Contribution of Nepal’s Free Delivery Care Policies in Improving Utilisation of Maternal Health Services

Document Type: Original Article

Authors

1 Oxford Policy Management/NHSSP, Kathmandu, Nepal

2 Oxford Policy Management, Kathmandu, Nepal

3 University of Leeds, Leeds, UK

4 Volunteer VSO, Nepal

Abstract

Background
Nepal has made remarkable improvements in maternal health outcomes. The implementation of demand and supply side strategies have often been attributed with the observed increase in utilization of maternal healthcare services. In 2005, Free Delivery Care (FDC) policy was implemented under the name of Maternity Incentive Scheme (MIS), with the intention of reducing transport costs associated with giving birth in a health facility. In 2009, MIS was expanded to include free delivery services. The new expanded programme was named “Aama” programme, and further provided a cash incentive for attending four or more antenatal visits. This article analysed the influence of FDC policies, individual and community level factors in the utilisation of four antenatal care (4 ANC) visits and institutional deliveries in Nepal.

 
Methods
Demographic and health survey data from 1996, 2001, 2006 and 2011 were used and a multi-level analysis was employed to determine the effect of FDC policy intervention, individual and community level factors in utilisation of 4 ANC visits and institutional delivery services.

 
Results
Multivariate analysis suggests that FDC policy had the largest effect in the utilisation of 4 ANC visits and institutional delivery compared to individual and community factors. After the implementation of MIS in 2005, women were three times (adjusted odds ratio [AOR] = 3.020, P < .001) more likely to attend 4 ANC visits than when there was no FDC policy. After the implementation of Aama programme in 2009, the likelihood of attending 4 ANC visits increased six-folds (AOR = 6.006, P < .001) compared prior to the implementation of FDC policy. Similarly, institutional deliveries increased two times after the implementation of the MIS (AOR = 2.117, P < .001) than when there was no FDC policy. The institutional deliveries increased five-folds (AOR = 5.116, P < .001) after the implementation of Aama compared to no FDC policy.

 
Conclusion
Results from this study suggest that MIS and Aama policies have had a strong positive influence on the utilisation of 4 ANC visits and institutional deliveries in Nepal. Nevertheless, results also show that FDC policies may not be sufficient in raising demand for maternal health services without adequately considering the individual and community level factors

Keywords

Main Subjects


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  1. Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Policy Plan. 2004;19(2):69-79.  doi:10.1093/heapol/czh009
  2. Family Health Division, Ministry of Health and Population. Maternity Incentive Scheme, Implementation Guidelines. Kathmandu: FHD; 2005.
  3. Murray SF, Hunter BM, Bisht R, Ensor T, Bick D. Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2014;14:30. doi:10.1186/1471-2393-14-30
  4. Borghi J, Ensor T, Neupane BD, Tiwari S. Financial implications of skilled attendance at delivery in Nepal. Trop Med Int Health. 2006;11(2):228-237. doi:10.1111/j.1365-3156.2005.01546.x
  5. Family Health Division, Ministry of Health and Population. Aama Programme, Implementation Guidelines. Kathmandu: FHD; 2009.
  6. Family Health Division, Ministry of Health and Population. Aama Programme, Implementation Guidelines, Second Amendment 2009. Kathmandu: FHD; 2012.
  7. Powell-Jackson T, Mazumdar S, Mills A. Financial incentives in health: New evidence from India’s Janani Suraksha Yojana. J Health Econ. 2015;43:154-169. doi:10.1016/j.jhealeco.2015.07.001
  8. Powell-Jackson T, Hanson K. Financial incentives for maternal health: impact of a national programme in Nepal. J Health Econ. 2012;31(1):271-284. doi:10.1016/j.jhealeco.2011.10.010
  9. Witter S, Khadka S, Nath H, Tiwari S. The national free delivery policy in Nepal: early evidence of its effects on health facilities. Health Policy Plan. 2011;26 Suppl 2:ii84-ii91. doi:10.1093/heapol/czr066
  10. Ensor T, Bhatt H, Tiwari S. Incentivizing universal safe delivery in Nepal: 10 years of experience. Health Policy Plan. 2017;32(8):1185-1192. doi:10.1093/heapol/czx070
  11. Ministry of Health and Population. Nepal Demographic and Health Survey 1996. Kathmandu: Ministry of Health and Population, New ERA, and ICF International; 1997.
  12. Ministry of Health and Population. Nepal Demographic and Health Survey 2016: Key indicators. Kathmandu: Ministry of Health and Population, New ERA, and ICF International; 2017.
  13. Gopalan SS, Das A, Mutasa R. What makes Health Demand-Side Financing Schemes Work in Low-and Middle-Income Countries? A Realist Review. J Public Health Res. 2014;3(3):304. doi:10.4081/jphr.2014.304
  14. Sampling and Household Listing Manual, Demographic and Health Survey Methodology, Maryland, ICF International; 2012. https://dhsprogram.com/pubs/pdf/DHSM4/DHS6_Sampling_Manual_Sept2012_DHSM4.pdf.  Updated September 30, 2012. Accessed October 26, 2016.
  15. DHS Program: New User Registration. http://dhsprogram.com/data/new-user-registration.cfm.  Accessed September 19, 2015.
  16. Ministry of Health and Population. Nepal Demographic and Health Survey 2001. Kathmandu: Ministry of Health and Population, New ERA, and ICF International; 2002.
  17. Ministry of Health and Population. Nepal Demographic and Health Survey 2006. Kathmandu: Ministry of Health and Population, New ERA, and ICF International; 2007.
  18. Ministry of Health and Population. Nepal Demographic and Health Survey 2011. Kathmandu: Ministry of Health and Population, New ERA, and Macro International; 2012.
  19. Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. 1973;51(1):95-124.
  20. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10.
  21. Sagna ML, Sunil TS. Effects of individual and neighborhood factors on maternal care in Cambodia. Health Place. 2012;18(2):415-423. doi:10.1016/j.healthplace.2011.12.006
  22. Khanal V, Adhikari M, Karkee R, Gavidia T. Factors associated with the utilisation of postnatal care services among the mothers of Nepal: analysis of Nepal demographic and health survey 2011. BMC Womens Health. 2014;14:19. doi:10.1186/1472-6874-14-19
  23. StataCorp. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP; 2013.
  24. Sharma SK, Sawangdee Y, Sirirassamee B. Access to health: women’s status and utilization of maternal health services in Nepal. J Biosoc Sci. 2007;39(5):671-692. doi:10.1017/s0021932007001952
  25. Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria--looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9:43. doi:10.1186/1471-2393-9-43
  26. Stephenson R, Baschieri A, Clements S, Hennink M, Madise N. Contextual influences on the use of health facilities for childbirth in Africa. Am J Public Health. 2006;96(1):84-93. doi:10.2105/ajph.2004.057422
  27. Sunil TS, Rajaram S, Zottarelli LK. Do individual and program factors matter in the utilization of maternal care services in rural India? A theoretical approach. Soc Sci Med. 2006;62(8):1943-1957. doi:10.1016/j.socscimed.2005.09.004
  28. Navaneetham K, Dharmalingam A. Utilization of maternal health care services in Southern India. Soc Sci Med. 2002;55(10):1849-1869.
  29. Bennett L. Dahal D, GovindaSwami P. Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey. Kathmandu: New ERA, and Macro International; 2008.
  30. Filmer D, Pritchett LH. Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India. Demography. 2001;38(1):115-132.
  31. Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan. 2006;21(6):459-468. doi:10.1093/heapol/czl029
  32. Agho KE, Dibley MJ, Odiase JI, Ogbonmwan SM. Determinants of exclusive breastfeeding in Nigeria. BMC Pregnancy Childbirth. 2011;11(1):2. doi:10.1186/1471-2393-11-2
  33. Powell-Jackson T, Tiwari S, Neupane BD, Singh M. An early evaluation of the Aama “Free Delivery Care” Programme. Kathmandu: Nepal Safer Motherhood Programme; 2010.
  34. Bhatt H, Tiwari S, Sharma S. Implementation of Aama in Nepal’s Post Earthquake Situation. Family Health Division: Nepal Health Sector Support Programme; 2016.
  35. Jacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan. 2012;27(4):288-300. doi:10.1093/heapol/czr038
  36. O’Donnell O. Access to health care in developing countries: breaking down demand side barriers. Cad Saude Publica. 2007;23(12):2820-2834.
  37. De Brouwere V, Richard F, Witter S. Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn. Trop Med Int Health. 2010;15(8):901-909. doi:10.1111/j.1365-3156.2010.02558.x