Incentive programs

Several types of incentives were introduced over time as part of the safe motherhood plans. The Maternity Incentive Scheme was a key policy introduced in 2005 to decrease financial barriers to accessing maternal and newborn care services.⁴¹ This program made cash payments directly to all women who delivered in a government health institution. Shortly after it was established, it introduced incentives for health workers and health facilities. The payment to women varied according to geography—NPR 1,500 in the mountains, NPR 1,000 in the hills, and NPR 500 in the terai—to reflect the higher travel costs in mountainous areas.⁴¹ The payment was meant to contribute to the transport costs of reaching a health institution, not to fully compensate women for all travel expenditures they incur. Since the introduction of the Maternity Incentive Scheme, transport costs have been part of all subsequent programs.

In 2006, the Maternity Incentive Scheme was renamed the Safe Delivery Incentive Programme. User fees were removed for women, and free delivery care was introduced in 25 districts with the lowest Human Development Index.⁴¹ All 17 mountain ecological zone districts were among the 25 districts with the lowest Human Development Index, plus 8 hill ecological zone districts.⁴¹ Government health facilities were also paid NPR 1,000 for every delivery performed regardless of the complexity of the delivery or the length of stay.⁴¹ Additionally, health workers in these 25 Safe Delivery Incentive Programme districts received a payment of NPR 300 for each delivery conducted regardless of whether the delivery was in a health institution or at home.⁴¹

User fees were removed for all districts in 2009, making delivery care available free of charge to all Nepali women. The program was also expanded from government health facilities to additionally cover some certified NGO-run and private health facilities. Facilities that could not provide CEmONC services were given funds to support referral costs. The payment for health workers’ conduct of home-based delivery was also gradually reduced and eventually removed in 2009.⁴¹ Additionally, the government introduced the incentive program that paid women NPR 400 when they completed four ANC visits as well as delivery in a health facility and one postnatal care visit.

The Safe Delivery Incentive Programme policy to abolish user fees was implemented in response to concerns about the level of out-of-pocket expenditures in the National Health Accounts, as well as the belief that it was key for Nepal to achieve the Millennium Development Goals related to increasing in-facility births. This policy also reflected global evidence suggesting that the abolition of user fees was a key strategy for encouraging institutional delivery.

Nepal’s actions to develop the Safe Motherhood policies are one example of adaptive learning and implementation processes in the health sector.⁶ Over time, these policies were evaluated with local assessments, and adapted based on the evidence so that challenges could be addressed. For example, an evaluation of financial incentives for maternal health, published in 2012, suggested that many women did not know about the Safe Delivery Incentive Programme or did not receive payments even if they attended facilities.⁴² Following the report, the Family Welfare Division of the MOHP commissioned 10 rounds of rapid cross-sectional, mixed-method studies to appraise the program. The 10th rapid assessment was conducted in 2017 across 11 districts and 69 health facilities, gathering data about usage of the delivery, transport, and ANC incentives; budgeting; quality of care; and other topics.⁴³ In each round, discussions took place both at national and district levels about how to address and resolve identified problems. This resulted in adjustments to policies, funding amounts, management structures, and training programs, such as an increase in the incentive amounts in 2018, as reflected in Figure 29.⁴¹

Overall, the government in Nepal has prioritized access to maternal and newborn health via the safe motherhood plans, ultimately contributing to reductions in maternal mortality and neonatal mortality. A senior public health official shared their view:

National policy on skilled birth attendants

Nepal introduced its National Policy on Skilled Birth Attendants⁴⁴ in 2006 to improve the skill quality of maternal, newborn, and child health (MNCH) staff; the policy recommendations for doing so are outlined in Figure 30. A subsequent HRH strategy draft, produced in 2012, has also contributed greatly to the broader growth of HRH in Nepal. A range of improvements in quality of care across ANC, family planning interventions, and institutional delivery (described in the What Did Nepal Do? section) suggests that investments in human resources for health are paying off.⁴⁵

Skilled birth attendance has also increased since this policy was enacted, from 26.0% in 2006 to 81.5% in 2022.¹⁷ Data from the 2021 Health Facility Survey¹³ found that higher percentages of delivery care staff have undergone structured delivery care training: 53.2% of staff in federal and provincial hospitals, 53.4% of staff in local-level hospitals, 25.2% of staff in private hospitals, and 48.2% of staff in PHCCs. In 2020, the National Health Training Center recorded the training of 9,489 skilled birth attendants (SBAs) via actions introduced in this policy.⁴⁶

Nepal has developed a range of MNCH-specific trainings for various cadres to upgrade the skills of existing cadres. Some of these trainings are described by a senior nursing official as follows:

Upskilled staff are especially crucial to improve the quality of care in remote areas where human resources for health can be scarcer. This is emphasized by a senior nurse:

While upgrading existing cadres, Nepal is also in the process of training a new professional midwife cadre for skilled MNCH care. Several universities have established a bachelor's degree program in midwifery, and the first few years of graduates have completed the program as of 2023. Over the long-term, Nepal plans to transition to midwives as the frontline providers of maternal and newborn health services.

Evidence suggests that several challenges still remain in terms of reaching full coverage of skilled birth attendance, especially when implementing the policy in rural areas. An evaluation of the SBA policy, administered to 502 staff across 15 districts, was commissioned by the MOHP in 2018.⁴⁷ It found that some staff scored poorly on clinical skills assessments. One key explanation was that only 7% of SBAs—and even lower in the mountain ecological zone—met the World Health Organization bar of conducting 15 deliveries a month to maintain minimal competencies.⁴⁷ Nepal then initiated programs to address these issues, such as a follow-up and enhancement program for SBAs, which provided supportive supervision and in-service training.⁴⁸ As of 2021, this program had been implemented in 47 districts throughout Nepal.⁴⁸ Women are now encouraged to deliver in facilities with higher volumes of deliveries, where they will be cared for by better-trained staff who see a larger number of deliveries and thus able to maintain their skills for both normal and complicated deliveries. Gaps in geographic distribution of HRH in Nepal remain in rural and remote areas, with recent policies aiming to mitigate shortages of health professionals.

Nepal also released a new strategy for 2020 to 2025 for skilled health personnel and SBAs, as well as the national HRH strategy from 2021 to 2030.⁴⁶ These strategies build on the 2006 policy and previous HRH initiatives, recognizing the need to improve the skills, training, and deployment of SBAs. Actions to take include improving the modular training package for maternal and newborn health service providers, strengthening the guidelines for continuous professional development, improving opportunities for on-site mentorship, and deploying skilled health personnel to roles that match their skills.⁴⁶ The broader strategy continues to improve strategies to recruit, motivate, and retain HRH in Nepal.

Cross Country Synthesis

Cross Country Synthesis

Senegal

Brazil

Cross Country Synthesis

Cross Country Synthesis

Senegal

Brazil

Community Health Workers

Community Health Workers

Perspectives

What impact have CHWs had on health outcomes in the four CHW programs examined by the Exemplars in Global Health program?

Community Health Workers Are The Key To Fighting Covid-19 And Rebuilding Health Systems

How have the most successful countries balanced paying CHWs with sustainability concerns? Should all countries pay CHWs?

Technical Advisory Group

Sections

Appendix