Conditional cash transfers are necessary but not sufficient for improving health. Good government-funded health care is essential, as are schemes which address social determinants of health.
The march of capitalism, with its reduced emphasis on public spending, while improving many national economies has also widened the gap between the rich and the poor. For millions of Indians, hunger is routine, malnutrition rife, employment insecure, health care expensive and livelihoods are under threat, arguing for an urgent need for social security. Over 80 per cent of the world's population lives in conditions without any guarantees to manage life's risks. The United Nations and other international agencies have argued that only 2 per cent of the world's Gross Domestic Product (GDP) is required to provide basic social security to the world's poor. They contend that such programmes provide growth with equity and are in the national interest of many countries.
Successful social protection programmes, many of them in South America, have demonstrated the use of innovative social security schemes and have countered capitalism's attempts to roll back social expenditures, cut deficits and finance fiscal stimulus packages for the economy. Argentina's universal child allowance programme and Brazil and Mexico's conditional cash transfer schemes are credited with reducing poverty and improving the health of populations. South Africa's Child Support Grants and Thailand's universal health care are also notable successes. Most of these schemes run on less than 0.5 per cent of national GDPs.
Redistributive transfers are not only desirable but are also hallmarks of civilised nations. They have multiplier effects and create more secure societies. Nevertheless, the philosophy, structures, economics and impact of these innovations are debated. Do they add to existing nutrition, health, education and employment services? Or do they replace existing public services and provisions? Are conditional cash transfer programmes a panacea to reduce poverty and improve health? Two schemes related to health are discussed here to highlight the complexity of the issues involved.
JSY a success: The Janani Suraksha Yojana (JSY) scheme is a conditional cash transfer (CCT) scheme to incentivise the use of health services. It is an intervention for safe motherhood and aims at reducing maternal and neo-natal mortality among poor women by encouraging institutional deliveries. It integrates financial assistance with delivery and post-delivery care for the mother and baby. The scheme also provides for the identification of pregnant women, antenatal care, assistance with transport and certification, postnatal care, and support and counselling services. Recent additions to these services include the cost of all medication and treatments, blood transfusions, consumables and diet. In some States, the scheme is complemented by the provision of public funds to private service providers in rural areas.
The programme has caught the attention of public health experts around the world for its scope, coverage and budget. The success of the scheme is currently being measured by the number of institutional deliveries, beneficiaries and financial assistance provided. Independent evaluations of the programme have confirmed its beneficial impact on antenatal care, health facility births and neonatal deaths. However, the assessment also noted wide inter-State and inter-district variations in the programme. It also documented the fact that the poorest and the least educated women had the lowest odds for enrolment.
While the JSY is a path-breaking initiative, its impact, when measured by maternal and child health outcomes, is dependent on the availability and accessibility of good health care services. Although the National Rural Health Mission (NRHM) has revitalised a neglected public health care delivery system, increased health finance, improved infrastructure, increased health personnel, established standards, trained health care staff, improved and streamlined health care delivery structures, many challenges still remain. The NRHM's functioning in its project mode and its competition with the State health services with their old ideas, platforms, ethos and morale complicate issues. These conflicts are not apparent in the evaluation of the NRHM with its focus on process indicators. For example, it records the monies spent on infrastructure, documents the increase in personnel, describes new priorities and records the recent benchmarks. However, there is a need to also evaluate indicators of efficient functioning. It needs to correlate its inputs and processes with health outputs in order to assess their effectiveness and to fine-tune its procedures. For example, data on the number of normal and complicated deliveries, maternal and neonatal outcomes should be correlated with the type of hospital infrastructure, personnel and health care provided. There is anecdotal evidence to suggest that 24 x7 health facilities with adequate medical staffing on their rolls continue to provide sub-standard care in violation of the established norms. The failure to document health outcomes of mothers and babies allows poor health care standards in many institutions to be masked by process indicators (e.g. institutional deliveries) employed for assessments. Unless good health care is provided at health institutions, CCTs for institutional deliveries will fall short of their goal of reducing infant and maternal mortality and improving standards of health.
Incentives for sterilisation: India's population policy with its narrow focus on surgical sterilisation, aided by incentives and coercion, resulted in disastrous consequences during the Emergency (1975-77). The vehement rejection, not just of the programme but of the government in power, made such measures taboo in the nation's public and political discourse.
And yet, sterilisation continues to be the sole population stabilisation strategy. While governments are conscious of avoiding coercive practices, incentives for tubal ligation and vasectomy continue to be provided. Vasectomy, despite its greater monetary value (compared to tubectomy), is not commonly accepted by Indian men. Its unpopularity is rooted in the cultural concepts of manhood and virility. Consequently, women continue to bear the responsibility for family size. However, the incentives for sterilisation have not reduced the fertility rate in many parts of India.
The correlation between family size, illiteracy and poverty, leads the naive and uninformed to conclude that the large number of children in each family is the cause of poverty, malnutrition and ill health. Little do they realise that for the uneducated and poor, larger the number of children, better their insurance and social security, particularly in their old age. The complete absence of social security forces the poor to rely on their children to provide the safety net. Class and caste issues interact and preclude universal explanations and call for a sensitive analysis of the context. Simplistic demographic transition models, which linked population growth to development without understanding non-European history, politics and contexts, have legitimised the argument that population control reduces poverty. The fact that poverty without social security results in increasing populations is rarely considered. Consequently, maps of “high risk” populations incorrectly identify the already marginalised groups (e.g. the poor, women, Muslims, Dalits, adivasis, etc.) for further stigmatisation. And yet, politicians, administrators and governments continue to emphasise contraception and sterilisation as the sole focus of population policies. Our current demographic approaches disregard questions of context, class, caste, religion and gender and classify people, us and them, based on narrow frameworks and value judgments. Without the provision of basic social security for the poor, the country's population will continue to increase. CCTs as tools to bring about social change, based on a simplistic understanding of issues, are doomed to failure.
Nuanced approach: CCTs are not a panacea for poverty, ill health or for stabilising populations. As related to health, they will deliver only within the context of an effective health care system. Without a good public health delivery system, the aim of CCTs to bring people to hospital, to obtain effective health interventions, will be defeated. The use of CCTs as a proxy for the delivery of good health care is fallacious. They may change health-seeking behaviour, but it requires a good health care system to reduce maternal and child mortality rates. Similarly, CCTs for population stabilisation, by rewarding contraception and sterilisation, without a basic social security net for the poor will not be utilised and will be ineffective.
CCTs are complex interventions and part solutions within a range of services provided for people. They cannot be an alternative to good health and social security services. Social determinants of health like clean water, sanitation, nutrition, housing, education, employment and social security play a major role in population health and growth. The use of CCTs should not result in the government abdicating its responsibility of providing public services to the poor. They should also not be viewed as another business opportunity for free market players. While recent efforts at improving health care delivery, food security and employment guarantee have made an impact, they have a long way to go before significantly influencing maternal and child mortality, family sizes and population numbers. CCTs are not complete solutions and call for a nuanced understanding of the strategy, context and issues.
(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)
