Women eat least, and last

By Dipa Sinha

Women are more vulnerable to malnutrition. But the targeted food programmes for women, including the National Maternity Benefit Scheme, focus only - and inadequately -- on the reproductive function of women. Ensuring that women secure their right to food is not seen as a desirable goal in itself, even though women are nutritionally deprived at all other stages of their life

Gender, apart from other economic, social and political factors, plays a major role in determining food security and nutritional status in India. Women tend to eat last and also the least in many families. It is often believed that boys/men require more food because they are physically more active. But women’s needs are greater, especially during adolescence, pregnancy and breastfeeding.

The effects of gender discrimination are reflected in data. In India, 60% of women in their childbearing years are stunted as a result of inadequate nutrition during their own childhood. About 80% of pregnant women in the country suffer from iron-deficiency anaemia. The low nutritional status of women has an inter-generational effect as the birth weight of infants exhibits a pronounced relationship with the nutritional status of the mothers.  A malnourished anaemic woman is more likely to deliver a baby with low birth weight. Such a baby will carry the handicap throughout its life, and so on. On the other hand, studies have shown that as the Body Mass Index of mothers increases, the mean birth weight of children also increases.

The central and state governments have several schemes that target specific groups of the population recognised as being more vulnerable, such as the poor, the aged and women. The schemes for women are the National Maternity Benefit Scheme (NMBS) and the Integrated Child Development Services (ICDS), which has a component of supplementary nutrition for pregnant women, lactating mothers and adolescent girls.

The National Maternity Benefit Scheme

The central government’s National Maternity Benefit Scheme (NMBS), modified to become the Janani Suraksha Yojana (JSY), was launched in the year 1995. It was part of the National Social Assistance Programme (NSAP) to be implemented by the Ministry of Rural Development and later transferred to the health ministry. Under the NMBS, pregnant women from BPL families were entitled to cash assistance of Rs 500 for up to two births, 8-12 weeks before delivery. 

From the outset, this scheme has been characterised by low allocations, under-utilisation, long delays and procedural complications. When the NMBS was launched, the targeted number of annual beneficiaries was fixed at 57.5 lakh expectant women (based on the estimated population of expectant mothers giving birth to a first or second child). However, in the 10 years between 1995-96 and 2004-05 the number of annual beneficiaries has never exceeded 15.8 lakh (or 27.4% of the target). Coverage under this scheme worsened after it was shifted to the Ministry of Health in 2001, with only 4.2 lakh (or 7.3% of the targeted number) receiving any benefit under this scheme in 2004-05.

The low coverage of beneficiaries is also reflected in the under-utilisation of funds over the years. According to the Sixth Report of the Commissioners to the Supreme Court in a case (Peoples’ Union of Civil Liberties versus Union of India and Others) submitted to the court in December 2005, in the three years between 2001-02 and 2003-04, on average only 38% of the allocated funds were utilised by the state governments. The amount allocated under the scheme has been grossly inadequate. To cover the target of 57.5 lakh mothers with a cash assistance of Rs 500 each, Rs 287.5 crore are required each year (and Rs 1,437.5 crore for five years).  However, the Government of India allocated a mere Rs 500 crore in the Tenth Plan period (2002-07), which is only 35% of the required amount.

The Sixth Report of the Commissioners identifies many reasons for the scheme’s lack of performance. Some of these reasons are:

  1. A change in the nodal agency from the Ministry of Rural Development to the Ministry of Health and Family Welfare and the corresponding transition period in the states.
  2. Changing objectives. A letter to all the state governments said, “The Government of India has now decided that the NMBS may be transferred (w.e.f. 1.4.2001) to the Department of Family Welfare to become part and parcel of the population stabilisation programme”. No official guidelines were introduced, but the transfer of the scheme and talk of the NMBS being replaced by the JSY resulted in changes in its implementation at the state level.
  3. The funds under the NMBS were directly transferred to the district level whereas the utilisation certificates were to be collected by the state nodal agencies, which led to a lot of confusion. A delay in the release of funds by the central government also resulted in the scheme’s poor performance.
  4. Another important reason is the lack of information and awareness about the scheme at the grassroots level in many states.
  5. A lack of involvement of panchayat institutions and multiple criteria for selection despite an SC order on involvement of village panchayats. Other institutions  substituted or complemented the panchayat, such as the primary health centres, anganwadis (to certify pregnancy and the first two births) and block and revenue officials (to certify BPL status). This made it procedurally difficult for pregnant women to get the assistance.
  6. The other important reason for low participation is the low rate of financial assistance under NMBS. In 1995, Rs 300 was fixed as the cash entitlement. It was raised to Rs 500 in 1998. Not only is the amount too low, there has been no increase since 1998.

The Janani Suraksha Yojana

Based on reports that the NMBS did not have any impact on maternal mortality, the scheme was modified into the Janani Suraksha Yojana (JSY) and launched in April 2005. The objectives of the JSY are reducing maternal and infant mortality through increased delivery at health institutions. The NMBS’ focus was the provision of maternity benefits. The guidelines for the implementation of the JSY say, “While the NMBS is linked to provision of a better diet for pregnant women from BPL families, the JSY integrates the cash assistance with antenatal care during the pregnancy period, institutional care during delivery and immediate post-partum period in a health centre by establishing a system of coordinated care by field level health worker.” The scheme links the cash assistance to ante-natal check-ups and an institutional delivery.

The initial guidelines did not retain the objective of ensuring food security, without any conditions, for all pregnant BPL women. This defeated the purpose of the original NMBS---to provide social security to pregnant women. Linking the benefits of the scheme to various conditions would severely undermine the rights of a woman to use the social assistance under the NMBS to access food, nutrition and rest during pregnancy and after, and also the rights of the child to breastfeed and get care. Calculations in the Sixth Report of the Commissioners showed that on an average nearly 65.5% of the eligible beneficiaries under NMBS would get zero direct cash assistance under the proposed JSY.

The Commissioners wrote to the Ministry of Health reminding them of the Supreme Court order of April 27, 2004. The order had said that no scheme covered by the orders of the SC shall be discontinued or restricted in any way without the prior approval of the Court and until further orders, the schemes would continue to operate and benefit all those who are covered by the schemes.

In response to the intervention by the Commissioners, the following modifications have now been made to the JSY:

  1. Rs 500 will be paid under JSY to all pregnant eligible BPL women irrespective of place of delivery. It is not mandatory to have ante-natal check-ups.
  2. In addition, women who have an institutional delivery will be paid Rs 200 in rural areas and Rs 100 in urban areas. Rs 1,500 will be given in case of delivery-related complication leading to a caesarean.  The BPL criterion has been removed for institutional deliveries.
  3. In low-performing states, the age bar and number of births for which assistance is provided under the NMBS, have been removed.

Shortcomings of the scheme

The NMBS/JSY is especially important because it is the only attempt in India to introduce ‘maternity benefits’. It has been ensured that the modified JSY does not dilute the provisions of NMBS, but shortcomings remain in the scheme. These will have an impact on the effectiveness of the NMBS/JSY as a scheme for ensuring maternity benefits or enhancing food security for pregnant women.

First, the problem of low allocations persists in spite of the JSY being part of the larger National Rural Health Mission. The Annual Report of the Ministry of Health (2005-06) says an allocation of Rs 100 crore was made for JSY under the RCH flexi-pool mechanism. Considering that the earlier NMBS itself would have required Rs 287.5 crore for full implementation, what would  be required under JSY (with its additional benefits) would be much more. Such low allocations expose the government’s lack of seriousness. It has been seen in many schemes that inadequate funds invariably lead to low utilisation.

Second, the amount of assistance per woman is so small that it is unlikely to really have any impact on the food and nutritional status of women. The Tamil Nadu government recently revised its maternity benefit scheme so that each pregnant woman would get a total benefit of Rs 6,000.  The impact of this change must be studied and other state governments and the central government must revise the scheme accordingly.

Third, since this scheme is targeted only at BPL women, all the problems associated with the identification and definition of BPL families apply here as well. In this context, the Parliamentary Standing Committee’s recommendation of an inbuilt mechanism for a periodic survey to verify the exact number of beneficiaries can be considered.

More importantly, the scheme does not in any way try to address the intra-family inequalities that make women more vulnerable to malnutrition. Surveys show that the cash assistance under the NMBS or the dry rations given by the ICDS go into the larger family ‘pool’ and get shared by all members of the family (with the pregnant woman probably getting the least). On the other hand, if there is greater social mobilisation in favour of the pregnant woman’s right to food and nutrition, the cash assistance can go a long way in helping the woman get the extra bit she needs during pregnancy.

A larger issue that needs to be thought about is that all the targeted food programmes for women, including the NMBS/JSY, focus on women performing their reproductive function. The focus is on pregnant women or adolescent girls having healthier babies or on reducing infant mortality rates. Women securing their right to food is not seen as a desirable goal in itself, even though women are nutritionally deprived at all other stages of their life. The existing programmes fail to address gender inequalities in access to food and at best can be seen as a small beginning which could have potential if implemented along with other programmes that address gender discrimination.

(Dipa Sinha is a Research Associate with the Office of the Commissioners to the Supreme Court. The views in this article are her own and not of the Office of the Commissioners or of the Right to Food Campaign.)

InfoChange News & Features, October 2006