By Kopal Mital

 
 
Introduction
 
A perusal of Article 42 contained in Part IV of the Indian Constitution would reveal that one of the goals of the state is to provide maternity relief.[1] While the provision of maternity relief will continue to be an ongoing goal, India needs to make significant progress when providing these reliefs to poorer women. This point can be supported by the findings of the 71st National Sample Survey (NSS) which found that in rural areas, institutional delivery in private hospitals was nine times more expensive than public hospitals. The survey also captured that in cases where there was additional pressure created on the existing high costs of maternal healthcare, it pushed 46.6% women to below the poverty line.[2] This highlights the extreme financial burden this medical procedure alone can pose on women. Perhaps recognising this concern of expense, the government introduced the Janani Suraksha Yojana, a one-time conditional cash transfer scheme.
 
This paper aims to demonstrate that conditional cash transfers are only palliative and are not long-term solutions to mitigating maternity costs, which contribute to deepening poverty. It supports this claim by engaging in a statistical and structural critique of these schemes for which it relies on the capabilities approach as formulated by Martha C. Nussbaum. It highlights that merely providing resources in the form of cash is not enough. This has to be supplemented with the provision and enhancement of skills to these women. It is these skills which they will be able to leverage to ensure economic security for themselves in the long run. The paper concludes by providing a possible solution which could guide policy-makers to ensure long-term and sustainable poverty alleviation and empowerment for women.
 
The next section examines the operation and the critique of the Janani Suraksha Yojana, a one-time conditional cash transfer scheme in detail.
 
Janani Suraksha Yojana: Operation and Critique
 
The Janani Suraksha Yojana ('JSY') coalesces medical support given at all stages of the pregnancy (which includes prenatal and post-natal care) with financial support in the form of a cash transfer to those who opt for institutional delivery in hospitals. This cash transfer is paid directly to the mother at the time of discharge from the hospital.[3]
 
As mentioned above, one of the aims of this scheme was to ensure more women opt for institutional delivery to ensure that the high cost of institutional delivery does not push these households below the poverty line. Therefore, the success of the scheme would depend largely on the number of women actively choosing institutional deliveries. However, the utilisation of this scheme has been limited. An analysis undertaken of the 2006 and 2016 National Family Health Survey[4] data revealed that considerable inequality and disparity still exists across the Indian states in terms of the utilisation of the scheme. Poor women in poor states lag far behind poor women in richer states in terms of the uptake of this scheme.[5] Therefore, the JSY scheme has had only modest success in helping vulnerable groups. 
 
Further, the scheme does not concretely address the issues faced by women from households below the poverty line who work in the informal sector. A study conducted in New Delhi found that most women who were working as street vendors or as domestic help returned to work as early as three weeks after delivery.[6] Majority of the women were back at work at the end of two months. The primary reason behind this was that these women were the sole earning members of the family. Their husbands did not contribute significantly to the income of the household either due to unemployment or being engaged in work with irregular pay.[7] Therefore, the lack of security surrounding income levels due to a lack of guaranteed and sustained employment forces a majority of these women to return to the workforce very soon after delivery.[8] The alternative is taking informal loans and selling their limited assets, potentially worsening the severity of their poverty in the long run.[9] It is these economic risks associated to maternity that must effectively be combatted. Based on the similar idea of a conditional cash transfer ('CCT') scheme like the JSY, schemes in Brazil and Mexico are often cited as providing more long term and robust protection to both the mother and children.
 
Bolsa Familia and Oppurtunidades/Progresa: A Look into Long Term CCT Schemes
 
Similar to JSY, Bolsa Familia and Oppurtunidades are also conditional cash transfer schemes. The premise of both Bolsa Familia in Brazil and Progresa in Mexico is that they seek to transfer cash to low-income families who fulfil certain conditions relating to education of children and health of the mother and child.[10] For example, under Progresa, women were provided with institutionally assisted delivery if they attended certain lectures related to pregnancy.[11] Under Bolsa Familia, women were provided with cash if they participated in regular pre- and post-natal monitoring.[12] In both Progresa and Bolsa Familia, cash was transferred to households if children maintained regular attendance to school.[13]
 
A certain economic security is ensured if conditions are diligently fulfilled. The security of cash and extra support in the form of free healthcare services provide a huge cushion against the maternal costs which we see plaguing Indian women working in the informal sector. Given these benefits, CCT schemes therefore, seem to many as the model all countries must adopt for providing maternity relief and for poverty alleviation of these vulnerable groups. However, CCT schemes are not without their faults and merit a closer examination. The next section engages in a statistical and structural critique of these schemes.
 
Critique of CCT schemes
 
Statistical Issues:
 
CCT programmes command significant favour as a policy. Proponents of the policy argue that cash transfers enable targeting. Once set up, they are easier and cheaper to administer.[14] Many comprehensive studies also support the short-term effectiveness of these policies in poverty alleviation. On the other hand, the evidence for sustained long-term impact of these schemes remain unclear. While researchers have acknowledged that the lack of such evidence may exist due to challenges of methodology in evaluating long term impact, many studies also find a fair share of results that are not 'statistically different from zero.'[15] This clearly indicates that the long-term impact of these schemes is minimal.[16] We must move away from the short-term appeal of these policies and target our efforts towards holistic approaches to poverty alleviation which provide long term results.
 
Apart from these statistical factors, there are qualitive and structural problems with the CCT schemes which have been analysed from the lens of the capabilities approach.
 
Qualitive Issues:
 
Martha Nussbaum's conceptualises her idea of capabilities approach by focusing on certain 'core human entitlements' that governments must empower citizens with. She calls this the 'basic social minimum' requirement for human dignity. As per Nussbaum, the path to reach this basic minimum is through the capabilities approach. This approach focuses primarily on human capabilities which is people's ability to do and to be "in a way informed by an intuitive idea of a life that is worthy of the dignity of the human being."[17] Therefore, Nussbaum argues that the notion of human dignity and creating a life of "truly human functioning" is central to the capabilities approach.[18] To this extent, she provides a list of 'central human capabilities' which range from bodily health and integrity to imagination and thought to play.[19]
 
The current system of CCT focuses disproportionately on the woman's role as a mother and caregiver. As highlighted above, the economic incentives to women are only disbursed if they comply with pre- or post-natal care (as seen in JSY). Further, in Bolsa Familia and Progresa, the burden of ensuring compliance with the conditionalities, inevitably fell on the mothers. A study also found that these programmes worked best where women had not taken any other work outside the household.[20] This reaffirms gendered notions of care and limits the role of women to caregivers. As a result, there is little or no opportunity with these women to pursue their desired activities.[21] Nussbaum also acknowledges this situation of caregivers. From the list identified by Nussbaum, pressure is created on certain items on the list like physical and emotional health. Little opportunity is left from them to develop in areas of play, senses and thought, practical reason, focus on cultivating affiliations beyond the family sphere, exercising control over their environment. The state must provide everyone with not just one of these capabilities but must account for development of all the central human capabilities.[22] She acknowledges that it would be possible to provide caregivers with all central capabilities. However, by way of certain arrangements, we could ensure at least some of the central human capabilities. In the context of the CCTs, we see that a public arrangement itself is taking away opportunities from women to develop in these core areas.
 
Structural Issues:
 
The underlying assumption of these schemes is that cash given in hand to the women will improve their economic autonomy.[23] This claim remains unsupported. First, these schemes do not take into account the gender dynamics that play out in the household and fail to address the needs of all members of the family, particularly the mothers. In patriarchal societies, where men exercise significant control and power, women are not able to fully realise economic autonomy. This is supported by the observation that there is neither dramatic reorientation in the household expenditure nor an increase in women's ability to exercise control over such spending decisions.[24] This has also contributed to the flimsy notions of creditworthiness of women. Believing in the regularity and security of these cash transfers, there has been an increase in the willingness of women to take on debt which they believe can be paid off through the amount received through these cash transfers. Therefore, they seem to be even more vulnerable to becoming debt-ridden than before.[25] We find that even after providing women with cash in hand, they are not able to convert these resources to live a good life because of the social environment. Amartya Sen has termed this as the 'conversion handicap.'[26] Nussbaum supports the formulation of conversion handicap as put forward by Sen but takes the argument further. She pushes for a move from a focus on 'means of living' to 'opportunities for activity.'[27] In the present context, it would mean that instead of handing cash, state should redesign the system to equip these women with the appropriate skills and tools to convert their resources.[28] One way to achieve this would be through education. Nussbaum also holds that education and gaining technical skills is the best way to achieve all the human capabilities.[29] Therefore, the solution we craft must combine provision of assets with skills. The next section proposes a solution which seeks to combine all of these fundamental elements.
 
The Way Forward
 
An experiment conducted by Abhijit Banerjee in Ghana gives an insight into the manner in which a long-term solution can be made operational. A randomized control test was carried out in which the participating women were presented with the choice to make cloth bags which were later purchased from them. A few of the beneficiaries were chosen at random and were offered a productive asset from a list. Most beneficiaries chose four goats.[30] Along with the asset, they were equipped with basic training about the care and upkeep of the goats. There was a 'hand-holding' component which proved to be crucial. Under this, women were given life-skills where they were provided with guidance about building productive assets and for dealing with obstacles they were facing or may face. This morale building was necessary for these women from extremely poor backgrounds who lacked belief and trust in themselves that they could prosper.[31] Nussbaum has termed this mindset as "adaptive preferences" where disadvantaged groups calibrate their preferences based on their perception of themselves and narratives society feeds them.[32] It was ultimately found that even though the goats were an additional responsibility, beneficiaries who were equipped with the assets performed better in terms of both production and earning than those women who did not have an asset. The difference was clearer when beneficiaries with an asset performed better even when the bags had a complex design. They worked at a much higher pace and met all the quality tests. The explanation for this as advanced by Abhijit Banerjee is that having a productive asset reduced their stress of survival and allowed them to channel their energy into learning and mastering this new skill.[33]
 
Banerjee's experiment is instructive as it helps us identify that essential element of a successful policy must include a combination of a guarantee of an asset, provision of tangible skills and psychological support and encouragement. This approach highlights the stark contrast to women working in the informal sector who are primarily engaged in activities that require little to no skill. They find themselves dependent on households giving them domestic chores or a vending spot to sell certain goods. As a result of which these women find themselves dependent on their external environment. However, creative skills (like bag-making) are marketable and provides these women with the confidence to leverage these skills to support themselves. It is this ability which will allow them to cope with economic costs of maternity better. The state must also look at designing and scaling such programmes and making them accessible to poor women across the country.
 
Duty of International Institutions
 
Despite the qualitative problems and statistical evidence to support the fact that CCTs are not effective in the long run, it still remains a popular scheme. In advancing solutions for poverty alleviation, it is frequently recommended by the International Labour Organisation and the World Bank.[34] It is interesting to note that World Bank has actively funded schemes like the Janani Suraksha Yojana in India for an IDA credit of 360 million dollars.[35] It continues to fund Bolsa Familia in Brazil. In 2020, it approved a loan of 1 billion dollars for increasing the reach of the Bolsa Familia programme.[36] It is important to question the funding decisions of World Bank in the wake of evidence which demonstrates that these policies do not bring about long-term benefit in poverty alleviation. The support in the form of these large loans will leave countries little to no incentive to phase out CCT schemes and move towards policies that focus on providing capabilities to their citizenry.  
 
This paper demonstrates that while CCT schemes are widely hailed as the model many countries should adopt for poverty alleviation, they have considerable shortfalls. Economic costs arising from maternity and the resultant vulnerability of households demands long-term solutions which are concrete, sustainable and scalable. To cure the disease and not just alleviate the symptoms of poverty, we must focus on shifting from resource-centric to capabilities-centric approaches. This would include implementing policies that contain the vital elements of guaranteed assets, provision of marketable skills and psychological support as identified through Banerjee's experiment. International institutions must also make an active effort to aid the shift to providing capabilities rather than just resources which would hopefully encourage countries to make such a shift too.
 
 
The author, Kopal Mital, is an undergraduate law student at the National Law School of India University (NLSIU), Bangalore.
 
 
[1] Art. 42, Constitution of India, 1950.  
 
[2] Pushpendra Singh and others, How Affordable is Childbearing in India? An Evaluation of Maternal Healthcare Expenditures' 16(4) Newborn and Infant Nursing Reviews (2016) available at https://www.sciencedirect.com/science/article/abs/pii/S1527336916300939 last seen on 25/11/2021
 
[3] Ministry of Health & Family Welfare, Janani Suraksha Yojana: Guidelines for Implementation 1 https://www.ilo.org/dyn/travail/docs/683/JananiSurakshaYojanaGuidelines/MinistryofHealthandFamilyWelfare.pdf  last seen on 25/11/2021
 
[4] National Family Health Survey India, 2005-6 http://rchiips.org/nfhs/nfhs3.shtml last seen on 25/11/2021; National Family Health Survey India, 2015-16  http://rchiips.org/nfhs/nfhs4.shtml last seen on 25/11/2021 
 
[5] Sohini Paul, Inequality in the Utilisation of Maternal Healthcare Services, 55(45) Economic and Political Weekly (2020) https://www.epw.in/journal/2020/45/special-articles/inequality-utilisation-maternal-healthcare.html last seen on 25/11/2021
 
[6] Christiane Horwood and others, Attitudes and perceptions about breastfeeding among female and male informal workers in India and South Africa BMC Public Health (2020) https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09013-9#citeas last seen on 21/11/2021; Gautum Bhan and others, Informal Work and Maternal and Child Health: A Blind Spot in Public Health and Research Bulletin of WHO 219, 220 (2020) https://www.who.int/bulletin/volumes/98/3/19-231258.pdf last seen on 22/11/2021  
 
[7] Supra 6.
 
[8] Supra 6.
 
[9] International Labour Officer (ILO), Extension of Social Protection 5 https://www.ilo.org/wcmsp5/groups/public/---ed_emp/---emp_policy/documents/publication/wcms_210468.pdf  last seen on 21/11/2021
 
[10] Supra 9, at 10-11.
 
[11] Ibid.
 
[12] Ibid.  
 
[13] Abhijit Banerjee and Esther Duflo, Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty (1st edn PublicAffairs, New York 2011) 79.
 
[14] Maxine Molyneux, Conditional Cash Transfers: A 'Pathway to Women's Empowerment? 1, 3 https://assets.publishing.service.gov.uk/media/57a08b4eed915d3cfd000c52/PathwaysWP5-website.pdf last seen on 21/11/2021
 
[15] Teresa Molina Millán, Tania Barham and others, Long-Term Impacts of Conditional Cash Transfers: Review of the Evidence https://academic.oup.com/wbro/article/34/1/119/5492445#135888571  last seen on 21/11/2021
 
[16] Supra 11; Juan E. Saavedra, The effects of conditional cash transfer programs on poverty reduction, human capital accumulation and wellbeing https://www.un.org/esa/socdev/egms/docs/2016/Poverty-SDGs/JuanSaavedra-paper.pdf (2016) last seen on 21/11/2021
 
[17] Martha C. Nussbaum, Frontiers of Justice: Disability, Nationality and Species Membership (The Tanner Lectures on Human Values, HUP, Cambridge 2007) 70
 
[18] Supra 13, at 74.
 
[19] Supra 13, at 76.
 
[20] Supra 14, at 53. 
 
[21] Supra 14, at 52-54. 
 
[22] Supra 13, at 76, 170.
 
[23] Supra 10, at 39.
 
[24] Ibid.
 
[25] Supra 10, at 40.
 
[26] Amartya Sen, The Idea of Justice (HUP, Cambridge 2009) 258.
 
[27] Ibid, at 233; Supra 13, at 73-74.
 
[28] Supra 13, at 284.
 
[29] Supra 13, at 322.
 
[30] Abhijit Banerjee and Esther Duflo, Good Economics for Hard Times: Better Answers to Our Biggest Problems (1st edn Public Affairs, New York 2019) 225
 
[31] Ibid, at 225.
 
[32] Supra 13, at 73.
 
[33] Supra 25, at 225.
 
[34] Supra 6, at 10-11.
 
[35] World Bank, Result Based Financing at the World Bank (2011) https://www.rbfhealth.org/sites/rbf/files/RBF_India.pdf last seen on 21/11/2021
 
[36]  World Bank, World Bank approves loan supporting the expansion of the Bolsa Familia Program (Press Release October 29 2020) https://www.worldbank.org/en/news/press-release/2020/10/29/world-bank-approves-loan-supporting-expansion-of-bolsa-familia-program  last seen on 21/11/2021