Data collated from a recent paper -studying the impact of the Covid-19 lockdown in 2020 by Jean Dreze and Anmol Somanchi reflect the grim condition of India’s looming malnutrition crisis.

In a co-authored essay around April 2020, we had argued how the “hidden costs of this pandemic” (and the administrative response to it) is likely to be most evident in a) the psycho-social costs emerging from the decline in incomes, rising unemployment for India’s most vulnerable population, and b) the nutritional distribution chart amongst the low social, economic groups (worst impacting women and children).

Dreze and Somanchi’s work, alongside other recent empirical findings, provide evidence for both these “hidden costs” now, more so for the latter.

A disturbing situation in India’s paradoxical nutritional landscape, where obesity ails India’s ultra-rich upper-class residents and malnutrition makes those at the bottom of the pyramid suffer, has been evident from the pre-pandemic period as well.

Undernourished mothers

Numbers from the 4th National Family Health Survey indicate how 53.1% of all women age 15-49 are anaemic. An alarmingly high rate of undernourished mothers results in low-weight, poorly nourished babies and infants, whose in-utero lack of nutrition can have lifelong consequences for them and their families. Twenty one percent of all children under 5 years remain unproductive or wasted (with low weight-to-height), as per India’s child wasting statistics.

In 2017, having recognised the critical importance needed to support maternal health and childcare, the government of India launched the Pradhan Mantri Matru Vandana Yojana – a centrally sponsored conditional cash transfer scheme.

Under the scheme, pregnant women and lactating mothers are entitled to Rs 5,000 for their first live birth subject to fulfilling certain conditions. The cash incentive is paid in three instalments with the first Rs 1,000 being awarded on early registration of the pregnancy at an anganwadi centre (often with the help of an Accredited Social Health Activist or ASHA worker).

Once the beneficiary receives at least one ante-natal check-up, they become eligible for the second instalment (of Rs 2,000). The Union government further complements this scheme with the Pradhan Mantri Surakshit Matritva Abhiyan that offers free, universal antenatal care to all pregnant women. The final instalment (Rs 2,000) is paid after the birth and immunisation of the child. Between the fiscal years of 2018 and 2020, almost 1.75 core eligible beneficiaries were paid Rs 5,931.95 crores.

By tying the cash-transfer to conditions, the government hoped to incentivise mothers to engage in undertaking basic (self) maternal and childcare. Meanwhile, the money provided offers financial support for the soon-to-be-mothers to meet their nutritional requirements.

However, the grassroot level implementation of such schemes has often remained blemished with structural flaws. For a start, the efficiency of conditional cash transfers has been brought into question given the high administrative cost (or “bureaucratic overload”) associated with factors like identifying eligible beneficiaries, targeting and monitoring the disbursements made to them, and ensuring that intended goals are met with a given scheme’s actual implementation.

Moreover, complaints about delayed payments of “assigned transfers” have been aggravated, especially since the pandemic.

Focus on pandemic

What’s startling is how, even after a year and a half since the pandemic hurt India’s citizens, particularly the poor, the government’s fiscal priority in allocating more funds to existing schemes still remains woefully low. the focus is only on providing public distribution system-supported food grains to the very poor as against supporting that with more funding for existing nutrition-focused welfare programmes.

In a rhetorical pitch to allocate most government resources towards the pandemic, budgetary outlays show how the Union government has abdicated its social and financial responsibility towards other equally serious health problems (click here for a discussion on poor implementation of existing family planning measures during the pandemic).

Pre-existing Union-sponsored schemes were allocated around Rs 2,500 crores every year for the last two fiscal years. But, in the financial year 2021-’22, the Pradhan Mantri Surakshit Matritva Abhiyan has been clubbed with other programmes under Mission Shakti for women’s protection and empowerment. By pooling in the budget of Rs 2,500 crores with other schemes, the effective allocation of Pradhan Mantri Surakshit Matritva Abhiyan has, therefore, significantly reduced.

Further, recognising the nature of logistical and administrative challenges posed by the pandemic, a recent study in the state of Rajasthan by IPE Global brings out micro-snapshots of poor health and nutritional programme implementation in places like Baran, Jhunjhunu, Jodhpur, and Udaipur during the 2020 lockdown period. The focus of the study was primarily on assessing the state of maternal and child care in Rajasthan during the pandemic.

Deterioration of healthcare services

Observed ethnographic findings from the report suggest how Maternal Child Health and Nutrition progammes were suspended, with regular health services like antenatal check-ups, immunisation, and child-growth monitoring being terminated for respondents across the state (much like the situation across the nation).

Meanwhile, reproductive healthcare workers (ASHAs and auxiliary nurse midwives) struggled to deliver adequate services to the public. Due to mobility restrictions, most reproductive healthcare workers were forced to work from home due to which physical tests and examinations were not conducted.

ASHA workers, anganwadi workers, and nurse midwives conducted counselling sessions online and provided supplementary tablets and contraceptive devices during house visits, but their services too were constrained due to administrative delays and shortage of tech-abled resources (most workers didn’t even have a smart phone for use).

Overburdened facilities

On-ground health workers were not provided enough Personal Protective Equipment so most respondent families refused to avail themselves of any physical help from these workers. We saw similar observations from our own centre’s field work in Lucknow.

Hospitals and government health facilities were overburdened by Covid-19 patients and were not able to provide adequate delivery services for non-Covid related treatment (including for high-risk pregnant women). With limited capabilities to afford the high fees of private hospitals, many rural women were compelled to opt for private delivery options that proved to be economically burdensome, and medically dangerous, for their families.

Further findings from surveyed districts across Rajasthan indicate how state government services eventually made up for the time and services lost in the initial phases. Towards the end of 2020, indicators of maternal health were nearly the same as it was in 2019, both state and district wise. Still, childcare took a more serious hit with the percentage of newborns weighing less than 2.5 kg rising in three out of the four districts surveyed.

Amidst falling incomes and a burdened state healthcare infrastructure, the robust functioning of Pradhan Mantri Surakshit Matritva Abhiyan was supposed to be critical during a public-health emergency. As per IPE’s report, only 27% of the registered beneficiaries received their three instalments 2020. A woman in Jhunjhunu in Rajasthan said, “It has been more than eight months since I submitted my documents. I have even had my child, but yet to get even the first PMMVY payment.”

Conditionalities associated with each transfer made it difficult for most beneficiaries to get their entitlements on time. Pregnant and lactating mothers struggled with access to nutrition when they needed it the most. Further, IPE’s findings from Rajasthan also reported that despite the meeting of conditions imposed on each entitled cash transfer, maximum beneficiaries still didn’t receive their instalment for months after the documents were submitted. The lack of direction and purpose marks a major red flag in evaluating the success of such ‘condition-based’ social programs.

Going forward, there is a lot for the Union and state governments to work on. Findings from districts of Rajasthan and Uttar Pradesh, as microcosmic case reflections, show how conditional cash transfers have limited effectiveness during times of crisis. Schemes like the Pradhan Mantri Surakshit Matritva Abhiyan are already troubled with bureaucratic overload and over-centralisation in due management of processing claims.

There are also challenges with details: for example, according to the Pradhan Mantri Surakshit Matritva Abhiyan’s original charter, the scheme’s eligibility remains applicable only for those women who are pregnant with their first child in the household while those mothers in the family who are pregnant with a second child will not be entitled to receive any support under the scheme. The reasons for which are unknown.

It is also about time that a renewed focus on improving community healthcare access through tech-abled, decentralised processes translates into an actual vision and action plan to include and ensure the well-being of all engaged key stakeholders, including the community health workers to recognise and treat their invaluable work and contributions on the ground with dignity.

The authors would like to thank Divya Balyan and Shipra Prakash along with their research team at IPE Global in Rajasthan for sharing their study and reported findings for this article. For insights on the field work in Uttar Pradesh by CNES, check our Visual Storyboard team’s video-essays, accessible here.

Deepanshu Mohan is Associate Professor and Director, Centre for New Economics Studies, Jindal School of Liberal Arts and Humanities, OP Jindal Global University.

Vanshika Shah and Advaita Singh are Senior Research Analysts with CNES.