Sunday, April 18, 2010

Saving India’s women

Livemint, April 4, 2010 : Analyses of social factors, which determine the impact of central programmes, can shape policies to save women’s live

Nirvikar Singh

Gendercide. That was how a recent Economist magazine cover story described the problem of 100 million girls and female foetuses being killed around the world, with population giants India and China being among the worst offenders. Changing this state of affairs will be a huge task, involving changing attitudes as well as incentives, working throughout the web of economic and social relationships that devalue women in many societies. Dowry practices, women’s access to the labour market and entitlement to inheritances, psychological biases and hurts that get passed on through generations, and many other factors come into play.

In India, the National Rural Health Mission includes specific efforts to tackle problems such as high maternal mortality ratios. This may not be the worst problem area for women, but it represents a place where specific, tangible public policy interventions can be designed and implemented. One such intervention is the Janani Suraksha Yojana (JSY), literally, the mothers’ protection plan. The scheme is narrower than this name might suggest, though the spirit embodied in the programme title is welcome. JSY provides monetary incentives for pregnant women to go to health facilities such as government-run community health centres for delivering their babies. Institutional deliveries reduce maternal mortality to the extent that complications can be tackled immediately and adequately, and there is better overall hygiene in such environments.

An important link in the chain are accredited social health activists (ASHAs), who are also given monetary rewards for bringing pregnant women to healthcare facilities for their deliveries. Other facets include counselling, antenatal care, and some post-natal monitoring. It will take time to see how exactly the scheme is changing health outcomes, but there is already evidence that institutional deliveries have increased. Over 10 million women have availed of JSY, and though it is hard to say how many of these would have gone to a health centre anyway, even in those cases, the scheme provides a timely and targeted income supplement.

Government reports tend to give percentages and numbers—they do not typically sort out causes and effects. That can only be done unambiguously through controlled experiments. However, examining patterns across India’s vastness can be revealing. Ambrish Dongre, at my university, has been looking at precisely this issue. He begins by asking the question, “What factors influence a woman’s benefiting from the JSY?” Do caste, wealth and education matter? Does it matter how big the village is, or how developed it is? Do ASHAs really make a difference? And how does distance from the nearest health facility affect the woman’s choice?

To answer these questions, Dongre looks separately at two groups of states. Those with low institutional delivery rates (such as Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan and Jammu and Kashmir) provide JSY benefits to all women going to government health centres. High-performing states (which include middle-income states) have some age, poverty status and caste restrictions on who is eligible: Hence, they must be analysed separately. Interestingly, in the low-performing states, scheduled caste women appear to be more likely to be beneficiaries than other castes, but in the other states, the benefits are somewhat more widely spread. In both groups of states, the benefits are spread across different wealth classes. A strong result in both types of states is that lack of education reduces the likelihood of a woman benefiting from JSY. This illustrates the complexity of even targeted interventions—if tackling maternal mortality requires educating women, a much broader and deeper intervention is required. But, of course, educating women ought to be a prime social goal in its own right.

In the low-performing states (but not the other group), having an illiterate husband also reduces the likelihood of the woman benefiting from JSY. Some other external or social effects are also striking. Developmental characteristics such as greater village size, or presence of a bank or post office, have positive effects. Importantly, local governments that are engaged in health-related decisions overall seem to be good for women’s choices with respect to JSY. The presence of other beneficiaries of the scheme matters positively, as does the presence of an ASHA. Distance from a health facility acts as a deterrent. Much of this is not surprising, but it confirms an approach to development and policy intervention that has been gaining steam. Even if targeting is not ideal, money, new ideas and institutional innovations can shake things up and begin processes of change.

Increasing institutional deliveries will reduce maternal deaths, but it will not directly reduce gendercide. Dongre’s analysis of which factors affect whether women benefit from JSY shows us how policy interventions interact with initial social and economic conditions. Studies such as Dongre’s can give us insights into designing future policies to save far more Indian women and girls.

Nirvikar Singh is a professor of economics at the University of California, Santa Cruz. Your comments are welcome at

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