SDIP had any impact on skilled birth attendance among the richest two-fifths of women. For these women, the SDIP simply encouraged them away from NGO or mission health institutions (where available) into government health institutions.

Inequality in the use of delivery care services provided by government health facilities means that the recipients of the cash incentive are disproportionately richer households. This is to be expected since there is no specific targeting of poorer households in the SDIP. Among women who were eligible and meant to receive the money, women with no education, unaware of the SDIP, living more than one hour from the health institution and Dalits were less likely to receive the cash.

## **Vouchers**

Most studies of vouchers schemes do not analyze differential uptake. For the STI voucher scheme in Nicaragua, there was no analysis of coverage of the target group, but the poor and those with more STIs were reported to be more likely to use their vouchers. For the Bangladesh MHV scheme, it contributed to reduced inequity in facility deliveries, but 49% of women in the top two quintiles benefited, even in targeted areas. By contrast, the Gujarat vouchers were well targeted but failed to cover all of the poor.

## **Social transfers**

Targeting of PROGRESA has been effective: 80% of its beneficiaries were estimated to be in the poorest 40% of the population (Gwatkin, Bhuiya, & Victora 2004), although later studies indicate that this may have dropped to 60%. It is very different in scale compared to many of the other DSF policies, however, covering 40% of rural households. Moreover, its targeting costs are substantial - estimated at 30% of total costs (Gertler 2000). For the Honduras BMI, it is reported to have reached 84% of its target group, but with 40% of beneficiaries in the top two quintiles.

# **Financial protection**

Reproductive health costs can be significant for households. However, while DSF schemes aim to improve the affordability of specific services, very few evaluation studies examine the impact of the policy on household spending on reproductive services or health care in general.

## **Cash incentives**

The SDIP evaluation (Powell-Jackson, Neupane, Tiwari, Morrison, & Costello 2008) is an exception: it concludes that the cash incentive protects a small proportion of households from catastrophic expenditure but fails to protect households from being forced into poverty that results from delivery care payments. In one district, Makwanpur, the cash incentive represented less than 20 percent of outof-pocket expenditure on institutional delivery care, an inadequate amount to reduce the impoverishing effects of these health care payments. In India the JSY scheme covered less than half the costs of women. In addition, around a third of women reported not having received the incentives (Lim et al. 2010).

## **Vouchers**

In general, vouchers are reported to have reduced user costs for services (unsurprisingly), but the significance of this in relation to household incomes or expenditure is generally not assessed. For the Bangladesh scheme, lower out-of-pocket payments by beneficiaries were recorded; however, only 6010