Cash Incentives for Maternity Care: Impact of Nepal's Safe Delivery Incentive Programme

Presenter: Timothy Powell-Jackson, London School of Hygiene & Tropical Medicine

Abstract

Background: Nepal's Safe Delivery Incentive Programme (SDIP) provides a conditional cash transfer to women who deliver in a public health facility, an incentive to providers for each delivery they attend and, in some parts of the country, a user fee exemption. The programme, the first of its type in a low-income country, was introduced in 2005 across the entire country with the purpose of increasing use of professional care at childbirth.

Objective: The paper assesses the targeting of the programme and estimates the impact of the conditional cash transfer on utilisation of maternity services.

Methods: The analysis draws on data from a household survey of women who recently gave birth, designed specifically to evaluate the SDIP. The impact of the conditional cash transfer on utilisation of maternity services is estimated using propensity score matching on a trimmed sample to ensure comparability between the treated and the untreated group.

Findings: Wealthier, more educated and less marginalised women were found to have knowledge of the programme during pregnancy, suggesting rollout of the SDIP has, unintentionally, favoured these groups. Recipients of the conditional cash transfer were disproportionately wealthier households reflecting inequality in the use of public health providers and the fact that the SDIP does not target specific groups. Single difference estimates of impact indicate that the SDIP has increased the proportion of women who deliver with a skilled attendant. The impact differed by wealth group. The poorest three-fifths of women were highly incentivised by the conditional cash transfer, with impact estimates indicating a 64-66 percent increase in utilisation. Meanwhile, there was no evidence the SDIP increased utilisation among women in the richest two wealth quintiles; it simply encouraged a shift away from private providers to public providers.

Conclusion: Large scale conditional cash transfer programmes can work in low-income settings where the capacity of government to manage is constrained. Limiting the SDIP to the public sector crowded out the private sector. The cash transfer offered by the SDIP represents only a fraction of the cost of health seeking at delivery and therefore, by incentivising greater use of services, risks exposing more households to catastrophic payments.