NATIONAL ALLIANCE FOR MATERNAL HEALTH AND HUMAN RIGHTS (NAMHHR)

Indira Gandhi Matritva Sahayog Yojana (IGMSY) - A Civil Society Comment We, the civil society groups working on maternal health, maternal nutrition, right to health, right to food, womens rights and workers rights, welcome this scheme to provide compensation for the wage-loss in pregnancy and maternity, as well as the financial support for adequate nutrition in this period. o We hope that it will enable poor women to get adequate rest during this period and enhance their food intake. o We welcome the fact that the beneficiaries are not restricted to the certified BPL group, but will extend to all women. o We also congratulate the government for recognizing the important productive and reproductive roles women play in the economy of the country, especially women who are not employed by the government and belong to the unorganized or informal sector workforce. We would in addition like to put forward a number of concerns and suggestions related to this scheme, some of them concerning the design of the scheme, but others related to the implicit assumptions and values underlying such a scheme. Recommendations 1. Maternity entitlements be available to all women, without any conditionality. The Age Eligibility and Parity Criteria should be done away with. 2. Increase AWW and ANM services on priority basis to ensure pregnancy care and nutrition 3. Strengthen existing health systems to provide comprehensive maternity care. 4. Disburse money in a single instalment during pregnancy, corresponding as far as possible to days of wages lost for rest and breast-feeding [minimum wages x days lost (last month of pregnancy and at least two months after childbirth)] 5. Women have the right to support for childcare especially for exclusive breastfeeding while at work. There is urgent need for workplace initiatives for supporting women with infants and young children (less than 2years) through provision of crches, so a separate budget line is needed for breastfeeding support, including crches. Where there are no crches, there should be complete reimbursement of six months wages if exclusive breastfeeding is expected 6. Publicly specify framework of evaluation of the IGMSY scheme, including enhanced nutrition and health indicators. There is a need to set up some mechanism for periodic monitoring through research, in the pilot phase 7. Involve civil society in monitoring and evaluation; involve community women in social audit and local monitoring committees 8. In case of a system failure that prevents women from meeting the conditions, there needs to be an accessible grievance redress mechanism which poor women can easily use; with a report on prompt action taken.

A. Fundamental Concerns relating to the scheme I. Equity concerns: Although the scheme has the potential to enhance the nutritional status and compensate for wage loss of informal sector women workers; yet those from the most vulnerable sections of society would find it most difficult to satisfy many of the proposed conditions. To be at a clinic and/or to approach a health provider several times during their pregnancy would mean investing scarce financial resources and time. Poverty and genderpower inequalities pose major hurdles for women to access health care services. Similarly, barriers to breastfeeding have been ignored, and no steps taken to concurrently create supportive conditions at work to support women to continue breast feeding, such as crches and nurseries, especially in the unorganized sector. Women below 19 and with more than 2 children who have been excluded from this scheme will actually need support from the state. This is again denial to those who need these services as much if not more than the others. If the IGMSY is meant to compensate for wage loss or to pay for additional nutrition for the mother, then there is no room for imposing a list of conditions. A constitutional entitlementi cannot be made conditional. In this regard the ruling of the Honourable Supreme Court dated November 20th 2007 on National Maternity Benefit Scheme is to be noted, which states that benefits will be given " irrespective of number of children and the age of the women. II. Design related concerns: The evidence base for formulating such a scheme needs to be analysed in great detailwhether cash incentives have led to improved nutritional intake or access to quality health services, without investments in strengthening the existing health system The scheme is based on conditions regarding health-seeking behaviour of women, thus it can be seen as a demand-side intervention. There appears to be an implicit, and perhaps erroneous, assumption that poor maternal-neonatal health is due to lack of demand for services. Further, in this way, all the social determinants of health are being ignored and no structural changes are being introduced. The scheme seems to imply that womens health will improve just by attending antenatal care and counselling sessions, without altering many of the conditions that make them unwell in the first place. III. Effectiveness of intervention: If we analyse the data on the condition of existing maternal health services in many parts of India (refer DLHS3, 2007-2008), it becomes clear that the limitations of supply of services have not been adequately acknowledged or addressed. Quality of care and abusive provider behaviour has often been cited by poor women as important barriers to accessing health care. DLHS-3 (2007-08) figures indicate that the local sub-centres and PHCs may not be in a condition to ensure availability of essential care in many states, yet conditions for the cash transfer relate to accessing care from these centres. Conditional cash transfers at the end of two trimesters of pregnancy are unlikely to be able to improve significantly the nutritional status of women suffering from

chronic malnutrition and severe anaemia which makes delivery difficult; and therefore maybe too late an intervention Unconditional food security for all women, without any conditions, is a primary requirement for the improvement of maternal nutrition, reduction of maternal anaemia and prevention of maternal mortality, which is caused to a significant extent by high rates of anaemiaii.

IV. Accountability related concerns: Significant problems have been noted in JSY in fund administration and disbursement and there are serious concerns relating to leakages and corruption. The scheme does not announce any measures to reduce these, although it is a similar demand-side intervention. What is the accountability mechanism of the Scheme, what will be the methods of grievance redress? V. Payment related concerns: Since the conditions for the JSY vary in different states, some women may be disqualified for the JSY while qualifying for this scheme. This would mean a significant time period with no maternity benefit. What are the benefits for women who have childbirth at home? Will they continue to additionally receive the NMBS (Rs 500) as mandated by the Honourable Supreme Court? (At present Court orders are being violated in many states) What are the benefits for a woman who experiences a stillbirth or neonatal/ infant death? Are women having third or higher order pregnancies eligible to benefit under this scheme if they do not have two surviving children (given that the JSY disqualifies these women in some states)? If the women are unable to fulfil the conditions because of a lack of available maternal health services (for registration, ante-natal care and immunization), will this disqualify them from all the benefits? What if women are unable to breastfeed exclusively for six months owing to lack of crches at the workplace? Are migrant women eligible to benefit from this scheme? VI. Launch of the scheme: What is the mechanism of the Government to introduce this scheme before the public? When does it actually come into action? Will this announcement include the details of maternal and nutrition services actually available (and accessible) for women, especially those required in order to fulfil the conditions? How is the scheme going to be monitored in the pilot phase, according to which indicators? Will the findings be made public? How is civil society being involved in the design, planning, implementation, monitoring and evaluation of the scheme?

[Acknowledgement: Prepared with inputs from many allies and individuals working on maternal health and rights in India]

As per Article 42, the state should make a provision for securing just and humane conditions of work and maternity relief. Eleven years after the Constitution was adopted, the Parliament enacted the Maternity Benefit Act in 1961. The law was enacted following convention of International Labour organisation which guaranteed maternity protection to women, as well as wages for three months, irrespective of their age, nationality, race or creed with effect from Sept 7, 1955. ii The Registrar General revealed that of the 70 to 80 thousand maternal deaths in India each year, 38% can be attributed to heavy bleeding (hemorrhage), 11% to infections (sepsis), 8% to unsafe abortions