Aama Program of Nepal

Aama Programme of Nepal

Aama programme is currently one of the important strategic approaches to achieve safe motherhood. This element is a way to achieve the strategy of national safemotherhood and newborn programme of Nepal to reach its goals and objectives.

The strategies of safe motherhood are:

• Promoting birth preparedness and complication readiness including awareness raising and improving the availability of funds, transport and blood supplies.
• Encouraging for institutional delivery.
• Expansion of 24‐hour emergency obstetric care services (basic and comprehensive) at selected public health facilities in every district.

It is basically a financial incentive scheme meant to assist women and her family financially for child bearing. This scheme first came as maternity incentive scheme. Maternity incentive scheme later evolved into Aama program in 2009. Under this scheme, certain amount of money is provided to women, health institutions and health workers in order to enable women to access health care and to encourage health care workers to provide quality care. This can also be termed as demand side financing.

Timeline

In 2005: Maternity incentive scheme (MIS): It provides specified incentives to women as a travel cost based on geographical region to deliver in health facilities in order to improve their health outcomes and those of their babies.

In 2006: MIS was renamed as the safe delivery incentive programme (SDIP)

In 2009: SDIP was further evolved into Aama Program, which comprises i) free institutional delivery care, characterized by the removal of user fees for all types of deliveries. (health centers provide the service free of charge and reimburse the amount of money later) and ii) the safe delivery incentive programme (SDIP), a cash incentive to women and care providers, which was initiated in 2005.

In July 2009: Aama Program also incorporated incentive to women, who completes 4 ANC visits and delivers their babies at health institutions and completes one postnatal visit.

Initiation

The Aama Programme was introduced to reduce financial barriers to women seeking institutional delivery. It aims to increase the number of institutional deliveries and thereby reduce maternal morbidity and mortality. The Aama Programme has evolved and matured over the years.

Factors for Initiation

  Number of factors played role in initiating Aama Program. Following are the major factors:

• Major financial support from UK, DFID: Prioritized safe motherhood
• Political commitment: government had a commitment to providing tangible benefits to the population.
• High cost of deliveries to household impeding institutional delivery

 

The Aama program is currently functioning in 1000 health institutions in the public sector, ranging from central hospitals to peripheral level health facilities. In addition it has started to enroll most not-for-profit institutions [community, mission and non-governmental organization (NGO)-run hospitals].

Cash payment to women	Incentives to the health facility	Incentives to health workers
For institutioonal delivery (ID): NPR 1,500 in mountain districts NPR 1,000 in hill districts NPR 500 in Tarai districts	NPR 1000 if <25 beds for a normal birth NPR 1500 if >25 beds for a normal birth NPR 3000 for a complicated birth NPR 7000 for a caesarean section (This amount includes the cost of drugs, supplies, instruments and the incentive to the health worker, and can be spent at the discretion of the health facility management committee)	NPR 300 per delivery at a health facility, paid out of reimbursement NPR 100 per delivery assisted at home (This has been reduced to promote institutional delivery) (The provider incentive (NPR 100) for attendance at home deliveries requires a birth registration form as proof that the health worker was in attendance)
NPR 400 will be given to woman if she attends 4 ANC visits at within first 4 months, Second visit: 6 months Third visit: 8 months Fourth visit: 9 months And must have an institutional delivery

Impact of AAMA programme:

Motivates mother and family for institutional delivery

Management of complications on time when they have institutional delivery

Reduce the cost of delivery care to households

Reduces the risk of catastrophic expenditure

Increases Antenatal care, thus helping in identifying the high-risk pregnancy early and allowing time to prepare mother and family for safe delivery

Decreases maternal mortality and morbidities

Lowers neonatal deaths and morbidities

A long way to go through: Critical Analysis:

There are no two opinions that it has played crucial role in increasing uptake of institutional delivery. Over 10 years from 1996 to 2006, the percentage of deliveries in a health facility in Nepal increased from 7.6% to 14%, and by 2009 this had further increased to 22.5%. The Aama programme has contributed to this increase, alongside many other policies including the earlier SDIP, training of SBAs and community factors, such as increased female education.

Aama program is a blanket approach; it provides specified amount of money to women based on geographical region regardless of their socioeconomic status.

Strengthening the capacities of existing health facilities is equally vital and must be identified by all the stakeholders, when the women and the newborns develop any complications, they should have all the capacities to manage it and efficient referral system that won’t delay their management.

Currently, there are 80 MOHP facilities in 53 districts that are able to provide basic emergency obstetric care services (BEOC), including complications not requiring surgery. In addition, there are 46 MOHP facilities in 33 districts able to provide comprehensive emergency obstetric care (CEOC) including caesarean sections (MOHP 2010). There should be expansion of BEOC and CEOC services even at the grass root level to the extent possible.

As the health centers are provided fixed amount of money per case, there is possibility that they tend to reduce the hospital stay and the indicated interventions. However on other side this might check unnecessary interventions that could have practiced if the fee for service payment system was existent.

The coverage of institutional delivery and skilled birth attendants remains low. The Skilled Birth Attendance Policy of 2006 has set a target of 60% of births to be attended by a trained health worker by 2015. However, according to Safe motherhood findings from Nepal Multiple Indicator Cluster Survey 2013, the percentage of skilled birth attendant at delivery is 55.6% and the percentage of Institutional deliveries is 55.2%. This clearly shows that we are halfway to the universal coverage of institutional delivery and skilled birth attendants indicating many women and newborns at risk while child bearing.

To reinforce this, in 2010, a Safe Motherhood Bill was drafted, which defines the rights of women to quality reproductive health care and maternal and newborn health care, and provides a legal framework, with accountability mechanisms, to enable them to exercise these rights.

To download national policy on skilled birth attendants: Click here

Sources:

• Bhusal CL, Singh SP, BC RK, Dhimal M, Jha BK, Acharya L, Thapa P, Magar A. Effectiveness and Efficiency of Aama Surakshya Karyakram in terms of Barriers in Accessing Maternal Health Services in Nepal. J Nepal Health Res Counc 2011 Oct;9(19):129-37
• Upreti SR; Baral SC; Tiwari S; Elsey H; Aryal S; Tandan M; Aryal Y; Lamichhane P; Lievens T: Rapid Assessment of the Demand Side Financing Schemes: Aama programme and 4ANC, 2012. Ministry of Health and Population; Nepal Health Sector Support Programme and HERD, Kathmandu, Nepal
• Baral G. An Assessment of the Safe Delivery Incentive Program at a Tertiary Level Hospital in Nepal.  J Nepal Health Res Counc 2012 Jan;10(20):118-24
• Department of Health Services. Annual Report. 2068/69.
• Ministry of Health and Population. National policy on skilled birth attendants. 2006. Nepal.
• Sophie Witter, Sunil Khadka, Hom Nath and Suresh Tiwari. The national free delivery policy in Nepal: early evidence of its effects on health facilities. Health Policy and Planning 2011;26.