Effect of a multifaceted social franchising model on quality and coverage of maternal, newborn, and reproductive health-care services in Uttar Pradesh, India: a quasi-experimental study

Persistence and heterogeneity of the effects of educating mothers to improve child immunisation uptake: Experimental evidence from Uttar Pradesh in India

Childhood vaccinations are among the most cost-effective health interventions. Yet, in India, where immunisation services are widely available free of charge, a substantial proportion of children remain unvaccinated. We revisit households 30 months after a randomised experiment of a health information intervention designed to educate mothers on the benefits of child vaccination in Uttar Pradesh, India. We find that the large short-term effects on the uptake of diphtheria-pertussis-tetanus and measles vaccination were sustained at 30 months, suggesting the intervention did not simply bring forward vaccinations. We apply causal forests and find that the intervention increased vaccination uptake, but that there was substantial variation in the magnitude of the estimated effects. We conclude that characterising those who benefited most and conversely those who benefited least provides policy-makers with insights on how the intervention worked, and how the targeting of households could be improved.

Markets, incentives, and health promotion can improve family planning and maternal health practices: a quasi-experimental evaluation of a tech-enabled social franchising and social marketing platform in India

BACKGROUND

Improving family planning and maternal health outcomes are critical to achieving the Sustainable Development Goals. While evidence on the effectiveness of government-driven public health programs is extensive, more research is needed on effectiveness of private-sector interventions, especially in low- and middle-income countries. We evaluated the impacts of a commercial social-franchising and social-marketing program - Tiko Platform - which created a local ecosystem of health promoters, healthcare providers, pharmacies, stockists/wholesalers, and lifestyle shops. It provided economic incentives through discounts and reward points to nudge health-seeking behaviors from enrolled women consumers/beneficiaries.

METHODS

An ex-post facto evaluation was commissioned, and we employed a quasi-experimental design to compare outcomes related to the use of family planning, and antenatal and postnatal services between users and non-users who had registered for Tiko in three North Indian cities. Between March and April 2021, 1514 married women were surveyed, and outcome indicators were constructed based on recall. Despite statistical approaches to control for confounding, the effect of COVID-19 lockdown on Tiko operations and methodological limitations preclude inferring causality or arguing generalizability.

RESULTS

We found a strong association between the use of the Tiko platform and the current use of temporary modern contraceptives [non-users: 9.5%, effect: +9.4 percentage points (pp), p-value < 0.001], consumption of 100 or more iron-folic-acid tablets during pregnancy [non-users: 25.5%, effect: +14 pp, p-value < 0.001], receiving four or more antenatal check-ups [non-users: 18.3%, effect: +11.3 pp, p-value 0.007], and receiving postnatal check-up within six weeks of birth [non-users: 50.9%, effect: +7.5 pp, p-value 0.091]. No associations were found between the use of the Tiko platform and the current use of any type of contraceptive (temporary, permanent, or rudimentary). Effects were pronounced when a community health worker of the National Health Mission also worked as a health promoter for the Tiko Platform.

CONCLUSION

Commercial interventions that harness market-driven approaches of incentives, social marketing, and social franchising improved family planning and maternal health practices through higher utilization of private market providers while maintaining access to government health services. Findings support a unifying approach to public health without separating government versus private services, but more rigorous and generalizable research is needed.

TRIAL REGISTRATION

NCT05725278 at clinicaltrials.gov (retrospective); 13/02/2023.

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

Lessons for the Design of Comprehensive Primary Healthcare in India: A Qualitative Study

Health systems with strong comprehensive primary health care (CPHC) are known to result in better health outcomes for people. In India, there is a recent push to strengthen CPHC through Ayushman Bharat. This study aimed to document lessons from successful CPHC initiatives in rural and urban India using a qualitative case study approach. A total of 72 CPHC initiatives were identified through desk review and 12 of these were studied as cases. The following two main models of CPHC delivery were seen in India: (a) a hospital or health centre with outreach and (b) social franchising model, prevalent in rural and urban contexts, respectively. Themes identified were related to organisation of services, workforce, financing and challenges in practice. Services being comprehensive, dialoguing with the community, addressing social determinants were themes under organisation of services. There is need for more generalists and training health professionals towards CPHC. Financing of CPHC especially in the rural context remains a major challenge and cannot be sustained with user fees. Leadership, values, team-based care and organisational culture play a vital role in the delivery of good quality CPHC. These findings contribute to the literature on what works and why, which could be used to design CPHC in India.

Key recommendations to strengthen public-private partnership for adolescent health in resource constrained settings: Formative qualitative inquiry in Mongolia, Myanmar and the Philippines

Background

Public health services can be inaccessible for adolescents. The private sector provides many services, but often in parallel to the public sector. This study aimed to understand current private sector engagement in adolescent health service delivery and develop recommendations to strengthen partnerships.

Methods

The study focussed on Mongolia, Myanmar and the Philippines. An initial participatory workshop in each country was followed by semi-structured key-informant interviews (32 in total) with public and private sector actors and adolescents to explore: perceptions of the public and private sectors, strengths and challenges, existing models of partnership, and insights for successful public-private partnership (PPP). Interview transcripts were analysed thematically, with findings and recommendations verified through a second workshop in Mongolia and the Philippines.

Findings

The private sector already plays a significant role in adolescent health care, and stakeholders reported a genuine willingness for partnership. Strengthened PPP was identified as necessary to improve service accessibility and quality for adolescents, unburden the public sector and introduce new technologies, with advantages for the private sector including improved access to training and resources, and an enhanced public image. Recommendations for strengthened PPP included the need to establish the foundations for partnership, clearly define roles and co-ordinate stakeholders, ensure capacity and sustainability, and monitor and evaluate efforts.

Interpretation

This is the first comprehensive study of public-private partnership for adolescent health in the Asia Pacific region. It identifies stakeholders are willing for stronger partnerships and the benefits this partnership will bring. We define eight key recommendations to enable this partnership across sectors.

Effect of a multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare) in health-care facilities in Tanzania: a cluster-randomised controlled trial

BACKGROUND

Quality of care is consistently shown to be inadequate in health-care settings in many low-income and middle-income countries, including in private facilities, which are rapidly growing in number but often do not have effective quality stewardship mechanisms. The SafeCare programme aims to address this gap in quality of care, using a standards-based approach adapted to low-resource settings, involving assessments, mentoring, training, and access to loans, to improve clinical quality and facility business performance. We assessed the effect of the SafeCare programme on quality of patient care in faith-based and private for-profit facilities in Tanzania.

METHODS

In this cluster-randomised controlled trial, health facilities were eligible if they were dispensaries, health centres, or hospitals in the faith-based or private for-profit sectors in Tanzania. We randomly assigned facilities (1:1) using computer-generated stratified randomisation to receive the full SafeCare package (intervention) or an assessment only (control). Implementing staff and participants were masked to outcome measurement and the primary outcomes were measured by fieldworkers who had no knowledge of the study group allocation. The primary outcomes were health worker compliance with infection prevention and control (IPC) practices as measured by observation of provider-patient interactions, and correct case management of undercover standardised patients at endline (after a minimum of 18 months). Analyses were by modified intention to treat. The trial is registered with ISRCTN, ISRCTN93644888.

FINDINGS

Between March 7 and Nov 30, 2016, we enrolled and randomly assigned 237 health facilities to the intervention (n=118) or control (n=119). Nine facilities (seven intervention facilities and two control facilities) closed during the trial and were not included in the analysis. We observed 29 608 IPC indications in 5425 provider-patient interactions between Feb 7 and April 5, 2018. Health facilities received visits from 909 standardised patients between May 3 and June 12, 2018. Intervention facilities had a 4·4 percentage point (95% CI 0·9-7·7; p=0.015) higher mean SafeCare standards assessment score at endline than control facilities. However, there was no evidence of a difference in clinical quality between intervention and control groups at endline. Compliance with IPC practices was observed in 8181 (56·9%) of 14 366 indications in intervention facilities and 8336 (54·7%) of 15 242 indications in control facilities (absolute difference 2·2 percentage points, 95% CI -0·2 to -4·7; p=0·071). Correct management occurred in 120 (27·0%) of 444 standardised patients in the intervention group and in 136 (29·2%) of 465 in the control group (absolute difference -2·8 percentage points, 95% CI -8·6 to -3·1; p=0·36).

INTERPRETATION

SafeCare did not improve clinical quality as assessed by compliance with IPC practices and correct case management. The absence of effect on clinical quality could reflect a combination of insufficient intervention intensity, insufficient links between structural quality and care processes, scarcity of resources for quality improvement, and inadequate financial and regulatory incentives for improvement.

FUNDING

UK Health Systems Research Initiative (Medical Research Council, Economic and Social Research Council, UK Department for International Development, Global Challenges Research Fund, and Wellcome Trust).

Midwives providing maternal health services to poor women in the private sector: is it a financially feasible model?

Governments in many low- and middle-income countries have increasingly turned to the private sector to address the gap in skilled birth attendance in rural areas. They draw on limited, but emerging evidence that the poor also seek private healthcare services. A question not addressed in this policy and strategy is: Can poor women pay the fees required for private-sector maternity care providers to financially sustain their practices? This article examined the financial viability of private-sector midwifery practices established to provide skilled birth services to Afghan refugee women in Baluchistan, Pakistan. An international non-governmental organization established 45 midwifery practices as part of a poverty alleviation project aimed at providing market-based solutions for female poverty. A retrospective micro-cost analysis was conducted on a sample of 11 practices. In-depth interviews were conducted with 33 stakeholders to explore the midwives' experiences of operating private practices, and the facilitators and barriers they experienced. The single midwife-practices saw a mean of 8.7 ANC patients (range 1-19), attended 2.9 births (range 0-10) and provided care to 1.6 postnatal patients (range 0-7). The average net income of the 11 practices in May 2014 was US$81, but the median was just US$12. To contextualize these incomes, the midwives earned, on average, 25% of Pakistan's minimum monthly living wage. The financial analysis showed only 3 out of 11 sampled practices could be considered financially viable. The qualitative data revealed that even in practices with reasonable client volumes, the patients' inability to pay was the critical factor in the midwife practices' low net incomes. The research provides empirical evidence of a potential pitfall of private funding models in resource-poor settings where providers rely on impoverished clients to pay user-fees. Such financial models essentially shift the government's responsibility to provide safe childbirth services onto providers who can least afford to offer such care.

The Ambiguity Imperative: "Success" in a Maternal Health Program in Uganda

Global health programs are compelled to demonstrate impact on their target populations. We study an example of social franchising - a popular healthcare delivery model in low/middle-income countries - in the Ugandan private maternal health sector. The discrepancies between the program's official profile and its actual operation reveal the franchise responded to its beneficiaries, but in a way incoherent with typical evidence production on social franchises, which privileges simple narratives blurring the details of program enactment. Building on concepts of not-knowing and the production of success, we consider the implications of an imperative to maintain ambiguity in global health programming and academia.

A more practical guide to incorporating health equity domains in implementation determinant frameworks

BACKGROUND

Due to striking disparities in the implementation of healthcare innovations, it is imperative that researchers and practitioners can meaningfully use implementation determinant frameworks to understand why disparities exist in access, receipt, use, quality, or outcomes of healthcare. Our prior work documented and piloted the first published adaptation of an existing implementation determinant framework with health equity domains to create the Health Equity Implementation Framework. We recommended integrating these three health equity domains to existing implementation determinant frameworks: (1) culturally relevant factors of recipients, (2) clinical encounter or patient-provider interaction, and (3) societal context (including but not limited to social determinants of health). This framework was developed for healthcare and clinical practice settings. Some implementation teams have begun using the Health Equity Implementation Framework in their evaluations and asked for more guidance.

METHODS

We completed a consensus process with our authorship team to clarify steps to incorporate a health equity lens into an implementation determinant framework.

RESULTS

We describe steps to integrate health equity domains into implementation determinant frameworks for implementation research and practice. For each step, we compiled examples or practical tools to assist implementation researchers and practitioners in applying those steps. For each domain, we compiled definitions with supporting literature, showcased an illustrative example, and suggested sample quantitative and qualitative measures.

CONCLUSION

Incorporating health equity domains within implementation determinant frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally addressing implementation and equity barriers simultaneously. These practical guidance and tools provided can assist implementation researchers and practitioners to concretely capture and understand barriers and facilitators to implementation disparities.

Effect of introducing human papillomavirus genotyping into real-world screening on cervical cancer screening in China: a retrospective population-based cohort study

Background:

China’s Fujian Cervical Pilot Project (FCPP) transitioned cervical cancer screening from high-risk human papillomavirus (HR-HPV) nongenotyping to genotyping. We investigated the clinical impact of this introduction, comparing performance indicators between HR-HPV genotyping combined with cytology screening (HR-HPV genotyping period) and the previous HR-HPV nongenotyping combined with cytology screening (HR-HPV nongenotyping period).

Methods:

A retrospective population-based cohort study was performed using data from the FCPP for China. We obtained data for the HR-HPV nongenotyping period from 1 January 2012 to 31 December 2013, and for the HR-HPV genotyping period from 1 January 2014 to 31 December 2016. Propensity score matching was used to match women from the two periods. Multivariable Cox regression was used to assess factors associated with cervical intraepithelial neoplasia of grade 2 or worse (CIN2+). The primary outcome was the incidence of CIN2+ in women aged ⩾25 years. Performance was assessed and included consistency, reach, effectiveness, adoption, implementation and cost.

Results:

Compared with HR-HPV nongenotyping period, in the HR-HPV genotyping period, more CIN2+ cases were identified at the initial screening (3.06% versus 2.32%; p < 0.001); the rate of colposcopy referral was higher (10.87% versus 6.64%; p < 0.001); and the hazard ratio of CIN2+ diagnosis was 1.64 (95% confidence interval, 1.43–1.88; p < 0.001) after controlling for health insurance status and age. The total costs of the first round of screening (US$66,609 versus US$65,226; p = 0.293) were similar during the two periods. Higher screening coverage (25.95% versus 25.19%; p = 0.007), higher compliance with age recommendations (92.70% versus 91.69%; p = 0.001), lower over-screening (4.92% versus 10.15%; p < 0.001), and reduced unqualified samples (cytology: 1.48% versus 1.73%, p = 0.099; HR-HPV: 0.57% versus 1.34%, p < 0.001) were observed in the HR-HPV genotyping period.

Conclusions:

Introduction of an HR-HPV genotyping assay in China could detect more CIN2+ lesions at earlier stages and improve programmatic indicators. Evidence suggests that the introduction of HR-HPV genotyping is likely to accelerate the elimination of cervical cancer in China.

Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries

If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the "hows" and "whys" of processes and pathways are essential for guiding policy and programme actions.

The effect of report cards on the coverage of maternal and neonatal health care: a factorial, cluster-randomised controlled trial in Uttar Pradesh, India

BACKGROUND

Report cards are a prominent strategy to increase the ability of citizens to express their view, improve public accountability, and foster community participation in the provision of health services in low-income and middle-income countries. In India, social accountability interventions that incorporate report cards and community meetings have been implemented at scale, attracting considerable policy attention, but there is little evidence on their effectiveness in improving health. We aimed to evaluate the effect of report cards, which contain information on village-level indicators of maternal and neonatal health care, and participatory meetings targeted at health providers and community members (including local leaders) on the coverage of maternal and neonatal health care in Uttar Pradesh, India.

METHODS

We conducted a repeated cross-sectional, 2 × 2 factorial, cluster-randomised controlled trial, in which each cluster was a village (rural) or ward (urban). The clusters were randomly assigned to one of four groups: the provider group, in which we shared report cards and held participatory meetings with providers of maternal and neonatal health services; the community group, in which we shared report cards and held participatory meetings with community members (including local leaders); the providers and community group, in which report cards were targeted at both health providers and the community; and the control group, in which report cards were not shared with anyone. We generated these report cards by collating data from household surveys and shared the report cards with the recipients (as determined by their assigned groups) in participatory meetings. The primary outcome was the proportion of women who had at least four antenatal care visits (ie, attended a clinic or were visited at home by a health-care worker) during their last pregnancy. We measured outcomes with cross-sectional household surveys that were taken at baseline, at a first follow-up (after 8 months of the intervention), and at a second follow-up (21 months after the start of the intervention). Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN11070792.

FINDINGS

We surveyed eligible women for the baseline survey between Jan 13, and Feb 5, 2015. We then randomly assigned 44 clusters to the provider group, 45 clusters to the community group, 45 clusters to the provider and community group, and 44 clusters to the control group. Report cards of collated survey data were provided to recipient groups, as per their random allocation, in October, 2015, and in September, 2016. We ran the first follow-up survey between May 16 and June 10, 2016. We ran the second follow-up survey between June 18 and July 18, 2017. We measured the primary outcome in 3133 women (795 in the provider group, 781 in the community group, 798 in the provider and community group, and 759 in the control group) who gave birth during implementation of the intervention, between Feb 1, 2016, and July 18, 2017 (the end of the second follow-up survey). The report card intervention did not significantly affect the proportion of women who had at least four antenatal care visits (provider vs non-provider: odds ratio 0·85, 95% CI 0·65-1·13; community vs non-community: 0·86, 0·65-1·13).

INTERPRETATION

Maternal health report cards containing information on village performance, targeted at either the community or health providers, had no detectable effect on the coverage of maternal and neonatal health care. Future research should seek to understand how the content of information and the delivery of report cards affect the success of this type of social accountability intervention.

FUNDING

Merck Sharp and Dohme.

Programmatic human papillomavirus testing in cervical cancer prevention in the Jujuy Demonstration Project in Argentina: a population-based, before-and-after retrospective cohort study

BACKGROUND

Human papillomavirus (HPV) testing for cervical cancer prevention was introduced in Argentina through the Jujuy Demonstration Project (2011-14). The programme tested women aged 30 years and older attending the public health system with clinician-collected HPV tests. HPV self-collection was introduced as a programmatic strategy in 2014. We aimed to evaluate the effectiveness of programmatic HPV testing to detect cervical intraepithelial neoplasia (CIN) of grade 2 or worse (CIN2+) in comparison with cytology-based screening.

METHODS

We did a population-based, before-and-after retrospective cohort study using data from the National Cervical Cancer Prevention Program for the Jujuy province in northwest Argentina. We obtained data for the cytology-based screening period from Jan 1, 2010, until Dec 31, 2011, and for the HPV-based screening period from Jan 1, 2012, until Dec 31, 2014. The primary outcome was detection of histologically diagnosed CIN2+ among women aged 30 years and older. To assess the outcomes in all individuals included in the study, we used multivariable logistic regression and propensity score matching. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was used for the before-and-after analysis of programmatic dimensions.

FINDINGS

Of the 29 631 women who underwent cytology-based screening in 2010-11, CIN2+ was detected in 236 (0·8%) individuals. Of the 49 565 women HPV tested in 2012-14 (clinician-collected tests, n=44 700; self-collection tests, n=4865), 693 (1·4%; 658 clinician-collected tests; 35 self-collection tests) were found to have CIN2+ after the first round of screening. Compared with cytology-based screening, the odds ratio of being diagnosed with a CIN2+ lesion was 2·34 (95% CI 2·01-2·73; p<0·0010) with clinician-collected tests, and 1·08 (0·74-1·52; p=0·68) when screened with self-collection tests, after controlling for age and health insurance status. Screening coverage was similar in both periods (52·7% vs 53·2%); improvements of programmatic indicators were observed in the HPV testing period in relation to laboratory centralisation, lower overscreening (6·6% vs 0·0%), higher adherance to age recommendations (79·3% vs 98·8%), and a decrease of inadequate samples (3·6% vs 0·2%).

INTERPRETATION

HPV testing in middle-income settings increases detection of CIN2+ lesions and allows for improvement of programmatic indicators. Evidence suggests that the introduction of HPV testing will accelerate the reduction of cervical cancer burden.

FUNDING

Argentinian National Cancer Institute and National Council of Scientific and Technologic Research.

Effects of a health education intervention on hypertension-related knowledge, prevention and self-care practices in Nigerian retirees: a quasi-experimental study

BACKGROUND

Education is vital to increasing knowledge, improving prevention and self-care practices for hypertension in older adults. This study aimed to determine the effectiveness of a health education intervention in improving hypertension (HT) knowledge, prevention and self-care practices among retirees in Enugu State, South-east, Nigeria.

METHODS

In this quasi-experimental study, we enrolled 400 participants in Enugu and Nsukka cities in Enugu State, south-east Nigeria. Participants were assigned to the treatment and control groups. Participants in the intervention/treatment group (T-group) received the intervention provided by public health experts and nurses and participants in the control group (C-group) received health talk without the intervention. Data collected at baseline (before intervention), 16 weeks (4th month) and follow-up (5th month) included demographic variables, knowledge about hypertension, prevention and self-care practices. We used paired samples t-test, Chi-square test and one-way ANOVA repeated measures for data analyses.

RESULTS

The mean age of the participants was 65.9 (± 8.9) years, the mean SBP and DBP were 136.5 (± 13.3) and 87.9 (± 9.1) respectively. More than half of the participants were (50.3%) were males, and the mean BMI was 23.9 (± 5.1) kg/m2. The paired comparison analysis showed that the mean HT knowledge score significantly increased in the T-group between baseline and 1 month (4th month) post-intervention compared to those in the C-group (P < 0.0001). Also, PA (P = 0.007), sleep pattern and quality (P = 0.003), substance use abstinence (P = 0.000), healthy diet (P = 0.000), and medication adherence (P = 0.000) improved significantly in the T-group compared to the control between baseline and 1 month after intervention. The repeated measures analyses showed statistically significant effects (between-groups analysis) for all outcomes with small to large effect sizes. Similarly, the repeated measures ANOVA analyses showed significant time-by-group interaction effects (within-groups) for all the outcomes with small to large effect sizes.

CONCLUSION

Community-based health education intervention targeted at older adults can increase HT knowledge, improve prevention and self-care practices of hypertension at the population level.

Delivering reproductive health services through non-state providers in Pakistan: understanding the value for money of different approaches

BACKGROUND

Delivering Reproductive Health Results(DRHR) programme used social franchising (SF) and social marketing (SM) approaches to increase the supply of high quality family planning services in underserved areas of Pakistan. We assessed the costs, cost-efficiency and cost-effectiveness of DRHR to understand the value for money of these approaches.

METHODS

Financial and economic programme costs were calculated. Costs to individual users were captured in a pre-post survey. The cost per couple years of protection (CYP) and cost per new user were estimated as indicators of cost efficiency. For the cost-effectiveness analysis we estimated the cost per clinical outcome averted and the cost per disability-adjusted life year (DALY) averted.

RESULTS

Approximately £20 million were spent through the DRHR programme between July 2012 and September 2015 on commodities and services representing nearly four million CYPs. Based on programme data, the cumulative cost-efficiency of the entire DRHR programme was £4.8 per CYP. DRHR activities would avert one DALY at the cost of £20. Financial access indicators generally improved in programme areas, but the magnitude of progress varies across indicators.

CONCLUSIONS

The SF and SM approaches adopted in DRHR appear to be cost effective relative to comparable reproductive health programmes. This paper adds to the limited evidence on the cost-effectiveness of different models of reproductive health care provision in low- and middle-income settings. Further studies are needed to nuance the understanding of the determinants of impact and value for money of SF and SM.

Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India

BACKGROUND

A prominent strategy to engage private sector health providers in low- and middle-income countries is clinical social franchising, an organisational model that applies the principles of commercial franchising for socially beneficial goals. The Matrika programme, a multi-faceted social franchise model to improve maternal health, was implemented in three districts of Uttar Pradesh, India, between 2013 and 2016. Previous research indicates that the intervention was not effective in improving the quality and coverage of maternal health services at the population level. This paper reports findings from an independent external process evaluation, conducted alongside the impact evaluation, with the aim of explaining the impact findings. It focuses on the main component of the programme, the "Sky" social franchise.

METHODS

We first developed a theory of change, mapping the key mechanisms through which the programme was hypothesised to have impact. We then undertook a multi-methods study, drawing on both quantitative and qualitative primary data from a wide range of sources to assess the extent of implementation and to understand mechanisms of impact and the role of contextual factors. We analysed the quantitative data descriptively to generate indicators of implementation. We undertook a thematic analysis of the qualitative data before holding reflective meetings to triangulate across data sources, synthesise evidence, and identify the main findings. Finally, we used the framework provided by the theory of change to organise and interpret our findings.

RESULTS

We report six key findings. First, despite the franchisor achieving its recruitment targets, the competitive nature of the market for antenatal care meant social franchise providers achieved very low market share. Second, all Sky health providers were branded but community awareness of the franchise remained low. Third, using lower-level providers and community health volunteers to encourage women to attend franchised antenatal care services was ineffective. Fourth, referral linkages were not sufficiently strong between antenatal care providers in the franchise network and delivery care providers. Fifth, Sky health providers had better knowledge and self-reported practice than comparable health providers, but overall, the evidence pointed to poor quality of care across the board. Finally, telemedicine was perceived by clients as an attractive feature, but problems in the implementation of the technology meant its effect on quality of antenatal care was likely limited.

CONCLUSIONS

These findings point towards the importance of designing programmes based on a strong theory of change, understanding market conditions and what patients value, and rigorously testing new technologies. The design of future social franchising programmes should take account of the challenges documented in this and other evaluations.