going forward, there is a lot for the Union Government -and State Governments to work on. Findings from districts of Rajasthan and UP, as microcosmic case reflections, show how ‘conditional cash transfers’ have limited effectiveness during times of crisis. Schemes like PMMVY are already troubled with ‘bureaucratic overload’ and over-centralisation in due management of processing claims.
There are also issues with details: for example, according to PMMVY’s original charter, the scheme’s eligibility remains applicable only for those women who are pregnant with their first child in the household while those mothers pregnant with a second child -in the family-won’t be entitled to receive any support under the scheme. Reasons for which are unknown.
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 the community health workers (ASHAs, ANMs) to recognise and treat their invaluable work and contributions on the ground with dignity.
(Deepanshu Mohan is Associate Professor of Economics and Director, Centre for New Economics Studies (CNES) at OP Jindal Global University. He tweets @Deepanshu_1810. Vanshika Shah and Advaita Singh are both, Senior Research Analysts with CNES. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses, nor is responsible for them.)