Aama Surakshya Karyakram: Free Delivery & Cash Incentives in Nepal

The Aama Surakshya Karyakram, usually shortened to the "Aama Programme" (aama means "mother" in Nepali), is Nepal's flagship safe-motherhood scheme that makes institutional childbirth free at the point of use and pays mothers a cash incentive to help offset the cost of reaching a health facility. It is managed by the Family Welfare Division (FWD) under the Department of Health Services (DoHS) and the Ministry of Health and Population (MoHP), and delivered through government hospitals, primary health care centres, health posts and accredited birthing centres across the country.

The programme evolved in stages. The Government of Nepal introduced the Maternity Incentive Scheme (MIS) in 2005 (roughly 2061/62 BS) to help mothers meet transport costs. In 2006 it became the Safe Delivery Incentive Programme (SDIP), adding free delivery care in 25 low Human Development Index districts. In 2009 (about 2065/66 BS) it was renamed the Aama Surakshya Karyakram and free delivery care plus the transport incentive were extended to all women nationwide who deliver in an eligible institution.

Over time the scheme absorbed related benefits: in 2012 it merged with a Rs 400 incentive for completing four antenatal care (ANC) visits, and free sick-newborn care was folded in for a period. Because Nepal's constitution guarantees basic health care free of cost, the Aama Programme sits alongside the wider push toward free basic health services and, more recently, the National Health Insurance scheme.

The core promise of the Aama Programme is that giving birth in a government-recognised health institution costs the mother nothing for the delivery itself. User fees were removed from all types of delivery care in 2009, so normal (vaginal) births, deliveries with complications, and caesarean sections performed at accredited facilities are provided free of charge to the mother, with the facility instead reimbursed by the government.

The government reimburses the health institution a fixed amount per delivery, differentiated by the type of birth and the size of the facility. Indicative Aama Programme reimbursement rates are around Rs 1,000 for a normal delivery in a hospital with fewer than 25 beds and Rs 1,500 in a hospital with 25 or more beds, Rs 3,000 for a complicated delivery, and Rs 7,000 for a caesarean section. These payments cover the cost of care so it can be delivered free to the mother.

Antenatal care (ANC) consultations, postnatal care and, at many facilities, free family-planning services are also part of the safe-motherhood package. It is important to understand the distinction: the reimbursement amounts above go to the health institution to keep the service free, while the transport and ANC incentives described below are cash paid directly to the mother.

In addition to free delivery, the mother receives a one-time transport cash incentive, popularly called sutkeri bhatta, paid at the time she is discharged after giving birth in an eligible institution. The amount is graduated by ecological belt to reflect the higher travel costs faced by women in remote, mountainous areas.

The long-standing graduated rates are Rs 1,500 in the mountain (himal) districts, Rs 1,000 in the hill (pahad) districts including the Kathmandu Valley, and Rs 500 in the Terai (madhesh) districts. The payment is intended to contribute toward - not fully cover - the cost of travelling to and from the health facility.

These rates are set by the Aama Programme operational guideline and have been revised over the years; the Government of Nepal has at points announced a doubling of transport incentives (to around Rs 3,000 mountain / Rs 2,000 hill / Rs 1,000 Terai), and local governments may top up the amount from their own revenue. Because the exact figure and the geographic classification of your district are governed by the current-year guideline, confirm the payable amount at your birthing centre before you are discharged.

To encourage women to attend recommended antenatal check-ups, the Aama Programme pays a separate ANC incentive to a mother who completes four antenatal care visits at the schedule set by the government - traditionally in the 4th, 6th, 8th and 9th months of pregnancy - and then delivers in a health institution and receives postnatal care.

The incentive introduced when this scheme merged with the Aama Programme in 2012 was Rs 400, and this is the figure most widely cited. The Government of Nepal has since announced a doubling of the ANC incentive to Rs 800; the amount actually payable depends on the current-year Aama guideline in force at your facility.

The ANC incentive is conditional: a mother who skips the required visits, or who does not complete institutional delivery and postnatal care as specified, may not qualify. Attending the full ANC schedule is also the single most important thing an expectant family can do to detect complications early - the money is a bonus on top of safer care.

A caesarean section (CS) is fully covered for the mother when performed at a government-recognised CS-capable institution: the mother does not pay for the operation, and the facility claims a higher government reimbursement - indicatively around Rs 7,000 for a CS - to cover the greater cost of surgical care. Complicated deliveries (for example, those involving haemorrhage, eclampsia or instrumental delivery) are similarly free to the mother, with the facility reimbursed at a higher rate (indicatively around Rs 3,000).

Not every birthing centre can perform a caesarean. CS and other emergency obstetric surgery are provided at hospitals with Comprehensive Emergency Obstetric and Newborn Care (CEONC) capacity. Where a woman must be referred to such a hospital, the cost of the emergency referral transport has not always been covered by the Aama package, so families should ask the referring facility what support is available.

Because the higher CS reimbursement is paid to the institution rather than to the mother, a caesarean does not increase the transport cash incentive the mother receives at discharge - that amount still depends on the ecological belt of the facility.

Eligibility is broad: the benefits are intended for women who give birth in a government health institution, or in an accredited non-governmental or private facility that participates in the Aama Programme. Free delivery care and the transport incentive were extended to all women nationwide from 2009, without a limit on the number of children (the earlier parity condition was removed).

To claim the incentives smoothly, carry identity documents - typically the mother's Nepali citizenship certificate and her antenatal care (ANC) card or maternal health record, which proves the ANC visits needed for the ANC incentive. Keep the ANC card updated at each visit, as it is the main evidence for the four-visit condition.

There is no separate government office to visit: the money is handed over at the birthing centre or hospital where you deliver, generally at the time of discharge. Ask the ward or accounts staff for both the transport incentive and, if you completed four ANC visits, the ANC incentive, and check that you receive the full amount to which you are entitled - studies have found that some mothers are paid less than the correct sum, so it is worth confirming the figure before you leave.

The single biggest reason families miss out is not knowing what they are owed. Because amounts vary by ecological belt and by the current-year guideline, ask your health facility at your first ANC visit exactly what your district's transport incentive and ANC incentive are, and confirm again at admission. Keep the ANC card, discharge papers and any receipt.

Deliver at an eligible, government-recognised birthing centre. Home births and births at non-participating private facilities do not qualify for the free-delivery reimbursement or the cash incentives. If you may need a caesarean or have a high-risk pregnancy, plan to deliver at, or be referred early to, a CEONC-equipped hospital.

Finally, treat the cash as a supplement, not the goal. The main value of the Aama Surakshya Karyakram is that it removes the fee barrier to skilled birth attendance, which is what actually saves the lives of mothers and newborns; the sutkeri bhatta and ANC incentive simply make it easier for families to reach that care.