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© Maternal healthcare markets Evaluation Team

Maternal healthcare markets Evaluation Team

Conducting multidisciplinary research on the role of the private and public health sectors in delivering maternal and reproductive health care.

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About

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.

Who we are

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.

Publications

MET have 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.

About
About MET 2 columns
About MET
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About Us - Who We Are - More about MET

The Maternal healthcare markets Evaluation Team 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 Dr Catherine Goodman. They are supported by a Scientific and Policy Advisor, Dr Veronique Filippi, and guided by a Steering Committee made up of Prof Anne Mills, Prof Mark Petticrew, Prof Simon Cousens and Prof Joanna Schellenberg.

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.

In an effort to contribute knowledge to advance the maternal health field, the evaluations conducted by MET LSHTM 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 will help 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.

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 market-based interventions to improve the delivery of high quality maternal health and family planning services in India (Matrika) and 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 effectiveness (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)

MET includes experts in health economics, epidemiology, anthropology, and statistics. The team is led by Dr Caroline Lynch and Dr Catherine Goodman. MSD for Mothers is a 10-year, $500 million global initiative to reduce maternal mortality.

This research was supported by funding from Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, through its MSD for Mothers programme. MSD had no role in the design, collection, analysis, and interpretation of data, in writing of the manuscripts, or in the decision to submit the manuscripts for publication. The content of these publications is solely the responsibility of the authors and does not represent the official views of MSD or MSD for Mothers.

Meet the team
More about MSD for Mothers

Meet the team
Profiles

Caroline
Lynch

Assistant Professor
Co-Principal Investigator, Project Lead (PROCEED)

Dr Caroline Lynch is the principal investigator for the Maternal healthcare markets Evaluation Team (MET). She is an epidemiologist with over the last 15 years’ experience working in Sub-Saharan Africa and the Asia-Pacific.

Her work within MET focuses on Family Planning, and she is technical lead on the evaluation of a supply chain model for Family Planning in Senegal. More broadly, Caroline has a keen interest in impact evaluation and the effect of migration on health.

Co-Principal Investigator, Project Lead (Nature of Competition)

Dr Catherine Goodman is a Reader in health economics and policy in the Department of Global Health and Development at the LSHTM, where she is head of the Health Economics and Systems Analysis Group (HESA). She has 18 years’ experience in applied health systems research in low- and middle-income settings, with a focus on private sector provision, health care financing and governance, and the economics of malaria control.

Scientific Advisor

Professor Veronique Filippi is a demographer and epidemiologist with expertise in health outcomes measurement and evaluation of complex interventions in RMNCH. Her interests include methods for measuring maternal morbidity in low-income countries; long term consequences of obstetric complications on mothers and babies; learning from maternal and neonatal near-miss events; birth and postpartum preparedness; and design and evaluation of complex interventions.

Loveday Penn-Kekana

Project Lead (Case Studies)

Loveday Penn-Kekana is a medical anthropologist and the qualitative lead for the 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.

Timothy
Powell-Jackson

Associate Professor
Project Lead (Matrika)

Dr Timothy Powell-Jackson is a health economist based in the Department of Global Health and Development, with over 12 years of experience working as a researcher in low- and middle-income countries. He first developed an interest in the economics of health systems while working at the Ministry of Health, Rwanda. Tim is trained as an economist with expertise in the evaluation of complex health interventions using both experimental and quasi-experimental econometric methods. His core interest is health systems research and the study of innovative demand- and supply-side financial incentive schemes.

Lenka
Benova

Assistant Professor
Project Lead (SAGE)

Dr Lenka Beňová is a quantitative social scientist with training in management, economics, Middle East studies and demography. Lenka leads the SAGE project. 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. Lenka has a keen interest in maternal health research and evaluation in low- and middle-income countries.

Isabelle
Lange

Research Fellow

Dr Isabelle Lange is a medical anthropologist and a qualitative Research Fellow in the Department of Infectious Diseases Epidemiology at the 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
Radovich

Research Assistant
Research Fellow

Emma Radovich 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. She holds an MSc in Demography & Health from LSHTM with a focus on family planning.

Kerry
Wong

Research Degree Student
Research Fellow

Kerry Wong is a Research Fellow in Health and Statistics. She is involved with analysis of DHS data for assessment of global maternal health. She also contributes to other analysis and writing of research outputs for MET. Kerry holds a Master’s degree in biostatistics from the University of Melbourne.

Camilla
Fabbri

Research Fellow

Camilla Fabbri is a Research Fellow in Health Economics. She is working on two field experiments embedded in the Matrika project, which evaluates a social franchise programme in Uttar Pradesh, India. The first of these 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.

Manon
Haemmerli

Research Fellow

Manon Haemmerli is a Research Fellow in Health Economics at the LSHTM. She is working 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 the LSHTM, with a focus on Health Economics.

Dr Francesca Cavallaro is a Research Fellow in Quantitative Methods for Programme Evaluation and will conduct quantitative analyses to evaluate the impact of the Informed Push Model in Senegal. She completed her undergraduate degree in Human Sciences at Oxford University. Francesca then worked in a sexual and reproductive health programme in western Kenya before joining the evaluation team at the 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.

Diane
Duclos

Research Fellow

Dr Diane Duclos is a qualitative Research Fellow at the LSHTM. She is working on the qualitative component of the evaluation of the Informed Push Model for Family Planning in Senegal. Diane holds a Masters degree and a PhD in Development Studies from the Graduate Institute of International and Development Studies (GIIDS, Geneva, Switzerland).

Dr Meenakshi Gautham is a Research Fellow in Health Systems and Policy Analysis. She is researching the private health sector in maternal healthcare in Uttar Pradesh, India.

Research Fellow

Sylvia
Marinova

Professional Services
Programme Manager
Communications Officer

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.

Former research team members

Mardieh
Dennis

Research Degree Student

Andreia
Santos

Assistant Professor

Ludovica Ghilardi

Sarah
Tougher

Assistant Professor

Gaurav Sharma

Suhail Shiekh

Elina Kaartinen

Projects
Projects MET
Projects MET left column
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Data quality survey team, Senegal
Data quality survey team, Senegal

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:

Promoting contraceptive use through evaluation and evidence (PROCEED)
Project PROCEED RS3786 FULL RELEASE HEWLETT SENEGAL

In Senegal, MET has been evaluating the effect of the Informed Push Model (IPM) on the availability of family planning stock in health facilities. We have also examined the effect of the intervention on Modern Contraceptive Prevalence Rates among women of reproductive age in Senegal. Our multi-dimensional approach examined the key elements of IPM, how it was implemented and how it changed. We aim to understand its acceptability within all levels of the health system and to determine the cost and cost-effectiveness of the model. We have also examined the wider family planning context and activities within which this intervention is being implemented.

As part of the evaluation, we aim to fully characterise the family supply chain model, which uses performance-based contracting. We have worked with key stakeholders, implementers, private operators, funders and the Ministry of Health to develop the theory of change for the intervention. This enabled us to understand how the model was expected to work and what the underlying assumptions were behind the intervention.

We also looked at the broader context in which the supply chain has been implemented. We used qualitative research methods, including in-depth interviews, observations and clinic diaries, to examine what happened when the supply chain model interfaced with the health system within which it operated. We also looked more broadly at the reproductive health landscape in Senegal and explored ways of measuring the implementation intensity of family planning programmes.

MET collaborates with a research consortium made up of the Institute for Health and Development (ISED) and the Department of Sociology, both at the Université Cheikh Anta Diop de Dakar, and the Convergence Santé pour le Développement (CSD).

Latest PROCEED publications

Policy brief (English) FAMILY PLANNING (FP) IN SENEGAL: What progress has been achieved among harder-to-reach groups? October 2017.

Policy brief (French) PLANIFICATION FAMILIALE (PF) AU SENEGAL: Quel progrès ont été accomplis parmi les groupes difficiles à atteindre? October 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.

Cavallaro FL, Duclos D, Baggaley RF, et al. Taking stock: protocol for evaluating a family planning supply chain intervention in Senegal. Reproductive Health (2016) 13:45.

For more information, please contact Dr Caroline Lynch.

Impact and process evaluations of a family planning supply chain using performance-based contracting of private sector logisticians in Senegal.

Matrika Impact Evaluation
Project Matrika

MET has evaluated the impact of the Matrika project in Uttar Pradesh. Matrika sought to establish a social franchise network, improve linkages between private health providers and the public sector, and improve community awareness and demand for maternal health services. Social franchising is the fastest growing market-based approach to organising and improving the quality of care in the private sector of low- and middle-income countries, but there is limited evidence on its impact and cost-effectiveness. This evaluation provided crucial and rigorous evidence on whether an innovative model of social franchising can contribute to better population health in a low-income setting.

The evaluation drew on quantitative and qualitative methods to show the impact of the Matrika project on the quality and coverage of health services along the continuum of care for reproductive, maternal and newborn health. We also aimed to understand the scale of the social franchise network, the extent to which various components of the programme were implemented and how impacts were achieved.

The study utilised a range of data collection tools, including: (1) two rounds of a household survey of 3600 women; (2) two rounds of a survey of 450 health providers; (3) direct observations of 250 births in public and private sector maternity facilities; (4) in-depth interviews with key informants; (5) village-level ethnographic fieldwork.

MET partnered with Sambodhi Research and Communications to evaluate the impact of the Matrika project.

Latest Matrika publications

Policy brief: SOCIAL FRANCHISING FOR MATERNAL HEALTH IN INDIA: Findings from an impact and process evaluation (May 2018)

Tougher S, Dutt V, Haldar K, et al. 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).

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.

For more information, contact Dr Timothy Powell-Jackson.

Impact and process evaluations of a Social Franchise in Uttar Pradesh, India.

Social Franchising case studies
Project Case Studies PACE

In designing the MSD for Mothers programme, MSD has put an emphasis on the role that the private sector can play in low- and middle-income countries by increasing the overall availability of care, improving the quality of care, as well as reducing the burden on the public sector. As part of the initiative, MSD for Mothers supported three social franchising models—the Matrika project in Uttar Pradesh, the Merrygold model in Rajasthan and the ProFam model in Uganda. The programmes shared some common elements, but differed in details and key features.

We used a mixed-methods approach to examine the similarities and differences in the design and implementation of these models. As we near the end of the project, we are able to describe the three programmes and how they have changed since their inception. We also have a better understanding of the experiences and perceptions of various stakeholders, including franchise operators and employees, community health workers, women and their families. We have documented patient pathways to see where women go for antenatal care and delivery services, and why, and captured the care they receive. We looked at the costs of setting up and running a social franchise and examined the financial sustainability of the three models. Finally, we assessed the quality of care provided.

Equity and sustainability are cross-cutting themes of the case studies. Equity has been explored through analysis of socio-economic differences in pathways of care, assessing whether differences in women’s socio-economic status affect care-seeking behaviour and care received. In terms of sustainability, explored financial sustainability and also provided insights on social sustainability from the point of view of franchisees, community health workers and women attending the facilities. We aimed to not only describe the models in detail, but also to understand the challenges they faced and how these challenges may have affected the quality of care and long-term sustainability of the programmes.

In Uganda, we partnered with the Policy Analysis and Development Research Institute (PADRI) to collect data on the ProFam social franchise. We also partnered with TRIOs in India to work with us on the case studies in Uttar Pradesh and Rajasthan.

Latest Case Studies publications:

Policy brief - HOW EQUITABLE IS SOCIAL FRANCHISING? Case studies of three maternal healthcare franchises in Uganda and India (February 2018)

Policy brief - QUALITY OF CARE DURING CHILDBIRTH IN UTTAR PRADESH, INDIA (February 2018)

Haemmerli M, Santos A, Penn-Kekana L, et al. How equitable is social franchising? A case study of three maternal healthcare franchises in Uganda and India. Health Policy and Planning (2018)

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.

For more information on the case studies, please contact Loveday Penn-Kekana.

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.

The Nature of Competition

 

Project NoC MATRIKA

Read the final report: The Nature of Competition faced by Private Providers of Maternal Health Services in Uttar Pradesh, India

MSD for Mothers-funded interventions have a strong focus on local private healthcare, including investment in social franchise networks, accreditation of private providers and development of community accountability mechanisms. These interventions take place within the context of markets where private for-profit providers compete for patients. Anticipating and interpreting the effects of these interventions requires an understanding of the nature of competition in these markets.

We have developed this understanding by studying the market for maternal health services in Uttar Pradesh. We adopted an economics-based markets perspective, considering providers and consumers as economic agents facing a wide range of financial and non-financial incentives, and drawing on theoretical insights and empirical evidence from the economics literature.

The data collection for this component included a mapping of public and private providers of maternal health services, followed by in-depth qualitative interviews with providers and other stakeholders to learn about their operation and incentives. We used the interviews to explore issues such as the structure and composition of the market (e.g. provider types, barriers to entry), provider conduct (e.g. marketing techniques, pricing decisions, relationships with other providers), factors perceived to affect demand, perceptions of the regulatory and health financing environment, and interactions with the public sector.

The study helps to interpret the results of evaluations of MSD for Mothers-funded programmes and inform the design of future private health sector interventions.

Latest Nature of Competition publications:

Research brief - HOW DO PRIVATE FACILITIES COMPETE FOR MATERNITY CASES? An analysis of the market for delivery care in Uttar Pradesh, India (February 2018)

For more information, please contact Dr Catherine Goodman.

Contextual analyses to characterise of the market dynamics at play in providing private maternal health services in Uttar Pradesh, India.

Secondary analysis to generate evidence (SAGE)
Project SAGE Full Release APHRC NAIROBI KOROGOCHO HOME VISITS

The SAGE project uses Demographic and Health Surveys (DHS) to gain insights into the patterns, transitions and choices women in low- and middle-income countries make in accessing reproductive and maternal healthcare services. The DHS are cross-sectional nationally-representative household surveys conducted in dozens of countries and are a vital data resource for cross-country comparative analyses. Our in-depth analysis includes countries from four geographic regions: Sub-Saharan Africa, Middle East/Europe, South/Southeast Asia and Latin America/the Caribbean.

The work is published as open access peer-reviewed papers and reports. Its main contributions include:

The largest analysis to date aimed at understanding where women receive reproductive and maternal healthcare services; it includes nearly one million women from 57 countries. Rigorous and transparent definitions of what constitutes need for, and use of, appropriate health services, consistent for family planning, antenatal care and delivery care. The development of the most detailed provider classification to date across different surveys, resulting in harmonisation and allowing multi-country comparisons. A literature review of published studies assessing the extent of private sector participation in providing reproductive/maternal health services, identifying current gaps in knowledge and useful directions of future inquiries. A critical assessment of the challenges encountered using DHS data for the purpose of understanding types of providers where women seek care, which could guide future improvements in data collection, DHS dataset structure and analysis approaches.

Latest SAGE publications:

Benova L, Tunçalp O, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Global Health (2018);3:e000779.

Radovich E, Dennis ML, Wong K, et al. Who meets the contraceptive needs of young women in Sub-Saharan Africa? Journal of Adolescent Health 62 (2018) 273–280.

Oakley L, Benova L, Macleod D, Lynch CA, Campbell OMR. Early breastfeeding practices: Descriptive analysis of recent Demographic and Health Surveys. Maternal & Child Nutrition (2018);14:e12535.

Dennis ML, Radovich E, Wong K, et al. Pathways to increased coverage: an analysis of time trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda. Reproductive Health (2017) 14:130.

Owolabi OO, Wong K, Dennis M, et al. 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.

Benova L, Macleod D, Radovich E, Lynch CA, Campbell OMR. 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, 1294–1308.

For more information, please contact Dr Lenka Benova.

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.

Harmonised indicators (DATA-HI)
Project HI Full Release DSW

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.

Health information systems (HIS) has been defined by the WHO as one of the building blocks of an entire health system. They should provide the basis for effective decision-making in the health sector, and ideally guide policy development and implementation, regulation, financing and human resource development, as well as research and training. Health information can be generated in various ways, one of which is routinely collected facility data. Routine data can be a valuable source, as in theory data should be available quite quickly and at relatively low cost. In many developing countries, however, the quality of routine data is highly variable; issues of data completeness, accuracy and timeliness are commonly reported in low- and middle-income countries. Furthermore, limited capacities at different levels pose barriers for the analysis and effective use of the available data for decision-making, and the use of data tends to be particularly limited at local and district levels.

The DATA-HI project shares 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.

In attempting to collect a harmonised set of indicators across these projects, the team aimed to minimise duplication of efforts and unnecessary burden of work, and facilitate comparability across projects, making data more relevant and meaningful for aggregation at a higher level. Many challenges were experienced along the way, and we share our lessons learned from the experience. While some of our lessons are specific to the collection of harmonised indicators across multiple projects, others are relevant to any data collection involving private facilities.

For more information, please contact Ms Loveday Penn-Kekana.

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.

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