Incentivizing universal safe delivery in Nepal: 10 years of experience.

Payments to users and providers of health services are an important ingredient in attempts to promote universal health coverage in low resource settings. The maternal health programme in Nepal explicitly recognizes that ensuring universal access to safe delivery care requires policies that both ensure effective services and overcome demand-side barriers. The programme has used three innovative financing initiatives to stimulate an increase in the use of facility-based delivery: the maternity incentive scheme (2005) reimbursing women for accessing a facility, activity payments in poor districts (2006) and universal free-delivery (2009). We examine the impact of these mechanisms on access to safe delivery services. Multiple waves of the Demographic and Health Survey were merged to provide household-level cross-sectional data on maternity services. A multilevel logit model was used to investigate the roll-out of the three policies across ecological zones assuming a district-wide treatment effect. An interrupted time-series approach that includes cross sectional data on deliveries at each period is used to detect the association between outcomes and policy. The maternal Incentive programme was associated with an increase in service delivery in hill and tarai areas. A positive effect in mountain areas was detectable as a result of the supply side payments made to facilities for delivery. Although use among the non-poor increased across the country, a positive effect on the poorest population was only present in mountain areas. The beneficial impact of maternal financing policies in Nepal is skewed towards areas and households that are geographically more accessible and wealthy. Inferior services in remote areas reduce the impact of financing policies. Policy may need to be refocused on poorer, less accessible areas if improvements in access to maternal health services are to continue.