Twenty-one percent of children in India under five years of age suffer from wasting, according to the 2017 Global Hunger Index. In addition, nutrition interventions in the country, including the Integrated Child Development Services and the National Health Mission, have not achieved adequate rates of coverage. A new journal article published in PLoS ONE examines whether conditional cash transfer programs can improve health and nutrition outcomes in India.
The study examines Mamata scheme, a conditional cash transfer program established in the state of Odisha that targets pregnant and lactating women. According to the study, Odisha has the third lowest average annual household income in the country. Launched in 2011, Mamata scheme provides partial wage compensation to pregnant and nursing mothers, with the aim of increasing the utilization of health services and improving infant and young child feeding practices. To be eligible for the program, women must be over 19 years of age with up to two live births. The program provides a cash transfer of 5,000 INR directly into beneficiaries’ bank accounts in four installments, as long as the beneficiary meets certain conditions, including registration of pregnancy, utilization of pre- and post-natal health services and counseling, and vaccination of children. The study estimates that the program provides 6 percent of average household annual income in Odisha.
The authors use survey data from 1,161 households in three districts from February-March 2014 to examine the impact of the program on eight health- and nutrition-related outcomes:
- pregnancy registration,
- receipt of prenatal services,
- receipt of iron and folic acid tablets,
- exposure to counseling during pregnancy,
- exposure to post-natal counseling,
- exclusive breastfeeding,
- full immunization, and
- household food security
The most commonly reported uses of the money transferred through the program were household savings and expenditure on food (27.9%) and expenditure on child health, food, and care (25.6%).
The results show that almost 60 percent of mothers in the study had enrolled in the program and that more than 90 percent of those enrolled had received money from the scheme, although there was some heterogeneity across districts. However, it appeared that transfers were smaller than expected from the specifications of the program, which the authors suggest could be due to delays in payments or to deposits of incorrect amounts. Mothers received an average of between 900 and 1300 INR less than the expected amount at three and six months after delivery, respectively. At nine months after delivery, mothers reported receiving an average of 4,500 INR (500 INR less than the full stated transfer amount).
Similarly, it appeared that the program was not effective in targeting households with lower socio-economic (SES) status. Only 12 percent of beneficiaries came from the lowest SES quintile, compared to 26.6 percent in the highest quintile. The findings for education level and caste were similar. Only 12 percent of beneficiaries had no education, and only 17 percent came from the scheduled tribes’ category. Thus, the program does not appear to have benefitted some of the most vulnerable women in the sample.
Regarding the specific study outcomes, the study finds that women who received money from the program were more likely to have received pre-natal care and more likely to have received iron and folic acid tablets during pregnancy from frontline health workers or social health activists. There was also a strong positive effect on registration of pregnancy. Similarly, the prevalence of food insecurity was found to be lower among women who received the transfer than among those who did not. However, the authors found no significant different between beneficiaries and non-beneficiaries regarding the receipt of post-natal counseling, exclusive breastfeeding, or full child immunization.
Women from higher SES quintiles were more likely to have received pre-natal services, iron and folic acid tablets, and counseling during pregnancy. Interestingly, women with higher education levels were less likely to receive iron and folic acid tablets from a frontline health worker or a social health activist, but were more likely to receive post-natal counseling.
The study provides evidence that cash transfer programs can have positive and significant effects on women’s and children’s health and nutrition outcomes in India. However, the authors caution that more research is needed to truly understand some of the findings. For example, the fact that more educated women were less likely to get iron and folic acid tablets from community health workers could be due to the fact that these women may have had access to private health services and received supplements from those sources instead. In addition, the authors emphasize that a strong local health system is needed to enable beneficiaries to fulfill the conditions of the transfer (i.e., attending pre- and post-natal doctors’ visits and counseling, receiving supplements and vaccinations, etc.).