Evaluations conducted by MET are generating evidence on the use, quality, equity and market dynamics of private maternal health services, and whether interventions such as social franchising can increase access to lifesaving care for all women.
MET is currently working on evaluation of MSD for Mothers: a 10-year, $500 million initiative focused on improving the quality of care women receive at health facilities during childbirth, and on increasing access to family planning.
MET has published more than 20 academic papers in the last four years, covering family planning provision, equity and quality of care in maternal health, and extensive secondary data analyses using the Demographic and Health Surveys.
The Maternal healthcare markets Evaluation Team (MET) at the London School of Hygiene & Tropical Medicine is conducting multidisciplinary research on the role of public and private health sectors in delivering maternal healthcare. MET is led by Dr Caroline Lynch and Prof Catherine Goodman. They are supported by a Scientific and Policy Advisor, Prof Veronique Filippi, and guided by a Steering Committee made up of Prof Anne Mills, Prof Mark Petticrew, Prof Simon Cousens and Prof Joanna Schellenberg. MET includes experts in health economics, epidemiology, anthropology, and statistics.
The evaluations conducted by MET are generating evidence on the use, quality, equity and market dynamics of private maternal health services, and whether interventions such as social franchising can increase access to lifesaving care for all women. Our research is helping to answer questions on how to improve the affordability and quality of both private and public maternal health services, including how and why interventions work, whether they are cost-effective, and their potential impact on maternal and reproductive health if replicated in other contexts.
Our findings have important implications locally, nationally and globally as governments and key stakeholders around the world consider how to integrate private providers into their strategies for achieving universal health coverage. Our results have been published since 2014 in formal peer-reviewed publications and through conference presentations, dissemination workshops, reports and policy briefs.
Working alongside in-country research partners, MET has developed an evidence base in two main areas:
Contextual analyses to better understand the private health sector
- Largest ever analysis of Demographic and Health Surveys from 57 countries to identify where women are seeking family planning, antenatal care and labour and delivery services, as well as the quality and equity of those services in the public and private sectors (SAGE)
- Characterisation of the market dynamics at play in providing private maternal health services in Uttar Pradesh, India (Nature of Competition)
Evaluations of MSD for Mothers interventions
- Impact and process evaluations of a maternal health social franchise in Uttar Pradesh, India (Matrika)
- Impact and process evaluations of a family planning supply chain using performance-based contracting of private sector logisticians in Senegal (PROCEED)
- Case studies of three social franchising models for maternal health in India and Uganda to distil lessons learned and answer questions on cost and sustainability (Case Studies)
- Lessons learned from a multi-institutional collaboration to collect routine M&E data on a set of harmonised indicators from private sector maternal healthcare programmes in India and Uganda (DATA-HI)
MSD for Mothers is a 10-year, $500 million global initiative to reduce maternal mortality.
This research is supported by funding from MSD, through its MSD for Mothers programme. MSD has no role in the design, collection, analysis, and interpretation of data, in the writing of manuscripts, or in decisions to submit manuscripts for publication. The content of all publications is solely the responsibility of the authors and does not represent the official views of MSD. MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, N.J., U.S.A.
Dr Lynch is an epidemiologist with nearly 20 years’ experience leading, designing, delivering, evaluating and influencing malaria control, maternal health and family planning programme across 30 countries. Currently, she is PI for two projects: the Maternal healthcare markets Evaluation Team (MET), and the LINK project - focused on strengthening data for decision-making for National Malaria Programmes in 13 high burden countries.
Catherine Goodman has been working in the field of health economics and health systems analysis at LSHTM since 1997. Her work focuses on understanding and improving private sector healthcare provision - understanding the growth of this sector, the incentives private providers face, and consequences for healthcare quality and access, and in evaluating interventions to address this. This has included studying multi-national private sector subsidy programmes for antimalarials, regulation of the retail and health facility sector, and quality improvement programmes for private providers.
Veronique Filippi is Professor in Maternal Health and Epidemiology. She is a demographer and epidemiologist, with expertise in health outcomes measurement and evaluation of complex interventions in RMNCH. Her interests include: developing methods for measuring reproductive and maternal morbidity in low income countries; documenting the long term health, social and economic consequences of obstetric complications; understanding how women manage their productive and reproductive needs after childbirth; learning from near-miss complications; improving quality of obstetric care through audit and maternal death reviews; improving respectful care and birth and postnatal preparedness.
Tim is a health economist with the Health Economics and Systems Analysis (HESA) Group, which is based in the Department of Global Health and Development, and Associate Professor in Health Economics. He is also a member of the Maternal and Newborn Health Group. He developed an interest in health economics while working at the Ministry of Health, Rwanda, on a two-year placement with the Overseas Development Institute Fellowship Scheme. Tim has expertise in the evaluation of complex health interventions using both experimental and quasi-experimental econometric methods.
Dr Benova is a quantitative population health scientist with training in management, economics, Middle East studies and demography. She currently leads the SAGE (Secondary data Analysis for Generating new Evidence) team. Previously, she headed operations in a start-up company in eldercare in the United States and worked as project coordinator with Médecins Sans Frontières in Nigeria, the West Bank and South Sudan. She was responsible for the design, implementation and evaluation of the health pillar of a conditional cash transfer program in Egypt between 2008 and 2010. Lenka has a keen interest in health-seeking behaviour, maternal health research, and evaluation in low- and middle-income countries.
Project Lead (Case Studies)
Loveday is a medical anthropologist and the qualitative lead for MET. She previously worked at the Global Health & Development Unit at the LSHTM, where she helped complete the Good Health at Low Cost Project and develop a distance-learning course on health systems. Prior to that, she worked for 10 years at the Centre for Health Policy at the University of the Witwatersrand, South Africa, leading a number of projects focusing on maternal health and health systems.
Dr Lange is a medical anthropologist and a qualitative Research Fellow in the Department of Infectious Diseases Epidemiology at LSHTM. Her work in maternal health centres around understanding women’s experiences of quality of care, the influence of hospital environments on health worker performance and satisfaction, and health policy development and transfer.
Emma is a Research Assistant on the SAGE project, using DHS data to understand the role of the private sector in reproductive healthcare in low- and middle-income countries. Before joining LSHTM, she designed a leadership and social change curriculum at an international women’s university in Chittagong, Bangladesh, and spent several years coordinating fundraising and outreach campaigns for U.S.-based reproductive rights advocacy organisations.
Kerry is a Research Fellow in Health and Statistics. She is involved with analysis of DHS data for assessment of global maternal health. Kerry holds an MSc in biostatistics from the University of Melbourne. Before joining LSHTM, Kerry worked to support a wide range of projects as a data manager and statistician at the International Centre for Equity in Health and the World Health Organization.
Manon is a Research Fellow in Health Economics. She worked on the cost evaluation of three social franchising programs in Uganda, Rajasthan and Uttar Pradesh. Manon holds a Masters in Physics from the Swiss Federal Institute of Technology in Lausanne, and an MSc in Public Health from LSHTM, with a focus on Health Economics.
Research Fellow (PROCEED)
Dr Cavallaro is an epidemiologist. She conducted quantitative analyses to evaluate the impact of the Informed Push Model in Senegal. She previously worked in a sexual and reproductive health programme in western Kenya, before joining the evaluation team at PACT Project/Partners in Health in Boston, where she helped design the evaluation of a complex intervention using community health workers to improve chronic disease management.
Dr Duclos is an anthropologist with experience working in developing, conflict and post-conflict settings. She has previously worked with Iraqi migrant and refugee communities in the Middle East using methods including participant observation, visual art narratives and biographical interviews. She worked on the qualitative component of the evaluation of the Informed Push Model for Family Planning in Senegal.
Dr Gautham is a Research Fellow in Health Systems and Policy Analysis. She has been the India Country Coordinator of the IDEAS project for maternal and newborn health at LSHTM, and is currently involved in researching antibiotic use and antibiotic stewardship in the private health sector, and AMR regulations. She works on the Nature of Competition study for MET.
Camilla is a Research Fellow in Health Economics in the Department of Global Health and Development. She works on two field experiments embedded in the Matrika project. The first looks at whether giving accurate information on the effectiveness of health care affects household perceptions and the demand for services. The second examines whether feedback and public reporting on performance of health providers improves the coverage of maternal health interventions.
Research Fellow (Matrika)
Sarah is a health economist in the Health Economics and Systems Analysis group of the Department of Global Health and Development. She joined LSHTM in 2008, and has a Masters Degree in Development Economics from Dalhousie University.
Sylvia joined LSHTM in 2006 and oversees the financial, contractual and administrative management of research projects on family planning, maternal and reproductive health within the Maternal and Newborn Health Group. Her background is in financial economics and human resources management.
Justine Marshall is the Communications Officer for MET. She is responsible for developing and implementing MET’s communications strategy, and supporting the team with all dissemination and advocacy activities.
MET-LSHTM has developed an evidence base in two main areas: Contextual analyses to better understand the private health sector; and in-depth impact and process evaluations of MSD for Mothers interventions in Uganda, Senegal and India.
Specific research areas are:
Impact and process evaluations of a family planning supply chain using performance-based contracting of private sector logisticians in Senegal.
Impact and process evaluations of a Social Franchise in Uttar Pradesh, India.
Case studies of three social franchising models for maternal health in India and Uganda to distil lessons learned and answer questions on cost and sustainability.
Investigating the nature of competition facing private healthcare facilities providing maternity care in Uttar Pradesh, India.
Contextual analyses using Demographic and Health Surveys from over 60 countries to identify where women are seeking family planning, antenatal care and labour and delivery services, as well as the quality and equity of those services in the public and private sectors.
Lessons learned from a multi-institutional collaboration to collect routine M&E data on a set of harmonised indicators from private sector maternal healthcare programmes in India and Uganda.
Our national and regional research partners
We have developed strong research collaborations both at national and regional levels. At national levels, MET-LSHTM has worked with the Université Cheikh Anta Diop in Senegal, PADRI in Uganda, and TRIOs, IMPACT partners and Sambodhi in India. At the regional level, MET-LSHTM has collaborated with the East, Central and Southern African health community (ECSA) – a body that feeds data and information to Ministry of Health permanent secretaries and directors of health throughout the region.
|2019||Gautham M, Bruxvoort K, Iles R, Subharwal M, Gupta S, Jain M, Goodman C||Investigating the nature of competition facing private healthcare facilities: the case of maternity care in Uttar Pradesh, India||Health Policy and Planning||Nature of Competition|
|2019||Sharma G, Penn-Kekana L, Halder K, Filippi V||BMC Reproductive Health||Matrika|
|2019||Bergamaschi N, Oakley L, Benova L||Journal of Global Health||SAGE|
|2019||Duclos D, Cavallaro FL, Ndoye T, Faye SL, Diallo I, Lynch CA, Diallo M, Faye A, Penn-Kekana L||Reproductive Health Matters||PROCEED|
|2019||Hanson C, Munjanja S, Binagwaho A, Vwalika B, Pembe AB, Jacinto E, Chilinda GK, Donahoe KB, Wanyonyi SZ, Waiswa P, Gidiri MF, Benova L||PLoS Med||SAGE|
|2018||Benova L, Dennis ML, Lange IL, Campbell OMR, Waiswa P, Haemmerli M, Fernandez Y, Kerber K, Lawn JE, Santos AC, Matovu F, Macleod D, Goodman C, Penn-Kekana L, Ssengooba F, Lynch CA||BMC Health Services Research||SAGE|
|2018||Radovich E, Dennis ML, Barasa E, Cavallaro FL, Wong KLM, Borghi J, Lynch CA, Lyons-Amos M, Abuya T, Benova L||BMJ Open||SAGE|
|2018||Cavallaro FL, Duclos D, Cresswell JA, Faye S, Macleod D, Faye A, Lynch CA||BMJ Gloal Health||SAGE|
|2018||Benova L, Neal S, Radovich E, Ross DA, Siddiqi M, Chandra-Mouli V||BMJ Global Health||PROCEED|
|2018||Radovich E, Benova L,2, Penn-Kekana L, Wong K, Campbell OMR||BMJ Global Health||
|2018||McElwee, E, Cresswell JA, Yao C, Bakeu M, Cavallaro FL, Duclos D, Lynch CA, Paintain L||Comparing Time and Motion Methods for Studying Personnel Time in the context of a Family Planning Supply Chain Intervention||Human Resources for Health||PROCEED|
|2018||Wong K, Radovich E, Owolabi OO, Campbell OMR, Brady O, Lynch CA, Benova L||Why not? Understanding the spatial clustering of private facility-based delivery and financial reasons for homebirths in Nigeria||BMC Health Services Research (2018), 18:397||SAGE|
|2018||Powell-Jackson T, Penn-Kekena L, Tougher S, Haemmerli M, Dutt V, Lange IL, Mahapatra A, Sharma G, Singh K, Singh S, Shukla V, Pereira S, Haldar K, Kumar P, Goodman C||SOCIAL FRANCHISING FOR MATERNAL HEALTH IN INDIA: Findings from an impact and process evaluation||POLICY BRIEF||Matrika|
|2018||Goodman C, Gautham M, Iles R, Bruxvoort K, Subharwal M, Gupta S, Jain M||HOW DO PRIVATE FACILITIES COMPETE FOR MATERNITY CASES? An analysis of the market for delivery care in Uttar Pradesh, India||POLICY BRIEF||Nature of Competition|
|2018||Haemmerli M, Santos A, Penn-Kekana L, Lange I, Matovu F, Benova L, Wong KLM, Goodman C||HOW EQUITABLE IS SOCIAL FRANCHISING? Case studies of three maternal healthcare franchises in Uganda and India||POLICY BRIEF||Social Franchising Case Studies|
|2018||Sharma G, Powell-Jackson T, Haldar K, Bradley J, Filippi V||QUALITY OF CARE DURING CHILDBIRTH IN UTTAR PRADESH, INDIA||POLICY BRIEF||Matrika|
|2018||Haemmerli M, Santos A, Penn-Kekana L, Lange I, Matovu F, Benova L, Wong K, Goodman C||How equitable is social franchising? A case study of three maternal healthcare franchises in Uganda and India||Health Policy and Planning (2018), Volume 33, Issue 3, Pages 411–419||Social Franchising Case Studies|
|2018||Powell-Jackson T, Fabbri C, Dutt V, Tougher S, Singh K||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||PLoS Med (2018), 15(3): e1002519||Matrika|
|2018||Benova L, Tunçalp O, Moran AC, Campbell OMR||Not just a number: Examining coverage and quality of antenatal care in low- and middle-income countries||BMJ Global Health (2018), 3:e000779||SAGE|
|2018||Radovich E, Dennis M, Wong K, Ali M, Lynch CA, Cleland J, Owolabi OO, Lyons-Amos M, Benova L||Who meets the contraceptive needs of young women in sub-Saharan Africa?||Journal of Adolescent Health (2018), Volume 62, Issue 3, Pages 273-280||SAGE|
|2018||Tougher S, Dutt V, Haldar K, Pereira S, Shukla V, Kumar P, Singh K, Goodman C, Powell-Jackson T||Effect of a multi-faceted social franchising model to improve maternal health: evidence from a prospective controlled before and after study in Uttar Pradesh, India||Lancet Global Health (2018), 6: e211–21||Matrika|
|2017||Goodman C, Gautham M, Iles R, Bruxvoort K, Subharwal M, Gupta S, Jain M||The Nature of Competition faced by private providers of maternal health services in Uttar Pradesh, India||REPORT||Nature of Competition|
|2017||Cavallaro FL, Benova L, Macleod D, Faye A, Lynch CA||FAMILY PLANNING (FP) IN SENEGAL: What progress has been achieved among harder-to-reach groups?||POLICY BRIEF||PROCEED|
|2017||Cavallaro FL, Benova L, Macleod D, Faye A, Lynch CA||PLANIFICATION FAMILIALE (PF) AU SENEGAL: Quel progrès ont été accomplis parmi les groupes difficiles à atteindre?||POLICY BRIEF||PROCEED|
|2017||Cavallaro FL, Benova L, Macleod D, Faye A, Lynch CA||Examining trends in family planning among harder-to-reach women in Senegal 1992-2014||Scientific Reports (2017), Volume 7, Article number: 41006||PROCEED|
|2017||Sharma G, Powell-Jackson T, Haldari K, Bradley J, Filippi V||Quality of essential care at the time of birth: Findings from clinical observations of labour and childbirth care at public and private sector facilities in Uttar Pradesh, India||Bulletin of the World Health Organization (2017), 95:419–429||Matrika|
|2017||Benova L, Macleod D, Campbell OMR, Lynch CA, Radovich E||Should I stay or should I go?: Consistency and switching of delivery locations among new mothers in 39 Sub-Saharan African and South/Southeast Asian countries||Health Policy and Planning (2017), Volume 32, Issue 9, Pages 1294–1308||SAGE|
|2017||Owolabi OO, Wong K, Dennis M, Radovich E, Cavallaro FL, Lynch CA, Fatusi A, Sombie I, Benova L||Comparing the use and content of antenatal care in adolescent and older first-time mothers in 13 countries of west Africa: a cross-sectional analysis of Demographic and Health Surveys||Lancet Child and Adolescent Health (2017), 1: 203–12||SAGE|
|2017||Oakley L, Benova L, Macleod D, Lynch CA, Campbell OMR||Early breastfeeding practices: Descriptive analysis of recent Demographic and Health Surveys||Maternal & Child Nutrition (2017), Volume 14, Issue 2, e12535||SAGE|
|2017||Dennis M, Radovich E, Wong K, Owolabi OO, Binagwaho A, Mbizvo MT, Cavallaro FL, Lynch CA, Benova L||Pathways to increased coverage: an analysis of time trends in family planning need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda||BMC Reproductive Health (2017), 14:130||SAGE|
|2016||Powell-Jackson T, Pereira SK, Dutt V, Tougher S, Haldar K, Kumar P||Cash transfers, maternal depression and emotional well-being: Quasi-experimental evidence from India's Janani Suraksha Yojana programme||Social Science and Medicine (2016). 162:210-8||Matrika|
|2016||Campbell OMR, Benova L, MacLeod D, Baggaley RF, Rodrigues LC, Hanson K, Powell-Jackson T, Penn-Kekana L, Polonsky R, Footman K, Vahanian A, Pereira SK, Santos AC, Filippi VG, Lynch CA, Goodman C||Family planning, antenatal and delivery care: cross-sectional survey evidence on levels of coverage and inequalities by public and private sector in 57 low- and middle-income countries||Tropical Medicine & International Health (2016), 21(4): 486-503||SAGE Series: who cares for women? Towards a greater understanding of reproductive and maternal healthcare markets|
|2016||Cavallaro FL, Duclos D, Baggaley RF, Penn-Kekana L, Goodman C, Vahanian A, Santos AC, Bradley J, Paintain L, Gallien J, Gasparrini A, Hasselback L, Lynch CA||Taking stock: protocol for evaluating a family planning supply chain intervention in Senegal||Reproductive Health (2016), 13:45||PROCEED|
|2015||Footman K, Benova L, Goodman C, Macleod D, Lynch CA, Penn-Kekana L, Campbell OMR||Using multi-country household surveys to understand who provides reproductive and maternal health services in low- and middle-income countries: a critical appraisal of the Demographic and Health Surveys||Tropical Medicine & International Health (2015), 20(5):589-606||SAGE Series: who cares for women? Towards a greater understanding of reproductive and maternal healthcare markets|
|2015||Campbell OMR, Benova L, Macleod D, Goodman C, Footman K, Pereira AL, Lynch CA||Who, What, Where: an analysis of private sector family planning provision in 57 low- and middle-income countries||Tropical Medicine & International Health (2015), 20(12):1639–1656||SAGE Series: who cares for women? Towards a greater understanding of reproductive and maternal healthcare markets|
|2015||Benova L, Macleod D, Footman K, Cavallaro FL, Lynch CA, Campbell OMR||Role of the private sector in childbirth care: cross-sectional survey evidence from 57 low- and middle-income countries using Demographic and Health Survey||Tropical Medicine & International Health (2015), 20(12):1657–1673|
|2015||Pereira SK, Kumar P, Datt V, Haldar K, Penn-Kekana L, Santos A, Powell-Jackson T||Protocol for the evaluation of a social franchising model to improve maternal health in Uttar Pradesh, India||Implementation Science (2015), 10: 77||Matrika|
|2014||Powell-Jackson T, Macleod D, Benova L, Lynch C, Campbell OMR||The role of the private sector in the provision of antenatal care: a study of Demographic and Health Surveys from 46 low- and middle-income countries||Tropical Medicine & International Health (2014), 20(2):230-9|
MSD for Mothers has just published its first research compendium, "Evidence for Impact," highlighting many publications by MET and containing an introduction by LSHTM Director, Professor Peter Piot.
MSD for Mothers Lead, Dr Naveen Rao, and Executive Director, Dr Mary-Ann Etiebet, gave special thanks to MET, commending us for being their “longstanding and prolific partners in generating disruptive evidence.”
The compendium includes publications by MSD for Mothers research partners that advance collective understanding of the problem of maternal mortality, inform the design and implementation of programs aiming to improve women’s health, and strengthen the global health community of practice to save women’s lives.
MET members Lenka Benova and Justine Marshall have published a new blog on the Healthy Newborn Network (HNN). The blog, Quality, not just quantity: antenatal care in LMICs, looks at the evidence and implications of the recent paper, Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries, by Lenka Benova, Özge Tunçalp, Allisyn C Moran, and Oona Campbell.
On 21 May 2018, the Maternal healthcare markets Evaluation Team (MET), together with the MARCH Centre, held a one-day research symposium:
Who should care for women?
Reflections on the private sector's role in reproductive & maternal health care
The private sector is an important provider of maternal and reproductive healthcare in many low- and middle-income countries. Overall the private sector provides around 37% of family planning, 44% of antenatal care, and 40% of deliveries, although there is substantial variation across countries and income groups.
This unique one-day symposium brought together implementers, researchers, and policymakers working on the private healthcare sector and maternal and reproductive health, to highlight innovations in the implementation of private sector engagement, and consider the implications for policy and practice.
Participants learned about the role of the private sector in maternal and reproductive health, the nature of private providers in low- and middle-income countries, and the impact of private sector interventions such as social franchising and contracting out.
Speakers and participants included:
- Professor Peter Piot, Director, LSHTM
- Dr Mary-Ann Etiebet, Executive Director, MSD for Mothers
- Professor Anne Mills, Deputy Director and Provost, LSHTM
- Professor Joy Lawn, MARCH Centre, LSHTM
- Professor Kara Hanson, LSHTM
- Dr Caroline Lynch, LSHTM
- Professor Catherine Goodman, LSHTM
- Dr Nirali Chakraborty, Metrics for Management
- Dr Lenka Benova, LSHTM, and ITM, Antwerp
- Dr Meenakshi Gautham, LSHTM
- Ms Loveday Penn-Kekana, LSHTM
- Dr Tim Powell-Jackson, LSHTM
- Dr Fred Matovu, School of Economics, Makerere University
- Dr Elizabeth Mason, International Accountability Panel; Every Woman, Every Child, Every Adolescent
- Professor Adama Faye, ISED, Senegal
- Dr Marcos Vera-Hernandez, UCL
- Dr May Me Thet, PSI Myanmar
- Dr Natasha Palmer, Independent Consultant
- Ms Nikki Charman, PSI
- Mr Sidd Goyal, Nivi
- Mr Matthew Rehrig, Children's Investment Fund Foundation (CIFF)
- Ms Susan Mitchell, SHOPS PLUS, Abt Associates
- Professor David McCoy, Queen Mary University of London
- Professor Oona Campbell, LSHTM
Thursday 8th February 2018
Magnolia Room, India Habitat Centre, Lodhi Road, New Delhi, India
Quality improvement, financial sustainability, consumer choice, and accountability – these were just a few of the topics that came up for vigorous discussion at the symposium in Delhi on the 8th of February 2018.
Thirty-seven delegates, representing government, implementing agencies, private sector providers, research institutions, international organisations, and consumer advocates, convened to consider the results of a three-year programme of research in India, evaluating select MSD for Mothers initiatives working with private providers to improve maternal health. The research was led by the London School of Hygiene & Tropical Medicine (LSHTM), with Indian partners Sambodhi Research and Communications, Impact Partners for Social Development, and TRIOs Development Support. During the workshop we situated these findings in the context of the broader Indian environment, leading to a day of debate, discussion and consideration of policy implications.
Setting the stage on maternal health and the private sector, LSHTM’s Professor Catherine Goodman posed three big-picture questions for delegates as they started the day: What do we want the whole health system to look like in 20 years? What role should the private sector play in that? What should governments and civil society do to shape that future?
Dr Meenakshi Gautham then presented the results of a study looking at the landscape of private maternity care in Uttar Pradesh and the nature of competition between private providers. Delegates heard that private delivery facilities operate in a highly competitive market, and use a wide range of price and non-price strategies to compete with one another, though many concerns around quality of delivery care remain. Discussion points following the presentation included the interplay of private and public sectors, the long-term financial viability of the private clinics studied, and whether consumers were genuinely ‘voting with their feet’ – choosing, and abandoning, facilities based on the quality of the services provided.
Throwing a spotlight on a government scheme to empanel private OBGYNs, the Ministry of Health and Family Welfare’s Dr Dinesh Baswal presented PMSMA, the Prime Minister’s Safe Motherhood Initiative. Under PMSMA, private OBGYNs volunteer their services for free in public facilities on the 9th day of each month to provide ANC services. The scheme focuses on generating awareness among private sector providers, facilitating, sustaining and recognising their participation. Both FOGSI and the Indian Medical Association (IMA) have supported PMSMA. Dr Baswal reported that more than ten million antenatal check-ups have been conducted across 12,800 facilities in 18 months through the scheme, with more than 4,800 private sector doctors registered. Of those doctors, at least 658 provided consistent services (more than 7 times in the past 14 months).
Does social franchising work for maternal health? This was the question tackled by LSHTM’s Loveday Penn-Kekana, presenting results of an evaluation of social franchising models in Uttar Pradesh and Rajasthan. Despite the enormous amount of effort and activity dedicated by committed staff to setting up the social franchises, the studies showed that the quality of care in these social franchises was poor, and that improving quality was persistently challenging. In the period that LSHTM evaluated, the social franchises studied struggled to establish a brand that attracts women, and there was no evidence that joining a social franchise led to increased numbers of patients. Furthermore, analyses showed that the social franchises were predominately serving women in the top three wealth quintiles.
Animated discussions followed Ms Penn-Kekana’s presentation, as delegates sought to understand why social franchising for maternal health programmes seemed to have fared poorly in India – was this something to do with the Indian context? Was it to do with maternal health? Was it different for family planning? Was the demand missing in these communities? Did these programmes need longer to become established before they could demonstrate positive results? Does the mismatch of expectations and reality reflect exaggerated expectations rather than a disappointing reality?
And where to next? After learning the lessons of social franchising, how do we apply these and try to develop the next generation of private maternity services that deliver for women at all socio-economic levels? Mr Sharad Agarwal gave us some insight into one approach with his presentation of Utkrisht: The Maternal and Newborn Health Development Impact Bond, of which HLFPPT is a member.
Delegates raised concerns about the incentives for quality improvement in the Utkrisht bond, given the evidence presented by Ms Penn-Kekana showing the failures of previous similar quality improvement (QI) programmes. MSD for Mothers’ Pompy Sridhar gave more information about the Bond’s unique performance system and incentives involved for facilities to meet QI standards.
Learning from implementing agencies’ experiences was an important component of the symposium. To that end, we heard from Jhpiego’s Dr Bulbul Sood about the Manyata programme, which uses accreditation as a tool for QI, from Dr Kranti Vora about Chiranjeevi yojana, a health insurance scheme promoting institutional delivery in Gujarat, and from Dr Vinoj Manning about Yukti Yojana, a public private partnership for abortion services in Bihar.
Dr Manoj Mohanan from Duke University contributed research findings from his latest work in Karnataka looking at performance incentive contracts in maternity care. His take-home message? While the evidence is mixed, it is too early to “throw the baby out with the bath water” for pay-for-performance. Dr Mohanan suggested that rather than the mechanism being faulty, the evidence is likely mixed because we have not yet thought in adequate detail about the structure of the contracts, and about which aspects of the contracts influence the problems we are trying to solve.
Turning to the perspective of the private maternal health providers, FOGSI President Dr Jaideep Malhotra presented on the challenges and initiatives of FOGSI members. Dr Malhotra finished with a call to the Government of India: “We (OBGYNs) are caring. We should be nurtured and supported to enable us to do the same for our patients on a daily basis.”
To conclude the day we heard from White Ribbon Alliance India’s Aparajita Gogoi about their research showing that, while the policy community may have moved on to questions of quality of care, many women still struggle just to access care. Respectful care – care that is free of discrimination based on caste, wealth, or education – is noticed and valued by all women.
Chair for the afternoon, Dr Himanshu Bhushan, left us with a question to take home and consider as we go on with our work: Why is the voice of the women not heard? A timely reminder for us all, working at all levels, to keep mothers at the centre of what we do.