Abstract
How to harness the private sector to improve population health in low-income and middle-income countries is heavily debated and one prominent strategy is social franchising. We aimed to evaluate whether the Matrika social franchising model-a multifaceted intervention that established a network of private providers and strengthened the skills of both public and private sector clinicians-could improve the quality and coverage of health services along the continuum of care for maternal, newborn, and reproductive health. We did a quasi-experimental study, which combined matching with difference-in-differences methods. We matched 60 intervention clusters (wards or villages) with a social franchisee to 120 comparison clusters in six districts of Uttar Pradesh, India. The intervention was implemented by two not-for-profit organisations from September, 2013, to May, 2016. We did two rounds (January, 2015, and May, 2016) of a household survey for women who had given birth up to 2 years previously. The primary outcome was the proportion of women who gave birth in a health-care facility. An additional 56 prespecified outcomes measured maternal health-care use, content of care, patient experience, and other dimensions of care. We organised conceptually similar outcomes into 14 families to create summary indices. We used multivariate difference-in-differences methods for the analyses and accounted for multiple inference. The introduction of Matrika was not significantly associated with the change in facility births (4 percentage points, 95% CI -1 to 9; p=0·100). Effects for any of the other individual outcomes or for any of the 14 summary indices were not significant. Evidence was weak for an increase of 0·13 SD (95% CI 0·00 to 0·27; p=0·053) in recommended delivery care practices. The Matrika social franchise model was not effective in improving the quality and coverage of maternal health services at the population level. Several key reasons identified for the absence of an effect potentially provide generalisable lessons for social franchising programmes elsewhere. Merck Sharp and Dohme Limited.
Highlights
Over the past few decades, India’s maternal mor tality ratio has declined substantially from 437 deaths per 100 000 livebirths in 1992–93 to 167 deaths per 100 000 livebirths in 2011–13.1,2 Despite these improve ments, maternal health still requires urgent attention
Evidence was weak for an increase of 0·13 SD in recommended delivery care practices
Maternal mortality remains high in Uttar Pradesh, India’s most populous state, with the most recent estimate of maternal mortality at 285 deaths per 100 000 livebirths.[2]
Summary
Over the past few decades, India’s maternal mor tality ratio has declined substantially from 437 deaths per 100 000 livebirths in 1992–93 to 167 deaths per 100 000 livebirths in 2011–13.1,2 Despite these improve ments, maternal health still requires urgent attention. India is the second largest contributor to the global burden of maternal deaths, accounting for 15% of all maternal deaths.[3] Maternal mortality remains high in Uttar Pradesh, India’s most populous state, with the most recent estimate of maternal mortality at 285 deaths per 100 000 livebirths.[2] The Indian Government has had some success in increasing facility births.[4] How ever, concerns about quality of care and the capacity of the public sector to meet the increased demand for institutional deliveries need to be addressed.[5] Whether the private sector can be harnessed to improve health is at the forefront of ongoing debates in India and internationally.[6,7]. Matrika social franchising model along the continuum of care for maternal, newborn, and reproductive health, and found consistent results of no measurable effect. By selecting households in close proximity (within 1 km) to the social franchise providers in intervention clusters, the study design gave the programme its best chance of showing an effect. The evaluation was one of the few studies that has rigorously examined the population effects of social franchising. The Matrika programme possibly had effects that were too small for the study to detect; effects of this magnitude are unlikely to have implications for public health
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