The scale of implementation is very varied – many are national policies, with nationwide implementation, whilst others are more limited, and often supported by external partners. A brief description is given here of some of the main schemes.

# **Cash incentives**

There are two major national cash incentive programs currently described in the literature, both encouraging facility-based deliveries, in India and Nepal, although other as-yet-undescribed programs are starting in a number of other countries, such as Zambia.

In India, the Janani Suraksha Yojana (JSY) program was launched in 2005 to increase institutional delivery among the poor and hence reduce maternal mortality<sup>2</sup> . It is a nationwide program with central funding, but focussed on the states with low institutional delivery rates. Local associations or health workers are encouraged to identify women and support their access to a full package of pregnancy care, using a birth micro-plan. Cash assistance is available to all women in low-performing states delivering in public institutions or accredited private institutions, and to women over 19 and below the poverty line in higher performing states. Scheduled caste and scheduled tribe women receive support whatever the area in which they live. The tariff of payments is higher for rural than urban areas, to allow for higher transport and lodging costs, and includes an incentive payment to health workers in low-peforming states. The cash is provided by the health institutions, generally at the time of the delivery. The service itself is supposed to be provided without charge in public facilities.

For deliveries in private facilities, women receive cash but are not entitled to free delivery services, nor are the health workers eligible for the incentive payments. In low performing states, there is no limitation on the number of births, while in high performing ones, the limit is two live births. Caesarians are carried out free of cost, but where no public facility is available, assistance is provided to fund private care. For poor women who choose to deliver at home, are over 19 and have had fewer than two live births, Rs 500 is made available to support their costs. Some financial support is also given to women who volunteer for sterilization immediately after delivering.

In Nepal, the Safe Delivery Incentive Programme (SDIP) was also launched in 2005. The package of financial benefits offered by the SDIP sought to change the behavior of both families and health workers. The level of cash incentive offered to women was set to reflect differences in geographical accessibility to health institutions across regions, covering between a third and a half of the transport cost. Initially, free care was available in districts with a low human development index score. In January 2009, this was extended to all areas of the country, with the new Aama program (which combined fee exemption with the existing cash payments).

Since then, a range of DSF has been developed in Nepal, including for ANC, PNC, and uterine prolapse, as well as for PMTCT, multi-drug resistant TB and HIV/AIDS<sup>3</sup> . At present, women receive $7 in transport payment for deliveries in lowland areas, $14 in the hills and $21 in the mountains. The same payments are made for women undergoing treatment for uterine prolapsed. For women who have completed four

> 2 This information is taken from the Ministry of Health website.

> http://mohfw.nic.in/dofw%20website/JSY_features_FAQ_Nov_2006.htm

> 3 Scoping report for the National Health Sector Support Programme, Witter & Prasai, December 2010

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