INDIA bears 25.4% of the global burden of malnutrition, although it only has 17% of the world’s population.¹ In 2015-16, 35% of India’s children were undernourished, only a small improvement from 43% 10 years earlier. The decadal decline in infant mortality rate (IMR), however, was more marked at 41 per 1,000 live births in 2015-16 compared to 57 in 2005-06.² And over that same 10-year period, the economy grew at roughly 7.8% per annum.

In addition to malnutrition, hidden hunger – the micronutrient deficiencies that occur when the intake of essential vitamins, minerals and amino acids is less than the level necessary for the growth and development of children and the maintenance of physical and mental functionalities in adults – is rampant among urban and rural populations. Nearly half the total population suffers from micronutrient malnutrition.³ This is one of the principal causes limiting India’s global economic potential.⁴ The World Bank reports that the annual cost of malnutrition in India driven by loss of productivity, illness and death is at least $10 billion.⁵

The crisis of malnutrition needs to be tackled in a targeted mission mode. This challenge is going to be even greater as the post-pandemic economy collapses, with GDP shrinking, unemployment increasing to an unprecedented level of 24%, and poverty increasing. Hunger will increase. Region-specific and innovative measures must be championed to ensure food security and proper nutrition to vulnerable groups such as pregnant women, children under the age of five, and adolescent girls. Globally, conditional cash transfers (CCTs) have proved to be an effective intervention for various developmental issues, including health and nutrition. In India too, several cash transfer schemes have been implemented by governments at the Centre and in the states. The present government is focused on reforming direct benefit transfers (DBT), which aim to increase cash payments flowing directly to the people. How to structure and combine cash transfers with other interventions is a key priority. This paper outlines how CCTs can be an effective solution to India’s burden of malnutrition.

 

Social protection, which gives poor and vulnerable households the resilience to withstand poverty, economic shocks and social discrimination and enables them to obtain food and healthcare, is recognized as an important strategy in improving maternal and child nutrition.⁶ A tool frequently used for social protection is a conditional cash transfer programme, which delivers cash directly to targeted households, usually poor and vulnerable groups. CCT programmes have increased considerably in number and size globally, pioneered by Mexico’s PROGRESA and Brazil’s Bolsa Escola programmes, which aimed to improve food security, health, and the nutritional and educational status of children.

In fact, Latin American countries were the first to introduce conditional cash transfers. Since then, there has been a growth in the number of Asian countries introducing such programmes including Bangladesh, Indonesia and the Philippines. India too has instituted such forms of social assistance for safe deliveries, nutrition supplements and for providing basic income in select cases.

There is strong evidence that CCT programmes improve household food security, increasing the resources available for household food consumption and thereby affecting nutritional status. The Lancet Series on Maternal and Child Undernutrition proposes interventions focused on children and estimates that through cash transfers to pregnant women and young infants, malnutrition and the disease burden could be reduced by 25% in the short term.⁹ In India, innumerable families grapple with the underlying determinants of child nutrition such as resources for food security, resources for childcare, and resources for access to healthcare and a safe environment.¹⁰

Cash transfers can directly address the burden of nutrition deficiencies in women, children and adolescents. They can, for instance, address one of the main reasons for poor uptake of health services in India – financial barriers. Post Covid-19, the need for an architecture for cash transfer to ensure a minimum income guarantee to poor and vulnerable households has been reinforced. A design for identifying beneficiaries, while keeping fiscal costs low, is already available.¹¹

 

In India, cash transfer programmes (especially CCT) have increased preventive healthcare visits and antenatal care-seeking. The Janani Suraksha Yojana is a case in point. It increased the percentage of institutional deliveries in India from 40.5% in 2002-04 to 47% in 2007-08¹² and has the potential to reduce maternal morbidity and mortality, improve child survival, and ensure equity in maternal healthcare in India.¹³ It is seen that households utilize the transfer to buy larger quantities of food and more nutritious and diverse food. In addition, there is strong evidence that CT programmes improve the mental health of beneficiaries, including reducing levels of stress.¹⁴ Studies also suggest that CT programmes may decrease domestic violence, which can positively impact maternal and child health outcomes.¹⁵

 

On the other hand, the administrative burden of conditional cash transfer (CCT) programmes is higher than that of unconditional cash transfers (UCT). The former involves monitoring household behaviour to assess compliance with conditions. It is not definitively clear that larger transfer size automatically mean greater impact. Evidence from the Transfer Project across sub-Saharan Africa suggests that transfers that are at least 20% of baseline household expenditures are more likely to have an impact on the intended outcomes.¹⁶

Demand-side interventions such as cash transfers are effective, but often require supply-side investments as well, particularly investments around provisioning of health services. And the duration of programme participation is crucial – evidence from Mexico and South Africa suggests that children who were exposed to the CT programme longer have better nutrition outcomes.¹⁷ However, in most cases, the pathways of impact have not been analysed and it is still unclear why some CT programmes have a significant impact on nutritional outcomes while others do not. Despite these ambiguities, conditional cash transfer programmes have become the preferred social intervention in developing regions of Latin America, Asia and Africa.

 

What are the five steps towards conditional cash transfers?

1. Effective targeting: Selecting the most eligible beneficiaries is the most important requisite of an effective CCT. A CCT must be designed to target poor households, for whom there is a stronger rationale to redistribute, but a narrower demographic target group would be poor households with young children in regions with high rates of malnutrition.

India has had a long history of redistributive poverty reduction programmes. A significant section of India’s workforce is in the unorganized sector, engaged in informal employment and characterized by low and irregular income. They need some social assistance in cash, in addition to public distribution of food and livelihood programmes such as the Mahatma Gandhi National Rural Employment Guarantee. In a globally integrated economy, social safety nets are even more relevant, but they work best when target populations are correctly identified.

2. Making banking systems efficient: Before a functional CCT system can be put in place, a corresponding efficient banking system needs to be expanded. That way the bank virtually comes to the beneficiary, rather than the latter going to the bank.¹⁸ What this means is that bank accounts of beneficiaries have to be Aadhaar-seeded, so that two beneficiaries don’t emerge in one household.

3. Restructuring ICDS: The Integrated Child Development Services (ICDS) Scheme,¹⁹ launched in 1975, is one of the Union government’s flagship programmes for early childhood care and development. It targets children and nursing mothers, and aims to break the vicious cycle of malnutrition, morbidity, reduced learning capacity and mortality. The ICDS has two components – the services component (immunization, health check-up, pre-school education, child growth monitoring by weighing) and the supplementary nutrition component (SNP). The SNP has two sub-components: one, hot cooked meals provided to 3-6 year-olds, and two, take-home rations given to pregnant and lactating mothers and 6-36 month-old children.

 

Firstly, the conversion of take-home rations for pregnant and lactating mothers and 6-36 month-old children into a cash transfer could improve the programme’s effectiveness.²⁰ Provided mothers of infants are appropriately counselled, they will use the cash to purchase complementary food resources for infants, especially after the six month period of exclusive breastfeeding is over. The introduction of semi-solid food for 6 month-old infants can reduce the malnutrition that affects half of all children by the time they are two years old. Pregnant mothers would be counselled by health service providers – accredited social health activists (ASHAs) and auxiliary nurse midwives (ANMs) – to use the cash transfer to consume a diet rich in protein energy content, and to purchase or prepare appropriate weaning foods for their 6-36 month-old children.

 

Secondly, most of the health-related ICDS services, currently being performed by the ICDS anganwadi worker (who comes under the ministry of women and child development), can be diverted to the health sector to be performed by primary health centres (PHCs), sub-centres and ANM and ASHA workers. The capacity of health workers to perform these functions of counselling pregnant and lactating mothers on breastfeeding and introducing weaning foods after six months of exclusive breastfeeding would need to be strengthened.

A major overhaul of the supply-side of services is also necessary, otherwise there is not much purpose in introducing CCTs which raise the demand for services. The ICDS worker and her helper’s functions should be reduced, so she can perform her tasks efficiently and build synergy with the PHCs, sub-centres, ANMs and ASHA workers. Thus restructured, the ICDS workers would focus on the hot cooked midday meals provided for 3-6 year-old children.

4. Revisiting existing subsidies: Another CCT that could positively impact levels of nutrition in India is the conversion into cash of all food subsidies presently given as cereals and sugar under the public distribution system (PDS) to households below the poverty line (BPL) and the poorest half of BPL households. The cash subsidy would be given to the same households, but the advantage of converting the food subsidy into cash transfers would be that it would reduce transaction costs for the government and reduce the diversion of PDS rice and wheat by middlemen for illegal profits.

 

As in the case of the other CCTs proposed earlier, the cash subsidy for purchasing food would require the transfer of money directly to the bank or post office accounts of the BPL/Antyodaya Anna Yojana (AAY) households. However, it would be appropriate to initiate a cash subsidy only in cities. This is because the availability of private sector shops that could supply the grain is not a problem in cities, while it may well be a problem in rural India.

5. Learning from pilot projects: The CCT would need to be piloted in a few cities before lessons can be learnt about the appropriate method of ensuring grain supply to BPL cardholders who receive cash transfers instead of grain subsidies. A promising CCT pilot undertaken by the Government of Bihar has the potential to be scaled up to address malnutrition. The Bihar Child Support Programme (BCSP) targeted pregnant women and mothers of young children, with the aim of reducing maternal and child under-nutrition. Under the scheme, women received Rs 250 per month if they enrolled after completion of the first trimester of pregnancy. The money was transferred directly into their bank account upon meeting certain conditions.

Further, they were eligible for the cash transfer for a period of 30 months (until the child was two years of age). The programme also designed a bonus of Rs 2,000. In one of the implementation blocks, the bonus would be received if the child was not underweight at age two, and in the other, women were eligible for the bonus if they had not become pregnant again at the end of two years after birth. Therefore, the potential total maximum value per child was Rs 9,500.²¹

The BCSP showed beneficiaries using the cash in a potentially ‘pro-nutrition’ way. They increased expenditure on food consumption and diversified the basket of food consumed, in addition to increasing expenditure on healthcare, sanitation/hygiene and childcare. Behaviourally, in most cases, the money was kept separate from general household expenditure. The additional cash was spent on fruits, green vegetables, dry fruit, dates and raisins. Many beneficiaries also bought milk and milk supplements.

 

This was matched by significant increases in maternal diet diversity as well as diversification of child diets, showing that the intended benefit of the cash transfer does indeed accrue to the mother and child. The social accountability effect of the programme was highlighted by the attendance of service providers – ANMs and ASHAs – on the Village Health Sanitation and Nutrition Day (VHSND). Overall, there was no evidence of leakage. Beneficiaries tended to withdraw their cash every couple of months rather than monthly, because of the cost and time required to visit the bank, and the unwillingness of banks to allow smaller withdrawals.²²

After reviewing the existing CCT schemes, the National Council of Nutrition led by NITI Aayog has also recommended pilot conditional cash transfer schemes in several districts across India. The think tank has suggested that CCTs be piloted in lieu of take-home rations at anganwadis in two districts each in Uttar Pradesh and Rajasthan.²³ These are important recommendations that need to be translated into policies by building convergence of multiple ministries²⁴ and instituting the direct benefit transfer scheme. This strategy of piloting small-scale interventions could yield rich policy lessons from regional and targeted CCTs, enriching present national nutrition policy and constituting a major agenda of government in the future.

 

However, it is important to reiterate that CCTs should not be introduced without three minimum requirements being put in place. First, the CCTs should correctly identify the poor in both rural and urban areas nationwide to ensure there are no exclusion and inclusion errors. Second, an identification system would need to be put in place to ensure that the intended beneficiaries are the ones receiving the funds, just as each beneficiary registered under the Janani Suraksha Yojana is provided a JSY card along with a mother and child health card.

Lastly, it is critical that an efficient banking system expands rapidly before a functional CCT system can be put in place. For this, the India Post Payments Bank can serve as the interface agency to utilize all of India’s 155,015 post offices as access points and the three lakh postal delivery personnel and Grameen Dak Sewaks who provide house to house banking services.

The three requirements for implementing CCTs are currently in place, so it would be appropriate to initiate some pilots on these CCTs so that policy lessons are learnt, and India moves ahead on tackling the burden of malnutrition.²⁵

 

India has a child malnutrition rate that is higher than the sub-Saharan Africa average,²⁶ although India has a higher per capita income, with faster GDP growth. Even Kerala, which ranks highest in India in terms of nutrition,²⁷ has child malnutrition rates similar to sub-Saharan Africa. It will be crucial to see how India charts its progress in tackling the burden of malnutrition. As India strives to improve the quality and accessibility of healthy nutritious food, what we should really be aiming to achieve is a transformative effect, wherein the improved nutritional status of our children, adolescents and women has a beneficial impact on learning in school and on productivity in work and labour.

The vulnerable groups would see the most direct positive impact on nutrition, gaining greater food sufficiency, improvement in diets, with a shift towards more vegetables, milk, eggs, fruit and meat. The urgency of these actions has only been reinforced by the Covid-19 pandemic. The combination of cash and the assurance of it over the forthcoming period under conditional cash transfers can be a crucial step in fighting malnutrition across the country. Active participation by synergizing efforts, combining experiences and expertise from all stakeholders, can usher in a nutrition revolution.

 

Footnotes:

1. India State-Level Disease Burden Initiative Malnutrition Collaborators, ‘The Burden of Child and Maternal Malnutrition and Trends in Its Indicators in the States of India: The Global Burden of Disease Study 1990-2017’, The Lancet (Child & Adolescent Health) 3(12), 1 December 2019, pp. 855-870. https://www.thelancet.com/action/showPdf?pii= S2352-4642% 2819%2930273-1

2. National Family Health Survey (NFHS-4, 2015-16).

3. H. Ritchie, D.S. Reay and P. Higgins, ‘Quantifying, Projecting and Addressing India’s Hidden Hunger’, Frontiers in Sustainable Food Systems, 30 April 2018. https://www. frontiersin.org/articles/10.3389/fsufs.2018.00011/full

4. J. Hoddinott, M. Rosegrant and M. Torero, ‘Challenge Paper: Hunger and Malnutrition’, presented at Global Copenhagen Consensus, 2012.

5. A.R. Measham and M. Chatterjee, Wasting Away: The Crisis of Malnutrition in India. Directions in Development, World Bank, Washington DC, 1999. http://documents.worldbank.org/curated/en/9373814687 50298803/Wasting-away-the-crisis-of-malnutrition-in-India

6. M.T. Ruel, H. Alderman and the Maternal and Child Nutrition Study Group, ‘Nutrition-Sensitive Interventions and Programmes: How Can They Help to Accelerate Progress in Improving Maternal and Child Nutrition?’, The Lancet 382(9891), 2013, 10 August 2013, pp. 536-551.

7. Oxford Policy Management, Bihar Child Support Programme, 2016. https://www. opml.co.uk/files/Publications/7597-improving-child-nutrition-maternal-health-bcsp/bcsp-executive-summary.pdf?noredirect=1

8. UNDP, Conditional Cash Transfer Schemes for Alleviating Human Poverty: Relevance for India. United Nations Development Programme, India, 2009.

9. Z.A. Bhutta et al., ‘What Works? Interventions for Maternal and Child Undernutrition and Survival’, The Lancet 371(9610), January 2008, pp. 417-440.

10. R. de Groot et al., ‘Cash Transfers and Child Nutrition: What We Know and What We Need to Know’. Innocenti Working Paper No 2015-07, UNICEF Office of Research, Florence, 2015.

11. S. Mehrotra, ‘A Minimum Income Guarantee Amidst Joblessness and Vulnerability: A Design for Income Transfers Post Covid-19 and Beyond’. ICRIER Occasional Paper, New Delhi, 2020.

12. A. Dongre, ‘Janani Suraksha Yojana – Institutional Deliveries and Maternal Mortality: What Does the Evidence Say?’, in India Infrastructure Report 2013: The Road to Universal Health Coverage. IDFC and Orient BlackSwan, 2014.

13. S.K. Gupta et al., ‘Impact of Janani Suraksha Yojana on Institutional Delivery Rate and Maternal Morbidity and Mortality: An Observational Study in India’, Journal of Health, Population and Nutrition 30(4), 2012. https://www.ncbi.nlm.nih.gov/pubmed/23304913

14. R. de Groot et al., 2015, op. cit.

15. Ibid.

16. B. Davis and S. Handa, ‘How Much Do Programmes Pay? Transfer Size in Selected National Cash Transfer Programmes in sub-Saharan Africa’. Innocenti Research Brief, UNICEF Office of Research, Florence, 2015.

17. L.C. Fernald, P.J. Gertler and L.M. Neufeld, ‘10-year Effect of Oportunidades, Mexico’s Conditional Cash Transfer Programme, on Child Growth, Cognition, Language, and Behaviour: A Longitudinal Follow-up Study’, The Lancet 374(9706), December 2009, pp. 1997-2005; J. Agüero, M.R. Carter and I. Woolard, The Impact of Unconditional Cash Transfers on Nutrition: The South African Child Support Grant. International Poverty Research Center Working Paper, 2009.

18. S. Mehrotra, Realising the Demographic Dividend: Policies to Achieve Inclusive Growth in India. Cambridge University Press, 2015.

19. Ministry of Women and Child Development, Government of India. https://icds-wcd.nic.in/icds.aspx

20. S. Mehrotra, 2015, op. cit.

21. Oxford Policy Management, ‘Bihar Child Support Programme: Impact Evaluation Endline Report’, 2017. https://www.opml. co.uk/files/Publications/7597-improving-child-nutrition-maternal-health-bcsp/bcsp-impact-evaluation-endline-report.pdf?noredirect=1

22. Ibid.

23. Business Standard, ‘Committee Constituted for Pilot Study on Conditional Cash Transfer in Lieu of Take-home Ration’, 21 December 2018. https://www.business-standard.com/article/news-cm/committee-constituted-for-pilot-study-on-conditional-cash-transfer-in-lieu-of-take-home-ration-118122101001_1.html

24. Ministry of Health and Family Welfare, Department of Financial Services, Department of Food and Public Distribution, NITI Aayog, State of Rajasthan, State of Uttar Pradesh, UNICEF, BMGF, DIMAGI etc.

25. S. Mehrotra, 2020, op. cit.

26. UNICEF, State of the World’s Children 2019: Children, Food and Nutrition: Growing Well in a Changing World. United Nations Fund for Children, 2019.

27. NFHS-4, 2015-16.