Cash Transfers are becoming more and more popular in the developing world. Well-designed cash transfer programs are reducing poverty and suffering in the short term and creating a generation of healthier and better-educated people in the long term (UNICEF 2017). CCTs or conditional cash transfer programs transfer cash to poor and vulnerable households, on a precondition that those households make specific investments in improving human capital conditions, mostly focusing on children. Health, nutrition, education, and many other factors are monitored by the government and the cash transfer is strictly conditional upon the meeting of these prespecified conditions. Nearly every country in Latin America has a CCT program - and its success has prompted many Asian and African countries to follow in their footsteps. Bangladesh, Turkey, and Indonesia have large-scale, moderately successful CCT’s while other countries like Pakistan, Malawi, Cambodia, and many more have pilot programs in place (Baez and Camacho 2011).

Cash transfers help increase the incomes of the poor, facilitate reform and help people live with the negative economic shocks (UNICEF 2017). CCTs have evolved from being the prodigal social policy development from a select few Latin American countries to a worldwide phenomenon. Mexico’s Progresa (renamed as Oportunidades in 2001) started with around 300,000 beneficiaries in 1997 but has now expanded to cover over 5 million households ("A Model From Mexico For The World" 2014). The idea is simple but effective- give money to mothers to encourage them to send their children to school and the health centre. Brazil’s Bolsa Familia program, which provides a monthly stipend to mothers to ensure their children attend school on a regular basis benefits roughly 11 million families In Columbia, the program has expanded from its inceptive goal of 400,000 to 1.5 million beneficiary households in 2007 (Baird et al. 2014).

The nature of CCT’s varies greatly depending on where and how they are implemented. They are highly context-specific, their results show large disparities concerning coverage, the share of government spending, and generosity of benefits concerning consumption. The target audience also varies - they range from children (sometimes even from before birth) to senior citizens. These programs come under a large umbrella of welfare programs and are usually administered by the ministry of social welfare or other independent but public, government agencies.

Mexico’s Oportunidades is one of the most well-known examples of CCT - not only because it was one of the first programs to be carried out, but also because of its widespread reach and impact. Brazil is also a significant example - it’s evolution as a small program which covers only two provinces to one which is funded by 20% of the GDP is impressive (University of California at Berkeley 2006). The Chilean Solidario program is highly customized, with social workers working with vulnerable groups to tailor the program to get them out of extreme poverty as fast as possible, and only targets the country's extreme poor (Benhassine et al. 2015).

Beliefs About the Root Causes of Poverty

There are often a variety of beliefs about the root cause of poverty, which are often reflected in social policies targeting poverty. According to a range of surveys conducted by the World Values Survey about why people are poor, 61% of Americans, 68% of Chinese, 42% of Indians and 25% of Mexicans Believed that Poor people are poor because of laziness and lack of willpower. In contrast, 87% of Germans, 80% of Pakistanis, 78% of Brazilians and 66% of South Africans believed that poverty is a result of an unfair society.

There is some diversity in normative beliefs about the root cause of poverty throughout the global south. A sentiment which is common among both groups is that hard working people should not be poor and if such a person was poor, there is a need for a corrective measure to pull them out of poverty. This is why CCT’s get more bipartisan support across cultures compared to other welfare schemes (Myers and Dietz 2002). CCT’s are hardly ever perceived as a charity scheme; rather, a larger emphasis is placed on the social contract placed between the beneficiaries and the state, wherein cash transfers are paid to return for socially desirable behaviours (Stiglitz 2013).

The Need for Conditional Cash Transfers

An argument for the need for CCT’s can be made that governments must use these policy instruments not just to boost economic growth, but also to mark progress in human development frontiers. CCT’s can be used as an incentive to motivate certain socially beneficial behaviour. For instance, in many parts of South Asia, the education levels of girls substantially lag behind that of boys ("Gender Equality In Asia-Pacific Education: International Women’S Day 2018 Statistical Snapshot" 2021). This is due to strong son preference at birth, and perception of daughters as a liability(UNFPA 2021). This prejudice against daughters often results in neglect of girl children with regards to household resources. In such a context, cash transfer schemes can be used to improve investment in the health and education of girl children.

CCT’s are also cost-effective in that cash is cheaper to deliver to target groups rather than in-kind benefits like food. This also puts less accountability on the state and precludes governments to presume what individuals or families need, and gives agency to the beneficiaries to decide where they spend the money received for their context-specific developmental needs (Saavedra and Garcia 2013).

Limitations and Preconditions: CCTs are not a Golden Bullet

CCT’s are the appropriate policy response for some situations, but not so much for others. For instance, CCTs are suitable for addressing chronically poor and vulnerable groups who are experiencing negative externalities like health, food or transitory shocks. However, an important precondition for implementing CCT’s is that the target beneficiaries must have access to financial institutions like banks. Without this, it becomes extremely difficult for the target population to access the benefits and for the program to be implemented. This is why the suitability of CCT’s in India is doubted, where 165 million of its most vulnerable population is without a bank account, despite the efforts of Jan Dhan Yojana and similar schemes. Along similar lines, it is unwise to introduce CCT’s at a time when there is a disruption or shortage in supply of essential goods, like food grains, natural gas etc. This could have negative effects on the economy, with the new non-labour income accounting for the purchase of these essential goods, rather than investment in human capital. This is not counterproductive, simply that it is not the expected outcome. Besides, deploying CCT’s is discouraged when the targeted beneficiaries are not clearly defined or it is not feasible to target beneficiaries appropriately (Stiglitz 2013).

In Context: Maternal Health in India

There are four primary causes leading to high Maternal Mortality Rate in India - barriers to emergency care, gaps in continuity of care, poor referral practices as well as unaffordability (Kerber et al. 2007). Majority of the women who die at birth are very young, often younger than 25. A large number of the deceased women in India are from rural areas, backward caste and economically vulnerable communities living in remote hamlets were especially vulnerable (Sanneving et al. 2013).

The structural disparities in social and cultural indicators can shape health outcomes, and in turn, health inequities. Analyzing the social and economic determinants of maternal health can improve health outcomes in that domain as well. The United Nations Development Program developed a framework to assess the social and economic attributes of maternal deaths. The elements of this framework are (Kerber et al. 2007):

1. 1. Individual attributes (Like age, knowledge of services, obstetric history, etc.)
2. 2. Family characteristics (access to resources, economic status, support from natal and prenatal family)
3. 3. Community context (rural-urban disparity, social position- class, caste, ethnicity)
4. 4. Cultural and social norms (women's status, health beliefs, religion)
5. 5. Health services (availability of services, accessibility)
6. 6. Structural determinants (law, policy and budget)

A cultural absence of post and antenatal care also contributes to a high number of maternal deaths. Most health centers are not equipped to deal with women after childbirth, so the mothers were sent home soon after(Sanneving et al. 2013). There are little mechanisms to follow up with the mother. Many instances of mothers dying on their way to and back from a healthcare facility were documented. When faced with obstetric emergencies, the time taken to reach a health center via a designated vehicle also acted as a deterrent when it came to preventing maternal deaths.

Another barrier to tackling maternal deaths is the poor nutritional status of pregnant women. Some government interventions designed to tackle Indian women’s nutritionally backward have been unsuccessful (Wendt et al. 2018). For instance, while Iron and Folic Acid tablets( IFA) are an effective method to prevent anemia, about 65% of pregnant women then, but only 15% of women actually consume them for the recommended duration (Kumar et al. 2016).

There are some other social and cultural factors which have a relationship with the high Maternal Mortality Rate (MMR) in India. For instance, 27% of the women in Uttar Pradesh, a large state in India, get married before the age of 18 (UNICEF 2019). This leads to earlier child births and higher maternal mortality. There are some cultural norms which are detrimental to women’s health as well. Fore example, in many parts of the country it is a tradition for mothers and their newborns to be isolated for the first month after child birth in their prenatal homes. This isolation not only increases chances for postpartum depression, but also negatively affects the woman’s physical health as she has fewer resources available in isolation (Konar and Chakraborty 2012). Preference for sons is also an overarching determinant of maternal death (Agarwal and Milazzo 2021), especially with older women, the risk of maternal death increases with a longer obstetric history. Many women who don’t have sons are forced to move ahead with their fourth or fifth pregnancy to conceive a male child, in spite of the family being aware of the risk. Women’s absence of bodily autonomy combined with lack of decision making and a lesser value being placed on their lives have led to an acute problem of women dying in motherhood.

Cash Transfers to Improve Maternal Health: Introducing Janani Suraksha Yojana JSY (Safe Motherhood Scheme)

In 2005, the Government of India launched a national level CCT program, ‘Janani Suraksha Yojana’ (Safe Motherhood Program) to promote institutional births among vulnerable women. In 2008, funds worth USD $275 million were allocated to the program, making it the largest cash transfer program in the world (Randive, Diwan and De Costa 2013).

The incentives for the program vary geographically. Women giving birth in regions with relatively lower maternal mortality or infant mortality rates are eligible for the cash benefit for their first two live births, if they belong to the Below Poverty Line (BPL) (62 PPP USD in rural areas and 75 PPP USD in urban areas) category, or are a member of a scheduled caste/tribe. In regions with high maternal and infant mortality rates, all women who deliver in a public facility get a cash transfer. All health services availed from a public facility is free of cost. The biggest difference between JSY, and previous maternal health interventions is that JSY focuses on reducing demand side barriers by encouraging more women to access health facilities.

The money is transferred to the mother’s family via direct benefit transfers, wherein money is electronically transferred to beneficiary bank accounts. At the time of its inception, JSY was limited to poor women (having a government issued BPL card), who were 19 years or older, for their first two live births. However, vulnerability for maternal death increases with each birth - however this scheme, in its preliminary form excluded most women. Further, there were several conditionalities which were to be met to avail the payment, like mandatory visits to the birth facility before birth to receive antenatal care. However, supply side constraints like lack of medical professionals, transportation to healthcare facilities etc have made this impractical for women living in remote and inaccessible areas, and this condition was later removed in the implementation phase. Currently, 48 hour stay at the healthcare center after delivery is the only condition in practice and the rest of the conditions such as mandatory visits to birth facilities, the expiration of eligibility after the first two births etc. (Kumar et al. 2016).

Studies have shown that implementation of the JSY cash transfer program has led to a significant rise in institutional deliveries, and reduction in maternal and infant mortality rates (Gupta et al. 2012). However, supply side constraints like lack of life saving obstetric care and referral care, and poor quality of care in general still remain an obstacle to achieving safe motherhood for many new mothers. While CCT programs are very useful to change individual behaviours and increase public service delivery utilisation, supply side constraints can limit their impact on outcome.

References

• "A Model From Mexico For The World". 2014. World Bank. https://www.worldbank.org/en/news/feature/2014/11/19/un-modelo-de-mexico-para-el-mundo.
• Agarwal, Neha, and Annamaria Milazzo. 2021. "Son Preference, Maternal Health, And Women’S Survival: A Cross-Cultural Analysis". Ideas For India.
• https://www.ideasforindia.in/topics/social-identity/son-preference-maternal-health-and-women-s-survival-a-cross-cultural-analysis.html.
• Baez, Javier, and Adriana Camacho. 2011. "Assessing The Long-Term Effects Of Conditional Cash Transfers On Human Capital: Evidence From Colombia". https://ftp.iza.org/dp5751.pdf.
• Baird, S., C. McIntosh, and B. Ozler. 2011. "Cash Or Condition? Evidence From A Cash Transfer Experiment". The Quarterly Journal Of Economics 126 (4): 1709-1753. doi:10.1093/qje/qjr032.
• Baird, Sarah, Francisco H.G. Ferreira, Berk Özler, and Michael Woolcock. 2014. "Conditional, Unconditional And Everything In Between: A Systematic Review Of The Effects Of Cash Transfer Programmes On Schooling Outcomes". Journal Of Development Effectiveness 6 (1): 1-43. doi:10.1080/19439342.2014.890362.
• Barrera-Osorio, F., and D. Filmer. 2015. "Incentivizing Schooling For Learning: Evidence On The Impact Of Alternative Targeting Approaches". Journal Of Human Resources 51 (2): 461-499. doi:10.3368/jhr.51.2.0114-6118r1.
• Benhassine, Najy, Florencia Devoto, Esther Duflo, Pascaline Dupas, and Victor Pouliquen. 2015. "Turning A Shove Into A Nudge? A “Labeled Cash Transfer” For Education". American Economic Journal: Economic Policy 7 (3): 86-125. doi:10.1257/pol.20130225.
• "Gender Equality In Asia-Pacific Education: International Women’S Day 2018 Statistical Snapshot". 2021. UNESCO Bangkok. https://bangkok.unesco.org/content/gender-equality-asia-pacific-education-international-women’s-day-2018-statistics-snapshot.
• Gupta, Sanjeev. 2012. "Impact Of Janani Suraksha Yojana On Institutional Delivery Rate And Maternal Morbidity And Mortality: An Observational Study In India". Journal Of Health And Population And Nutrition. https://pubmed.ncbi.nlm.nih.gov/23304913/.
• Kerber, Kate J, Joseph E de Graft-Johnson, Zulfiqar A Bhutta, Pius Okong, Ann Starrs, and Joy E Lawn. 2007. "Continuum Of Care For Maternal, Newborn, And Child Health: From Slogan To Service Delivery". The Lancet 370 (9595): 1358-1369. doi:10.1016/s0140-6736(07)61578-5.
• Konar, Hiralal, and Asit Baran Chakraborty. 2012. "Maternal Mortality: A FOGSI Study (Based On Institutional Data)". The Journal Of Obstetrics And Gynecology Of India 63 (2): 88-95. doi:10.1007/s13224-012-0258-1.
• Kumar, Arjit, Beena Sachaan, Pankaj Bharadwj, and J P Srivastava. 2016. "A Study Of Utilization Of Janani Suraksha Yojana (Maternity Benefit Scheme) In Urban Slums". Indian Journal Of Public Health Research & Development 7 (2): 322. doi:10.5958/0976-5506.2016.00115.7.
• MoHFW. 2015. "National Family Health Survey". NFHS-4 FACT SHEETS FOR KEY INDICATORS BASED ON FINAL DATA: International Institute for Population Sciences.
• Randive, Bharat, Vishal Diwan, and Ayesha De Costa. 2013. "India’S Conditional Cash Transfer Programme (The JSY) To Promote Institutional Birth: Is There An Association Between Institutional Birth Proportion And Maternal Mortality?". Plos One. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0067452.
• Saavedra, Juan, and Sandra Garcia. 2013. "Educational Impacts And Cost-Effectiveness Of Conditional Cash Transfer Programs In Developing Countries: A Meta-Analysis". SSRN Electronic Journal. doi:10.2139/ssrn.2333946.
• Sanneving, Linda, Nadja Trygg, Deepak Saxena, Dileep Mavalankar, and Sarah Thomsen. 2013. "Inequity In India: The Case Of Maternal And Reproductive Health". Global Health Action 6 (1). doi:10.3402/gha.v6i0.19145.
• Stiglitz, Joseph E. 2013. The Price Of Inequality. New York: W.W. Norton. Superti, Luiz H. 2019. "Effects On Fertility Of The Brazilian Cash Transfer Program: Evidence From A Regression Discontinuity Approach". SSRN Electronic Journal. doi:10.2139/ssrn.3484588.
• UNFPA. 2021. "PREVENTING SON PREFERENCE AND UNDERVALUING OF GIRLS IN ASIA PACIFIC". https://asiapacific.unfpa.org/sites/default/files/pub-pdf/preventing_son_preference_and_undervaluing_of_girls_in_asia_pacific_0.pdf.
• UNICEF. 2019. "Ending Child Marriage A Profile Of Progress In India". New York. https://www.unicef.org/india/media/1176/file/Ending-Child-Marriage.pdf.
• UNICEF. 2017. "Making Cash Transfers Work For Children And Families". New York. https://www.unicef.org/lac/sites/unicef.org.lac/files/2019-11/Making%20cash%20transfers%20work%20for%20children%20and%20families.pdf.
• University of California at Berkeley. 2006. "Evaluating Brazil’S Bolsa Escola Program:Impact On Schooling And Municipal Roles". Berkeley. https://are.berkeley.edu/~esadoulet/papers/BolsaEscolaReport6-6.pdf.
• Wendt, Amanda S., Rob Stephenson, Melissa F. Young, Pankaj Verma, Sridhar Srikantiah, Amy Webb-Girard, Carol J. Hogue, Usha Ramakrishnan, and Reynaldo Martorell. 2018. "Identifying Bottlenecks In The Iron And Folic Acid Supply Chain In Bihar, India: A Mixed-Methods Study''. BMC Health Services Research 18 (1). doi:10.1186/s12913-018-3017-x.