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.

BACKGROUND: 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. METHODS: 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. FINDINGS: 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. INTERPRETATION: 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. FUNDING: Merck Sharp and Dohme Limited

Associations between recent intimate partner violence and receipt and quality of perinatal health services in Uttar Pradesh

Background India suffers some of the highest maternal and neonatal mortality rates in the world. Intimate partner violence (IPV) can be a barrier to utilization of perinatal care, and has been associated with poor maternal and neonatal health outcomes. However, studies that assess the relationship between IPV and perinatal health care often focus solely on receipt of services, and not the quality of the services received. Methods and findings Data were collected in 2016–2017 from a representative sample of women (15-49yrs) in Uttar Pradesh, India who had given birth within the previous 12 months (N = 5020), including use of perinatal health services and past 12 months experiences of physical and sexual IPV. Multivariate logistic regression models assessed whether physical or sexual IPV were associated with perinatal health service utilization and quality. Reports of IPV were not associated with odds of receiving antenatal care or a health worker home visit during the third trimester, but physical IPV was associated with fewer diagnostic tests during antenatal visits (beta = -0.30), and fewer health topics covered during home visits (beta = -0.44). Recent physical and recent sexual IPV were both associated with decreased odds of institutional delivery (physical IPV AOR 0.65; sexual IPV AOR 0.61), and recent sexual IPV was associated with leaving a delivery facility earlier than recommended (AOR = 1.87). Neither form of IPV was associated with receipt of a postnatal home visit, but recent physical IPV was associated with fewer health topics discussed during such visits (beta = -0.26). Conclusions In this study, reduced quantity and quality of perinatal health care were associated with recent IPV experiences. In cases where IPV was not related to care receipt, IPV remained associated with diminished care quality. Additional study to understand the mechanisms underlying associations between IPV and care qualities is required to inform health services

Matrika Household Survey in India

Data produced as part of a study to evaluate the impact of the Matrika social franchising model – a multi-faceted intervention that established a network of private providers and strengthened the skills of both public and private sector clinicians – and determine whether it has improved the quality and coverage of health services along the continuum of care for maternal, newborn and reproductive health in Uttar Pradesh, India. The datasets cover two rounds of a household survey, performed in January 2015 and May 2016, of women who had recently given birth

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

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

The Health System’s Response to and the Impact of COVID-19 on Health Services, Providers, and Seekers: A Rapid Review in the Wake of the Pandemic

Background: The COVID-19 pandemic disrupted global healthcare systems, requiring rapid adaptations. This study evaluates the impact on health systems and services in India during the peak of the first wave and its aftermath. It analyses disruptions, adaptive measures, and challenges faced by healthcare providers and seekers to enhance future preparedness. Methods: Primary studies conducted in India exploring the impact of COVID-19 on health services provision, utilisation, availability, and the well-being of providers and seekers were included. Electronic searches were conducted in six databases: PubMed, MEDLINE, Embase, Global Health, CINAHL, and the WHO database on COVID-19. The results were analysed using narrative synthesis. Results and Conclusion: The review examined 38 articles with 22,502 subjects. Health service provision, utilisation, and availability were significantly impacted, particularly in outpatient departments (n = 19) and elective services (n = 16), while emergency services remained sub-optimal (n = 20). Adaptations were made in precautionary measures, protocols, staff allocation, training, personal protective equipment (PPE), infrastructure, and resources. Providers faced mental health challenges including depression, stress (n = 14), fear of infection (n = 9), stigmatisation (n = 5), and financial repercussions (n = 5). Seekers also encountered notable challenges (n = 13). Future preparedness necessitates improved healthcare infrastructure, resource optimisation, and comprehensive protocols. Lessons should inform strategies to mitigate disruptions and prioritise the well-being of providers and seekers in future outbreaks

Volumetric properties of transfer of D(+)-glucose and sucrose from water to mixed aqueous solutions at 298.15 K

2549-2554Apparent molar volumes (ϕv) and apparent molar compressibilities (KS,2,ϕ) of D(+)-glucose and sucrose have been determined in aqueous solutions of potassium chloride (0.5, 1.0, 2.0 and 4.0 mol kg-1), strontium chloride (0.25, 0.5 and 2.0 mol kg-1), barium chloride (0.25, 0.5 and 1.0 mol kg-1) and guanidine hydrochloride (0.25, 0.5 and 2.0 mol kg-1) at 298.15 K from their density and sound velocity data. Partial molar volumes (Vo2) and adiabatic compressibilities (KoS,2) at infinite dilution have been determined from the respective apparent molar properties and used to calculate partial molar volumes (Vo2,tr) and adiabatic compressibilities KoS,2,tr) of transfer for saccharides from water to aqueous potassium chloride, strontium chloride, barium chloride and guanidine hydrochloride solutions. Transfer parameters have been discussed in terms of solute-cosolute interactions on the basis of a cosphere overlap hydration model. Interaction coefficients have also been calculated from transfer parameters

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

Effect and cost-effectiveness of educating mothers about childhood DPT vaccination on immunisation uptake, knowledge, and perceptions in Uttar Pradesh, India: A randomised controlled trial.

BACKGROUND:To assess the effect of health information on immunisation uptake in rural India, we conducted an individually randomised controlled trial of health information messages targeting the mothers of unvaccinated or incompletely vaccinated children through home visits in rural Uttar Pradesh, India. METHODS AND FINDINGS:The study tested a brief intervention that provided mothers face-to-face with information on the benefits of the tetanus vaccine. Participants were 722 mothers of children aged 0-36 months who had not received 3 doses of diphtheria-pertussis-tetanus (DPT) vaccine (DPT3). Mothers were randomly assigned in a ratio of 1:1:1 to 1 of 3 study arms: mothers in the first treatment group received information framed as a gain (e.g., the child is less likely to get tetanus and more likely to be healthy if vaccinated), mothers in the second treatment group received information framed in terms of a loss (e.g., the child is more likely to get tetanus and suffer ill health if not vaccinated), and the third arm acted as a control group, with no information given to the mother. Surveys were conducted at baseline (September 2015) and after the intervention (April 2016). The primary outcome was the proportion of children who had received DPT3 measured after 7 months of follow-up. The analysis was by intention to treat. A total of 16 (2.2%) participants were lost to follow-up. The coverage of DPT3 was 28% in the control group and 43% in the pooled information groups, giving a risk difference of 15 percentage points (95% CI: 7% to 22%, p < 0.001) and a relative risk of 1.52 (95% CI: 1.2 to 1.9, p < 0.001). The information intervention increased the rate of measles vaccination by 22 percentage points (risk difference: 22%, 95% CI: 14% to 30%, p < 0.001; relative risk: 1.53, 95% CI: 1.29 to 1.80) and the rate of full immunisation by 14 percentage points (risk difference: 14%, 95% CI: 8% to 21%, p < 0.001; relative risk: 1.72, 95% CI: 1.29 to 2.29). It had a large positive effect on knowledge of the causes, symptoms, and prevention of tetanus but no effect on perceptions of vaccine efficacy. There was no difference in the proportion of children with DPT3 between the group that received information framed as a loss and the group that received information framed as a gain (risk difference: 4%, 95% CI: -5% to 13%; p = 0.352; relative risk: 1.11, 95% CI: 0.90 to 1.36). The cost per disability-adjusted life year averted of providing information was US$186, making the intervention highly cost-effective with respect to the WHO-recommended threshold of once the gross domestic product per capita (US$793 in the case of Uttar Pradesh). Key study limitations include the modest sample size for this trial, limiting power to detect small differences in the framing of information, and the potential for contamination among households. CONCLUSIONS:Providing mothers of unvaccinated/incompletely vaccinated children with information on tetanus and the benefits of DPT vaccination substantially increased immunisation coverage and was highly cost-effective. The framing of the health information message did not appear to matter. TRIAL REGISTRATION:The trial is registered with ISRCTN, number ISRCTN84560580