Financial incentives for maternal health evaluation of a national programme in Nepal

People often behave in ways that are not in their best long term interest. Financial incentives are increasingly being used by governments to persuade individuals to improve health-related behaviours. In developing countries, financial incentives have been shown to increase uptake of preventive health interventions, but it is not well understood whether financial incentives are effective when targeted towards more complex types of care or when implemented at scale in low-income countries. This thesis explores the impact of financial incentives on health seeking behaviour, in the context of the Safe Delivery Incentive Programme (SDIP) in Nepal. Launched nationwide in 2005, the SDIP seeks to encourage greater use of professional care at childbirth by providing cash to women after they give birth in a health facility, as well as an exemption from user fees for those residing in the least developed districts. The thesis develops a theoretical model of the programme's causal pathway and draws on consumer choice theory to derive a set of predictions. These are tested empirically using a variety of econometric methods applied to household data (from a secondary data source and a primary data source). The analysis comprises three main parts. First, it estimates the demand for maternity care using discrete choice models to understand the most important factors influencing a household's decision of where to give birth. By focusing on the role of price, this analysis serves as an ex-ante evaluation of the SDIP. Second, it investigates implementation of the SDIP. The analysis uses a number of key process indicators that emerge from the conceptual framework to explore what factors may have constrained the implementation process. Third, it estimates the impact of the SDIP on health seeking behaviour at childbirth in two areas of Nepal using propensity score matching and longitudinal methods of analysis. It finds that the programme had a modest impact on utilisation of women who had heard of the SDIP, but because programme uptake was low, it has led to only a small increase in skilled birth attendance across the entire population. Implications for financial incentive programmes and maternal health care in low- income countries are explored.