Pro-Poor Maternity Benefit Schemes and Rural Women - India ...

COMMENTARY

Pro-Poor Maternity Benefit Schemes and Rural Women Findings from Tamil Nadu P Balasubramanian, T K Sundari Ravindran

Background

A cross-sectional study based on women beneficiaries under the Muthulakshmi Reddy Maternity Benefit Scheme in five districts of Tamil Nadu shows that scheduled caste and landless women in the sample were disadvantaged in receiving benefits. Overall, only one-fourth of the women who delivered first or second order births in the sample received monetary assistance under the scheme.

T

P Balasubramanian (kcm_rural08@dataone. in) is with the Rural Women’s Social Education Centre, Chengalpattu, Tamil Nadu and T K Sundari Ravindran ([email protected]) is with the Achutha Menon Centre for Health Science Studies, Thiruvananthapuram. Economic & Political Weekly

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june 23, 2012

amil Nadu’s successive governments have come out with many innovative pro-poor policies to promote social equity. These policies have been aimed at addressing the needs of different target groups ranging from children to the aged. For example, the mid-day meal scheme for schoolchildren, scholarships for girls and dalit students, pensions for widows and the aged, and support for poor women wanting to get married. A modest childbirth assistance scheme, named after Muthulakshmi Reddy, Tamil Nadu’s first woman doctor and social activist, was launched in 1987 and is known as the Muthulakshmi Reddy Maternity Benefit Scheme (MRMBS). Initially, its beneficiaries were offered Rs 300 to cover the expenses of childbirth. The amount was enhanced to Rs 500 in 1995. In September 2006, the amount was raised significantly and a clear set of guidelines were drawn to disburse the money. Between September 2006 and April 2011, cash assistance of Rs 6,000 was given to pregnant women living below the poverty line (BPL) to compensate for the wage loss during pregnancy and for help in getting nutritious food to avoid low birth weight babies. The money was provided usually in two equal instalments, the first in the seventh or later months of pregnancy and the second within three to six months after delivery (Table 1, p 20). In May 2011, the newly elected state government announced its intention to double the support amount to Rs 12,000. This article discusses the programme implemented from September 2006 to April 2011. Eligibility and Procedures The MRMBS was meant for the first two deliveries of BPL women, excluding those who owned mobile phones, motor vehicles

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and land. Over the years the eligibility criteria has undergone various changes. In its present version, all BPL women who access the services of a primary health centre (PHC) are eligible for the benefits, but the annual household income limit has been raised to Rs 24,000 from Rs 12,000. Sri Lankan repatriate women are also eligible for the benefits. However, the scheme continues to cover only the first two deliveries. While there is no clause that states that only women who access a public facility are eligible for coverage by the scheme, procedural difficulties prevent private facility users from receiving the benefits. Eligible women have to submit the application forms of their respective villages to the village health nurse (VHN). The VHNs are authorised to certify the poverty status of the pregnant women and the application must be submitted along with the following documents: (1) Family income certificate provided by the village administrative officer – VAO (the annual household income should be below Rs 24,000). (2) Copy of the antenatal care service card provided by the public health facility. (3) Ration card provided by the civil supplies and consumer protection department. If the woman is a Sri Lankan repatriate, a certificate of repatriate status is also needed. The application and the necessary documents are duly forwarded to the block medical officer through the sector health nurse (SHN), the community health nurse (CHN) and the medical officer of the PHC covering the woman’s village. As per the guidelines, Rs 3,000 is provided before delivery and the remaining afterwards. During the period between 15 September 2006 and 31 March 2011, nearly six lakh women benefited annually under the schemes and on an average about 1,600 women received the money per day. About 50-60% of the deliveries which occurred in the state were covered under the programme and more than Rs 300 crore were spent per year. This conditional cash transfer scheme has had a significant effect on the proportion of women seeking institutional delivery and has especially increased the use of public sector health facilities for delivery care. Utilisation of PHCs for 19

COMMENTARY Table 1: Annual Number of Beneficiaries under the MRMBS Year

2006-07 2007-08 2008-09 2009-10 2010-11 Total

No of ANC Mothers Registered@

12,63,473 12,63,744 12,49, 326 NA NA

No of Deliveries Reported@ (Both Home and Institutional Births)

No of Beneficiaries under MRMBS Scheme #@

Amount Disbursed# (Rs in Crores)

11,23,662 11,34,834 11,13,451

2,41,095 6,79,831 5,79,821 5,99,126 5,44,710 26,44,583

100 296.64 349.26 358.60 326.19 1,430.69

Percentage of Women Benefited to the Total Deliveries

21.45* 59.9 52.1 – – –

*The scheme was introduced on 15 September 2006 and hence the data shows beneficiaries for only six months for 2006-07. @ Compiled from The Hindu, Annual Public Health Administration Report 2008-09, Government of Tamil Nadu and Data from the Directorate of Public Health, Tamil Nadu.

delivery care increased significantly and the private sector share to total institutional delivery started declining in recent years. This article looks at the characteristics of the Muthulakshmi scheme beneficiaries based on primary data collected from recently delivered women. The main questions that we seek to answer are: • What proportion of rural poor women who were eligible for the scheme benefited and what proportion were left out? • What are the characteristics of women who did not receive the benefit and their stated reasons for not receiving the assistance? Data and Profile Data for the study is drawn from a crosssectional survey on “Differential and Determinates in Utilisation of Reproductive Healthcare Services in Tamil Nadu” done by the Rural Women’s Social Education Centre – RUWSEC, a non-governmental organisation (NGO) working for women’s health and reproductive rights issues. The survey covered 20 villages across five districts. Of the 32 districts in Tamil Nadu, the five selected were Kancheepuram, Nagapattinam, Cuddalore, Dharmapuri and Kanyakumari. Kancheepuram and Nagapattinam have socio-economic and health indicators close to the state averages. Cuddalore and Dharmapuri have poor indicators and Kanyakumari has better socio-economic and health indicators. In each district four villages were selected randomly; two close to a PHC and the other two far away. There were 8,444 households in the sample villages and a total of 494 deliveries were reported in the year prior to the date of survey. The data collection was done during NovemberDecember 2008. The data here pertain to these 494 recently delivered women. 20

All the women who delivered were covered by the study. About two-fifths of the women (38%) belonged to the scheduled castes/scheduled tribes (SCs/STs). One-third belonged to the castes classified as “Most Backward Castes” (MBC) and include the labouring castes who are just above the SCs in the caste hierarchy. The remaining 28% belonged to “other” caste groups. Of the total, 50% women had more than eight years of schooling and another 30% had six to eight years of schooling. Only 8% of the respondents had no schooling. Although all the study participants lived in rural areas, only about 14% had some amount of land. The average landholding size of the landowning households was two acres. Most of the women (85%) reported not working outside their homes because they had infants to take care of. However, 10% worked as casual labourers despite having small children and only 23 women (5%) were in regular employment or were vegetable vendors and small shopkeepers. The utilisation of pregnancy care services was almost universal: 99% of the mothers received some form of antenatal care (ANC) and around 70% had four or more ANC visits. Almost all deliveries (98%) had taken place in a health facility and only 2% (10 women) were home deliveries while 82% delivered in public health facilities. Only 18% delivered in private hospitals. Caste and Economic Status Of the 494 deliveries 484 were institutional deliveries and the rest were home deliveries. Of the total, 424 were first or second deliveries and 70 were of the third or higher order. Third and higher order deliveries are not covered by the scheme; however, three of these 70 women june 23, 2012

who did not have two living children prior to the current delivery received assistance from the scheme (Table 4, p 21). An analysis of the profile of women who were not eligible for the scheme by reason of having a higher order pregnancy showed that the vast majority of the women (53%) belonged to the SC/ST community, although they were only 38% of the total population. More than 88% of the women were from landless households. The following analysis focuses on the 424 women who delivered their first or second babies. Only about one-fourth (25) had received the monetary assistance under the MRMBS, which is very low as compared to the state’s aggregate figures (52% in 2008-09). Contrary to expectations, a higher proportion of higher caste women (33.6%) were beneficiaries of the scheme as compared to the lower caste groups (25.3% for SCs/STs and 17.8% for MBCs). Again, a higher proportion of women (44%) who belonged to landowning households were beneficiaries as compared to women from landless households (21.9%). The differences are statistically significant. Further, a significantly higher proportion of women who worked outside the home had benefited from the scheme (Table 2). Table 2: Profile of Women Who Were Ineligible for Benefits Because of Higher Order Delivery (3+) Caste

Frequency

SC/ST MBC Others Total Landowning Landless Land owned Total

Per Cent

37 16 17 70

52.86 22.86 24.29 100.00

62 8 70

88.57 11.43 100.00

There is significant association between use of public sector facilities for pregnancy and delivery care services and the proportion receiving maternity benefit. Of the mothers who had all the ANC visits in the public facility and another 26% who used both public and private sectors, 28% got the money. As per the policy criteria women who have registered with the VHN but were admitted to a private hospital for delivery, or sought ANC in the private hospitals can also get the assistance. So it is clear that these women judiciously combined the two sectors to vol xlviI no 25

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receive the benefits. Of those who had all the ANC visits in the private sectors only 6% obtained the money. Those who delivered in the PHC had a greater probability of receiving the benefit as compared to those who delivered elsewhere: 45% of mothers who delivered in the PHCs as against 20.6% in the district and taluk hospitals and 18.8% of mothers who delivered in private nursing home got the benefits (Table 3).

The district-wise variations in percentage of beneficiaries were highly significant. Of the five districts chosen, Kancheepuram had the highest number of MRMBS beneficiaries (44%), followed by Dharmapuri (35.7%), and Kanyakumari (29%). On the other hand Cuddalore (4.3%) and Nagapattinam district (6.8%) recorded the lowest percentage.

Table 3: Proportion Receiving Maternity Benefit Assistance for First and Second Deliveries (by Socio-economic Characteristics, November 2007November 2008)

Regression analysis indicates that caste, landowning status, occupation of the women and source of the first ANC had significant net effects on receiving the maternity benefits (Table 5). In comparison to women of other caste groups, the SCs/STs and MBCs women were 46% and 49% respectively less likely to receive the monetary benefits. Similarly women belonging to landless households had 63.5% less chances of getting the benefits while women employed in remunerative occupations had a greater likelihood of receiving the benefits as compared to women who were home makers. Mothers who had their first ANC in the government sector were three times more likely to avail of the schemes as compared to those who accessed the private providers.

Variables

% Received

Total N Chi-Square Value

Caste SC/ST 38 (25.33) MBC 27 (17.76) Others 41 (33.61) Landowning status Landless 80 (21.92) Land owned 26 (44.07) Education Illiterate 9 (33.33) Primary (1-5 years) 20 (33.33) Middle (6-8 years) 23 (19.01) Secondary and above (9 and above) 54 (25) Women’s occupation Household work 85 (22.85) Wage labourers 15(45.45) Salaried/small business 6 (31.58) Total 106 (25)

9.074* 150 152 122 13.3** 365 59 5.5 NS 27 60 121 216 8.72* 372 33 19 424+

Reasons for Not Receiving Benefits

+ Five were home deliveries of which two received the assistance. * significant at 0.05% level of significance. ** significant at 0.01 level: NS- Not significant.

Table 4: Proportion Receiving Maternity Benefit Assistance for First and Second Deliveries (by Source of Pregnancy and Delivery Care, November 2007- November 2008) Variables

% Received

Source of first ANC visit Public 91(29.35) Private 15 (13.16) Total 106 (25) Source of all the ANC visits No ANC 0 (0) Public 81 (28.02) Private 3 (6) Government and private 22 (26.19) Total 106 (25) Source of institutional delivery Government hospitals 53 (20.62) Government health centres 35 (45.45) Private hospitals 16 (18.82) Total 104 (24.82)

Total N Chi-Square Value

11.66** 310 114 424 11.43** 1 289 50 84 424+ 21.63** 257 77 85 419

+Five were home deliveries of which two received the assistance. * significant at 0.05% level of significance. ** significant at 0.01 level: NS- Not significant. Economic & Political Weekly

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june 23, 2012

Social and Economic Variables

About 9% mentioned that they were not aware of the scheme and its procedures. The remaining 3.5% said they were told they were ineligible since they had delivered in private hospitals (Table 6, p 22). Factors associated with not receiving the benefits varied significantly by caste. The proportion of those who had applied and not received the assistance was very high among SCs/STs (59.5%) followed by MBCs (56%) while it was only 34.2% among women from the higher castes. Similarly 25% among SC/ST women could not furnish the necessary documents while the percentage was much lower among women of other castes. Similarly, while among the landless 55.8% had applied and not received the benefit and another 20% were not able to provide the necessary documents, the corresponding figures for landowning households were 21% and 18% respectively. Non-eligibility based on economic status was the most important reason for not receiving the benefit among those who owned land. Anecdotal evidence indicates that often the MRMBS funds were allocated to all sections of the population and not restricted to the poorest or the SC/ST groups to avoid social repercussions – probably a backlash from the non SC/ST caste groups in the villages.

When we asked about the reasons for not receiving the benefits among mothers Conclusions with first and second order pregnancies, The state government’s initiative in prowe found that “applied but not received viding financial assistance to poor moththe money” was the top-most reason ers for improving their maternal health mentioned (52.2%) by non-beneficiaries. status has yielded good results in inSince the survey was conducted among creasing the rate of institutional delivery. women who had already delivered, some In particular, the utilisation of government of them several months Table 5: Effect of Social and Economic Variables on Accessing Benefits Variables N Odds ratio at 95% CI ago, this points to an unCaste* acceptable delay in paySC/ST 150 0.541459 (0.306244 - 0.957334) ment even when it did MBC 152 0.50762 (0.282511-0.912098) come through, thus defeatOthers Ref 122 ing the very purpose of Landowning status** Landless 365 0.364562 (0.199248-0.667035) the scheme. “Not able to Landowned Ref 59 provide the relevant docOccupation* uments” was the second Un remunerated 372 0.479577 (0.251342-0.915064) major reason (20%), folRemunerated Ref 52 lowed by another 15.4% Source of 1st ANC** Public sector 310 3.016853 (1.59111-5.720156) who reported that they Private sector Ref 114 belonged to the better 424 economic class (above Total -2 Log likelihood 439 poverty line) and were not Variable(s) entered step 1; Caste, Occupation, Landowning, and Source of 1st ANC. eligible for the scheme. * P< 0.05 ** P< 0.001.

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COMMENTARY Table 6: Reasons for Not Receiving MRMBS Assistance by Caste and Landowning Status (First and Second Deliveries, November 2007-November 2008)

Reasons for not receiving

Applied but not received the money Not able to provide the documents requested Not aware of the scheme and its procedures Above poverty line Others (private hospital delivery) Total

Caste Landowning Status Total Higher ‘Most Backward SC/ST LandLandless Castes Castes owned Numbers Numbers Numbers Numbers Numbers Numbers % (%) (%) (%) (%) (%)

26(34.2)

71(56.4) 69(59.5) 7(21.2) 159(55.8) 166

15(19.7) 10(13.6) 22(29) 3(4) 76

21(16.7) 11(8.7) 21(16.7) 2(1.6) 126

health facilities for pregnancy and delivery care is high. However, although aggregate statistics show that about half of the women received benefits from the MRMBS, many of the poor women who were eligible and needed the assistance did not receive it. One reason is the documentation required and the lengthy application process. However, the reasons as to why the proportion of those who applied did not receive the amount after completing all the formalities was substantially higher among the landless and the SC/ST women rather than the socially economically better-off groups are not clear. Overall, this study clearly shows that poorer women of the lower

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29(25) 6(18.2) 59(20.7) 6(5.2) 3(9.1) 24(8.4) 6(5.2) 14(42.4) 35(12.3) 6(5.2) 3(9.1) 8(2.8) 116 33 285

52.20

65 20.44 27 8.49 49 15.41 11 3.46 318 100.00

caste groups who need the assistance in large numbers did not receive it for varied reasons. However, the socially and economically better off had greater chances of availing the support. This is totally against the original vision of the policy. There were also significant differences across districts in the proportion who received the MRMBS benefits. Both these findings call for further investigation and good monitoring mechanisms to check implementation. The fact that a substantial proportion of women who had already delivered several months ago were yet to receive the benefits defeats the very purpose of the scheme, which

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was to provide nutritional supplements for the pregnant woman and compensate the loss of wages. Further, limiting coverage by the scheme to the first two deliveries results in the exclusion of women from the landless and socially marginal castes who need the assistance the most. It remains to be seen whether the revamped scheme of the newly elected government which has doubled the amount in terms of monetary benefits attends to and succeeds in addressing the gaps and issues which have emerged from this study. References Balasubramanian, P and T K Sundari Ravindran (2011): “Differentials and Determinants in Utilisation of Public and Private Health Facilities Reproductive Health Services; A Case Study from Rural Tamil Nadu, India”, A project report submitted to ARROW Malaysia, Rural Women’s Social Education Centre, Chengalpattu, Tamil Nadu. Data Obtained from Joint Director of State Bureau of Health Information (2009): Directorate of Public Health Department of Health and Family Welfare Chennai, Tamil Nadu. Government of Tamil Nadu, Annual Public Health Administration Report 2008-2009, viewed on 25 June 2011 (http://www.tnhealth.org/dph/ File6.pdf). Ramya Kannan (2011): “State Prepares to Dole Out Rs 12,000 as Maternity Aid”, The Hindu, Chennai Edition, 24 June, p 5.

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