Increasing access to delivery services
Maternal mortality is a major global public health problem and despite significant advances remains the leading cause of mortality of women of reproductive age worldwide. According to the Nepal Demographic and Health Survey 2011, an overwhelming majority (64.7 %) of births took place at home. Lack of professional assistance at delivery is considered an important factor that contributes to high maternal mortality and morbidity.
We supported the Government of Nepal to initiate the Safe Delivery Incentive Programme (SDIP) under the maternal health financing policy in 2005 as a cost sharing scheme to increase access to safe delivery services for women. This programme has devolved and matured over the years into a national free care and financial incentive scheme that is available for all women delivering at both public and private health facilities. It has been a highly successful programme contributing to increasing institutional deliveries and thereby reduce maternal morbidity and mortality. Through our support to the Ministry of Health between 2004-2010, we worked closely to initiate, develop and monitor this programme now known locally as Aama, meaning mother.
We undertook a study looking at the burden of cost in maternal health. It identified transport costs as a major barrier to accessing professional assistance for deliveries. In 2004-2005, we supported the government to design and develop a policy to incentivise women to go to a health facility to deliver their babies, and guidelines for the Maternity Incentive Scheme (MIS). We adapted the MIS in 2006 into the Safe Delivery Incentive Programme (SDIP), which included financial incentives, and supported the introduction of free care in 25 low Human Development Index (HDI) districts.
In 2007, we introduced a six monthly monitoring system for SDIP, assessing fiduciary risk and reducing under and over claiming. This ‘rapid assessment’ still continues.
Between 2008 and 2010, after a successful pilot phase, we supported the expansion of the Aama programme to more districts and to 52 private facilities and reviewed its success in contributing to the increased number of institutional deliveries.
From 2010, our consortium partners OPM facilitated the merging of Aama with the 4 Antenatal Care incentive scheme (designed to encourage at least 4 ANC visits) and supported the government to address issues in the programme, such as improving fund flow and supported it to consider the incentive in light of the possible introduction of social health insurance.
Options and OPM have worked hand in hand with the government for over 10 years to develop and implement this innovative and widely respected demand side financing scheme that has had significant benefit to the government of Nepal and ultimately to improving maternal outcomes in Nepal.
- Development of the evidence based Aama incentive scheme.
- Introduction of free health care in 25 low Human Development Index (HDI) districts.
- Introduction of six monthly monitoring through rapid assessments.
- The Aama programme has contributed to increasing the percentage of women who completed 4 ANCs from 29% in 2006 to 60% in 2014 and institutional deliveries from 18% in 2006 to 55% in 2014.
- Linking cash payments to mothers for attending antenatal care and delivering at a health facility have given a 15-22% rate of return on the cost of introducing the changes and significant time saving for mothers.
Percentage of women who completed 4 ANCs has increased from 29% to 60% between 2006 & 2014
Institutional deliveries have risen from 18% to 55% in the same period