Safe Motherhood in Nepal

Between 2006 and 2009, the SSMP Equity and Access Programme (EAP), managed by ActionAid, has worked in selected VDCs of eight districts to increase equitable access to maternal and neonatal health care services. It adopted a targeted rights based, socially inclusive approach to demand creation, working primarily through women’s groups and networks and using the REFLECT methodology. While changes cannot be all directly attributed to EAP, comparison of household baseline and end-line survey data show great improvements in knowledge, attitudes and practices related to health care seeking across all caste groups including, importantly, a closing of the equity gap for several key indicators. Institutional delivery rates have doubled in the three year programme period, to approximately 50% of total births in the target areas, which is considerably higher than the national average of around 18%. The EAP provides important lessons related to targeting of poor and excluded communities, community mobilisation, voice capture, public private partnerships and engaging with health service providers to improve local health services. These potentially have high relevance to planning for the next phase of the Nepal Health Programme.

The high financial cost of delivery is an important barrier to accessing skilled attendance in Nepal. To help mitigate this barrier HMG Nepal has decided to implement a strategy to provide financial assistance through cost sharing to women seeking skilled delivery care. Although there were, and remain, sound reasons for piloting the strategy, or at least phasing it in, the Government believe that in the interests of equity the strategy should be implemented for the entire country at the same time.

The objective was to measure costs and willingness-to-pay for delivery care services in 8 districts of Nepal. Household costs were used to estimate total resource requirements to finance: (1) the current pattern of service use; (2) all women to deliver in a health facility; (3) skilled attendance at home deliveries with timely referral of complicated cases to a facility offering comprehensive obstetric services. The average cost to a household of a home delivery ranged from 410 RS ($5.43) (with a friend or relative attending) to 879 RS ($11.63) (with a health worker). At a facility the average fee for a normal delivery was 678 RS ($8.97). When additional charges, opportunity and transport costs were added, the total amount paid exceeded 5300 RS ($70). For a caesarean section the total household cost was more than 11 400 RS ($150). Based on these figures, the cost of financing current practice is 45 RS ($0.60) per capita. A policy of universal institutional delivery would cost 238 RS ($3.15) per capita while a policy of skilled attendance at home with early referral of cases from remote areas would cost around 117 RS ($1.55) per capita. These are significant sums in the context of a health budget of about 400 RS ($5) per capita. The financial cost of developing a skilled attendance strategy in Nepal is substantial. The mechanisms to direct funding to women in need must to be improved, pricing needs to be more transparent, and payment exemptions in public facilities must be better financed if we are to overcome both supply and demand-side barriers to care seeking.

In terms of implementation, a major strength of the NSMP was the use of innovative and robust methods for monitoring and research; KIM was specifically tailored for the Nepali context and the needs of NSMP and formed a central part of their monitoring strategy. The KIM tool is an adapted version of the Participatory Ethnographic Evaluation and Research (PEER) approach and is designed with the belief that the social context is a key factor in determining health and health-related behaviours. For NSMP this meant recognising that social context, as well as access, constraints are important in deterring women’s utilisation of quality midwifery and essential obstetric care services. This now forms a key aspect of SSMP’s support to the Government’s MNH strategy.

The DFID-supported Support to Safe Motherhood Programme (SSMP) supports Government of Nepal\'s National Safe Motherhood Programme (NSMP) by contributing to improved maternal & neonatal health. This support includes among others, inputs to enable the Family Health Division (FHD) to develop/review the long term National SM plan. The FHD has the responsibility to plan, manage, monitor and review maternity incentives scheme. The high financial cost of delivery is an important barrier to accessing skilled attendance in Nepal. To help mitigate this barrier Government of Nepal has decided to implement a strategy to provide financial assistance through maternity incentives scheme to women seeking skilled delivery care, skilled birth attendants. The scheme also provides subsidy to health institutions on the basis of deliveries conducted.