In Govt’s Maternal Health Scheme, Big Gap Between Intent And Reality
Initiatives to make the Pradhan Mantri Matru Vandana Yojana more effective has not quite worked out the way it should, we find
Months after her death in a catastrophic health crisis in Nanded, Anjali Waghmare’s family is still repaying the loan they took from a private contractor for her delivery. This is not an isolated incident of high out-of-pocket expenditure on hospitalisation in Maharashtra, as Behanbox has reported. Sangeeta, a mother of two daughters, borrowed Rs 15,000 for her third delivery at a private hospital because the family did not want any complications in case the child was a boy.
Cane-cutter families in Maharashtra pay an average of Rs 30,000 for institutional deliveries. In a situation with debilitating health infrastructure and precarious living, this daily-wage migrant community also struggles with proper documentation to access maternity entitlements. This is a glaring gap in translating the constitutional right under the National Food Security Act (NFSA) 2013 for accessing maternal benefits.
In the run-up to the general election, we analyse the Pradhan Mantri Matru Vandana Yojana, the Indian government’s flagship maternal health scheme, to understand why women like Anjali or Sangeeta, who are entitled to the scheme, are struggling for financial support. We found that maternal entitlements have remained stagnant over the years despite the rise in the cost of healthcare. Fewer women are enrolling under the scheme because of a complicated documentation process too.
Few Hits, Major Misses
On paper, supporting motherhood is one of the government’s stated strategies for promoting women’s empowerment or nari shakti. Two critical vehicles for realising this are the Matru Vandana Yojana and Janani Suraksha Yojana. Both are cash transfer schemes, conditional upon realising certain outcomes. The first is meant to compensate for ‘partial wage loss’ during pregnancy, and the latter aims to promote institutional deliveries.
In 2022, the government reinstitutionalised the Matru Vandana Yojana which is now under Mission Shakti’s Samarthya sub-scheme for women’s economic empowerment. It now extends benefits for two live births as opposed to one, but only if the second is a girl child. The intention, according to the government, is to improve the child sex ratio and reduce crimes against the girl child. The recent changes also allow the right-holder to re-apply for a fresh case in the event of a miscarriage or still-birth.
Until 2022, payments were released in three instalments, now reduced to two (Table 1). Conditions of early registration and regular ante-natal check-up (ANC) care were merged in the revised scheme. With Janini Surasha Yojana, right-holders may receive an average of Rs 6,000 which includes the instalment-wise payment of Rs 5,000 under Matru Vandana Yojana. For the second live birth, Rs 6,000 is released in one instalment post delivery.
This average amount of Rs 6,000 was stipulated under the NFSA which came into effect over 10 years ago. The recent changes have not accommodated the rise in prices or considered the persisting high out-of-pocket expenditure on deliveries, as seen in Anjali’s and Sangeeta’s cases. The National Family Health Survey (NFHS-5) in 2019-21 reported that households paid Rs 24,663 in private and Rs 3,245 in public hospitals for deliveries.
An analysis by the Accountability Initiative in 2023 showed that the inflation-adjusted payment under Matru Vandana Yojana should have increased by at least Rs 1,600. The minimum wage prescribed by the government is also more than double the payment under it. Even similar state schemes – Odisha’s Mamata scheme and Tamil Nadu’s Dr Muthulakshmi Reddy scheme – have revised the cash transfers to Rs 10,000 and Rs 18,000, respectively, for right-holders.
Further, the migrant women in Maharashtra informed BehanBox that they did not have the requisite documents to access any of the maternity health schemes. Documents have to be filed by potential right-holders at different stages of the instalments. The earlier condition, that the husband’s Aadhaar card be provided, was removed only recently. For the first instalment, the pregnant woman is required to furnish her Aadhaar card, along with the Mother and Child Protection (MCP) card which records the utilisation of services for mother and child health, and bank or post office account details. The second instalment requires the MCP card as well as the child’s birth certificate. At every step, women may have to fill out multiple forms, ranging from registration to the seeding of Aadhaar with bank account or even updating the Aadhar itself. Jean Dreze, Reetika Khera, and Anmol Somanchi have noted that this complicated process of documentation and verification, often not clearly articulated or received by marginalised women, denies them their right under the scheme. In Bihar as well, only 50% of women who had filed for maternity entitlements under the Matru Vandana Yojana qualified for it.
Data on right-holders linked to Aadhaar presents an interesting tale too. In 2021, 72% of eligible citizens were linked to Aadhaar and this increased to 98% in 2022; but the same year saw fewer pregnant women and lactating mothers seeking benefits under the scheme itself which raises questions about the efficacy of the documentation process.
Increased Scope, Decreasing Benefits
The number of pregnant women and lactating mothers who have received benefits under the scheme has been decreasing since 2019-20 (Figure 1), according to information provided under the Right to Information by the Ministry of Women and Child Development. This is counterintuitive to the scheme’s increased scope of extending benefits up to second live birth and the move to reduce conditionalities.
At the same time, the number of right-holders receiving payments has also declined between 2022-23 and 2023-24. Over 312 lakh pregnant women and lactating mothers received payments in 2022-23 compared to only 22 lakh in 2023-24 (till March 6, 2024). This is a worrying development as it implies that benefits are not only being denied to right-holders registered for the first live birth but also the second. Also, it is not necessary that right-holders who have received payments may have received all instalments. As highlighted in Accountability Initiative’s analysis, in 2022-23 (till November 21, 2022), only 29% had received all instalments, while 64% of right-holders received one instalment. NITI Aayog in 2020 had also noted that there are delays in instalment-wise payments, with fewer right-holders receiving the last instalment.
The decreasing number of right-holders enrolled has also translated into lower budgetary prioritisation. The planned allocation has been decreasing since 2019-20. For all years, revised expenditures (Revised Estimates (REs) are further lower than BEs (refer Note). Budgeted expenditure (Budget Estimates (BEs)) were slashed by almost 50% mid-of-year in 2020-21. Only over 50% of BEs were spent in 2021-22 (Figure 2).
Note: The Union Government releases the budget on February 1 every year. The budget includes the government’s expected expenditure (Budget Estimates) for the year. Revisions (Revised Estimates) are made to these Budget Estimates mid-of-year for any remaining expenditure. Both are planned allocations. Actual spending (Actuals) records how much of the planned allocation is spent or utilised.
Long Way Ahead
Like Anjali and Sangeeta, there were at least 198 lakh pregnant women and lactating mothers in 2022 who could have availed benefits for two live births under the scheme. Only 59 lakh, however, were enrolled in that year. If 198 lakh women did receive their entitlements, the cost of running the Matru Vandana Yojana would have been Rs 10,252 crore in 2022, much higher than the currently approved and allocated budgets.
Some of the proposed initiatives under the scheme include self-beneficiary registration through an online application and verification of Aadhaar and IFSC for smoother disbursement of payment. But, without adequately addressing the issue of complex documentation, rise in costs, low internet usage, access to banking services and awareness among women about the scheme, cosmetic changes will remain ineffective.
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