Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India.

Manoj Mohanan,Aparna Seth,Grant Miller,Jeremy D Goldhaber-Fiebert,Veena Das,Soledad Giardili,Sunil S Raj,Jeremy I Schwartz,Marcos Vera-Hernández,Tracy L Rabin

doi:10.2471/blt.16.179556

Abstract

ObjectiveTo evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program.MethodsWe investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models.FindingsThe programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered.ConclusionSocial franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.

Highlights

Diarrhoea and pneumonia are leading causes of childhood morbidity and mortality despite being targeted by global investment in health for decades
In India, nearly 500 000 children younger than 5 years died from diarrhoea or respiratory infections in 2013.2 These poor health outcomes were partially due to the low quality of care in both public and private health sectors, including absenteeism, poor knowledge and the know–do gap, i.e. the gap between knowledge of appropriate care and the care delivered.[3,4,5,6,7,8,9,10,11,12]
Despite the rapid growth of social franchising in developing countries, there is little evidence that it affects the quality of care provided on a large scale,[14,15,16] except for a recent programme in Myanmar where the introduction of social franchising was accompanied by a substantial increase in the number of health-care workers.[17,18]

Summary

Introduction

Diarrhoea and pneumonia are leading causes of childhood morbidity and mortality despite being targeted by global investment in health for decades. Efforts to improve the quality of primary care in developing countries have focused on a variety of strategies, ranging from training and performance incentives to organizational innovations in the private sector and the use of new technologies, such as telemedicine.[13] One prominent approach is social franchising, which is similar to commercial franchising. Franchisees, who are typically existing local providers, in turn, receive training and follow service delivery protocols established by the franchisor. They benefit from marketing, branding, supply chain management and diagnostic services organized by the franchisor. Despite the rapid growth of social franchising in developing countries, there is little evidence that it affects the quality of care provided on a large scale,[14,15,16] except for a recent programme in Myanmar where the introduction of social franchising was accompanied by a substantial increase in the number of health-care workers.[17,18]

Methods

Results

Conclusion