The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal.
BACKGROUND
Nepal's Safe Delivery Incentive Programme (SDIP) was introduced nationwide in 2005 with the intention of increasing utilisation of professional care at childbirth. It provided cash to women giving birth in a health facility and an incentive to the health provider for each delivery attended, either at home or in the facility. We explored early implementation of the programme at the district-level to understand the factors that have contributed to its low uptake.


METHODS
We conducted in ten study districts a series of key informant interviews and focus group discussions with staff from health facilities and the district health office and other stakeholders involved in implementation. Manual content analysis was used to categorise data under emerging themes.


RESULTS
Problems at the central level imposed severe constraints on the ability of district-level actors to implement the programme. These included bureaucratic delays in the disbursement of funds, difficulties in communicating the policy, both to implementers and the wider public and the complexity of the programme's design. However, some district implementers were able to cope with these problems, providing reasons for why uptake of the programme varied considerably between districts. Actions appeared to be influenced by the pressure to meet local needs, as well individual perceptions and acceptance of the programme. The experience also sheds light on some of the adverse effects of the programme on the wider health system.


CONCLUSIONS
The success of conditional cash transfer programmes in Latin America has led to a wave of enthusiasm for their adoption in other parts of the world. However, context matters and proponents of similar programmes in south Asia should give due attention to the challenges to implementation when capacity is weak and health services inadequate.
Powell-Jackson
Timothy
T
Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK. Timothy.Powell-Jackson@lshtm.ac.uk
Morrison
Joanna
J
Tiwari
Suresh
S
Neupane
Basu Dev
BD
Costello
Anthony M
AM
D005260:Female; D005382:Financing, Personal / Q000191:economics*; D017144:Focus Groups; D006293:Health Promotion / Q000191:economics*; D006302:Health Services Research; D006801:Humans; D007407:Interviews as Topic; D008427:Maternal Health Services / Q000191:economics*; D009042:Motivation; D009390:Nepal; D010349:Patient Compliance; D011247:Pregnancy