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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 fr...
Autores principales: | , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BioMed Central
2018
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154932/ https://www.ncbi.nlm.nih.gov/pubmed/30249294 http://dx.doi.org/10.1186/s13012-018-0813-y |
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author | Penn-Kekana, Loveday Powell-Jackson, Timothy Haemmerli, Manon Dutt, Varun Lange, Isabelle L. Mahapatra, Aniva Sharma, Gaurav Singh, Kultar Singh, Sunita Shukla, Vasudha Goodman, Catherine |
author_facet | Penn-Kekana, Loveday Powell-Jackson, Timothy Haemmerli, Manon Dutt, Varun Lange, Isabelle L. Mahapatra, Aniva Sharma, Gaurav Singh, Kultar Singh, Sunita Shukla, Vasudha Goodman, Catherine |
author_sort | Penn-Kekana, Loveday |
collection | PubMed |
description | 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. |
format | Online Article Text |
id | pubmed-6154932 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2018 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-61549322018-09-26 Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India Penn-Kekana, Loveday Powell-Jackson, Timothy Haemmerli, Manon Dutt, Varun Lange, Isabelle L. Mahapatra, Aniva Sharma, Gaurav Singh, Kultar Singh, Sunita Shukla, Vasudha Goodman, Catherine Implement Sci Research 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. BioMed Central 2018-09-24 /pmc/articles/PMC6154932/ /pubmed/30249294 http://dx.doi.org/10.1186/s13012-018-0813-y Text en © The Author(s). 2018 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. |
spellingShingle | Research Penn-Kekana, Loveday Powell-Jackson, Timothy Haemmerli, Manon Dutt, Varun Lange, Isabelle L. Mahapatra, Aniva Sharma, Gaurav Singh, Kultar Singh, Sunita Shukla, Vasudha Goodman, Catherine Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India |
title | Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India |
title_full | Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India |
title_fullStr | Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India |
title_full_unstemmed | Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India |
title_short | Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India |
title_sort | process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in uttar pradesh, india |
topic | Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154932/ https://www.ncbi.nlm.nih.gov/pubmed/30249294 http://dx.doi.org/10.1186/s13012-018-0813-y |
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