NHIR Health Protection Research Unit in Vaccine and Immunisation 

The NIHR Health Protection Research Unit in Vaccines and Immunisation is a partnership between Public Health England (PHE) and the London School of Hygiene and Tropical Medicine, in collaboration with the University of Cambridge. Our unit is one of 14 Health Protection Research Units (HPRUs) across England, part of an investment by the National Institute for Health Research (NIHR) to protect the health of the nation. The HPRUs fund high quality research that enhances the ability of PHE to use innovative techniques to protect the public’s health and minimise the health impact of emergencies, such as COVID-19. The HPRU in Vaccines and Immunisation looks at the effectiveness and safety of vaccines, how many people are being vaccinated, disease trends, and the impact of introducing new vaccines. We also look at what people think about vaccines and how we can make it easier for people to access vaccinations. The team based in GHD investigate immunisation delivery systems and public interactions with vaccines in the UK.

Team

• Sandra Mounier-Jack
• Tracey Chantler
• Sadie Bell
• RD student: Oyinkansola Ojo-Aromokudu

Other team member from other faculties:

• Anthony Scott
• Pauline Paterson
• Heidi Larson
• Mark Jit
• Helen McDonald
• Liam Smeeth
• Nick Davies
• Gemma Walker

RIVER-EU: Reducing Inequalities in Vaccine uptake in the European Region - Engaging Underserved communities

The RIVER-EU project aims to improve measles, mumps and rubella (MMR) and human papillomavirus (HPV) vaccination access and uptake among underserved populations in Europe by adjusting existing and/or developing new system-level interventions tailored to underserved populations.

As one of the partners in the RIVER-EU project, we will conduct a qualitative study to explore enablers to higher vaccination uptake than average among Bangladeshi communities in England for certain childhood vaccinations. The study will involve interviews with Bangladeshi community members and healthcare professionals.

Team

• Sandra Mounier-Jack
• Sadie Bell

Psychological wellbeing of health workers across twelve countries in Sub-Saharan Africa – levels, determinants, and consequences

Health workers are at high risk of poor mental wellbeing due to their particularly strenuous work demands. This is a particular concern in heavily constrained health systems, such as in most low and lower-middle-income countries. To date, however, little attention has been payed to this issue by research and practice. The study therefore aims to assess psychological wellbeing of health workers and to understand reasons for poor (or good) psychological wellbeing as well as potential consequences for performance and turnover, using quantitative and qualitative methods.

Contact

• Julia Lohmann

Funding

Wellcome Trust

Publications

Julia Lohmann

Papers 

• Lohmann J, John D, Dzay A. Much research, but little learned to date: A scoping review on mental health of health workers in low- and lower-middle income countries and roadmap for future research, 12 February 2021, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-215108/v1] Lohmann J, John D, Dzay A. Prevalence and factors associated with poor mental health among healthcare professionals in low- and lower-middle-income countries: a systematic review protocol. Syst Rev. 2019;8:294.
• Lohmann J, Shulenbayev O, Wilhelm D, Muula AS, De Allegri M. Psychological wellbeing in a resource-limited work environment: examining levels and determinants among health workers in rural Malawi. Hum Resour Health. 2019.17:85.

Dates

2019-2023

 

Psychosocial wellbeing of health workers in Burkina Faso, The Gambia, and Senegal during the 2020 COVID-19 pandemic 

As SARS-CoV-2 is making its way around the world, health workers are at particular risk of being affected in various ways. Research during or in the wake of the Ebola epidemic in West Africa between 2014 and 2016 has described the profound impact on health workers mental health and psychosocial wellbeing. However, many questions remain open. The current pandemic offers an opportunity to fill gaps in knowledge by capturing health workers experiences and their effect on mental health and psychosocial wellbeing throughout the evolution of the outbreak, using a mix of “traditional” qualitative interviews conducted remotely and regular follow-up via WhatsApp audio messages. By documenting “in real time” what health workers at the frontline of a disease outbreak go through, we aim to inform current support activities, and to generate useful information for policy makers and managers designing future disease outbreak strategies and interventions.

Funding

Wellcome Trust, GCRF

People

• Julia Lohmann
• Melisa Martinez Alvare
• Marème Diallo

Partners

MRC Unit in The Gambia at LHSTM Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formation, Sénégal Centre de Recherche en Santé à Nouna, Burkina Faso Ministries of Health in Burkina Faso, The Gambia, and Senegal Heidelberg Institute of Global Health, Germany

Dates

2020-2021

Closing the gap in antenatal syphilis and HIV detection and treatment in Indonesia

The dual elimination of mother-to-child transmission (EMTCT) of HIV and syphilis through screening and treatment of pregnant women has been identified as a global public health priority. Indonesia, the 4th most populous country in the world, has a national HIV prevalence rate among pregnant women of around 0.3% (15,900 women) with some provinces (e.g. Jakarta) close to the 1% threshold for a generalised epidemic. Comparable estimates for syphilis in pregnancy are unavailable but thought to be similar to those for HIV. The country also has the lowest rate of antenatal screening and treatment for HIV/syphilis in South-East Asia. Despite 98% of pregnant women attending antenatal care at least once during pregnancy, only 10% are tested for HIV and 1% for syphilis (using a mixture of rapid tests and laboratory-based testing). Only 48% of those testing positive for HIV and 30% for syphilis receive treatment.

This poses a formidable challenge and is recognised as one of the most significant gaps in antenatal care in Indonesia. Persistent barriers to antenatal screening for HIV/syphilis include (but are not restricted to): limited awareness among health workers of the need for universal screening; some women are fearful of the test; lack of local standard operating procedures at the clinic level; supply chain gaps in tests and treatments; problems with the referral processes; and difficulties tracking women as they move across the health system. Context-specific interventions to better support the integration of HIV and syphilis testing and treatment into the ANC platform are urgently needed in Indonesia.

Continuous Quality Improvement (CQI), which involves local ANC teams systematically collecting and reflecting on local data to inform the design and implementation of service delivery, has been effectively used to strengthen ANC services in a number of Sub-Saharan African countries. This approach holds considerable promise for Indonesia, a highly populous and diverse country where a ‘one size fits all’ approach to the delivery of quality ANC rarely applies. Using a cluster-randomised design, we will evaluate the effectiveness, cost-effectiveness, acceptability, fidelity and reach of a multi-faceted CQI intervention to improve antenatal testing and treatment of HIV/syphilis in ANC clinics in 6 districts across 3 Provinces (West Java, South Sumatra and South Kalimantan).

This 3-year multi-disciplinary trial will involve clinicians, epidemiologists, economists, social scientists, health services reserachers and policy-makers from the London School of Hygiene & Tropical Medicine, the University of Gadjah Mada, the Indonesian Ministry of Health, World Health Organization and the Kirby Institute. Stakeholders from each study site will also be engaged in the research process including development of a scale-up strategy. This research has the potential to contribute significantly to improved maternal and child health in Indonesia while also strengthening the underlying health system.

Principal investigators:

Professor Virginia Wiseman
Professor Ari Probandari (Universitas Sebelas Maret, Indonesia)
Professor Shunmay Yeung (London School of Hygiene & Tropical Medicine, UK)

 

Project funder: MRC UK

Project collaborators:

• Professor John Kaldor (Kirby Institute, University of New South Wales, Australia)
• Professor Yanri Subronto (University of Gadjah Mada, Indonesia)
• Dr Marco Liverani (London School of Hygiene & Tropical Medicine, UK)
• Professor Matthew Law (Kirby Institute, University of New South Wales, Australia)
• Professor Rebecca Guy (Kirby Institute, University of New South Wales, Australia)
• Professor Rosanna Peeling (London School of Hygiene & Tropical Medicine, UK)
• Dr Ignatius Praptoraharjo (Gadjah Mada University)
• Dr Shita Dewi (Gadjah Mada University)

Addressing quality in the private healthcare sector: A randomised controlled trial of the SafeCare Quality Improvement Programme in Tanzania

SafeCare is a quality improvement model developed by the NGO PharmAccess, aimed at lower-level public and private health facilities in sub-Saharan Africa. The private sector is a major and growing source of care, but there are concerns about quality and safety, and these are insufficiently addressed by government regulation or international hospital accreditation standards. SafeCare was designed to address this gap, offering realistic setting-appropriate standards and stepwise certification, as well as access to credit for implementing improvements.

We undertook a large-scale randomised controlled trial to evaluate the impact on quality of care of the roll out of SafeCare to private for-profit and faith-based facilities in Tanzania. The trial assessed the effects on the quality of care received by patients through comparison of 237 intervention and control facilities after 1.5–2 years of implementation. To do this, we:

• measured clinical quality through standardised patient surveys
• observed infection prevention and control (IPC) behaviours
• conducted in-depth interviews with facility in-charges and implementing staff to assess the perceived benefits and costs of participating, and the factors affecting quality improvement and business performance.
• interviewed national level key informants to explore how the SafeCare model had shaped the market for healthcare and the policy environment

The results are expected to make an important contribution to the evidence base on improving private sector care, and to the literature on measuring process quality of patient care.

Publications

• Jessica J C King, Jishnu Das, Ada Kwan, Benjamin Daniels, Timothy Powell-Jackson, Christina Makungu, Catherine Goodman, How to do (or not to do) … using the standardized patient method to measure clinical quality of care in LMIC health facilities, Health Policy and Planning, Volume 34, Issue 8, October 2019, pages 625–634
• Wiseman V, Lagarde M, Kovacs R On behalf of Members of the Standardised Patients Working Group, et al Using unannounced standardised patients to obtain data on quality of care in low-income and middle-income countries: key challenges and opportunities BMJ Global Health 2019;4:e001908
• Timothy Powell-Jackson, Jessica J C King, Christina Makungu, Nicole Spieker, Susannah Woodd, Peter Risha, Catherine Goodman, Infection prevention and control compliance in Tanzanian outpatient facilities: a cross-sectional study with implications for the control of COVID-19, The Lancet
• Jessica J C King, Timothy Powell-Jackson, Christina Makungu, James Hargreaves, Catherine Goodman, How much healthcare is wasted? A cross-sectional study of outpatient overprovision in private-for-profit and faith-based health facilities in Tanzania, Health Policy Plan,  

  2021 Jun 3;36(5):695-706. doi: 10.1093/heapol/czab039.

• King, J. J. C., Powell-Jackson, T., Makungu, C., Spieker, N., Risha, P., & Goodman, C. (2021). A multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare): a cluster-randomised controlled trial in healthcare facilities in Tanzania Lancet Global Health. doi.org/10.1016/S2214-109X(21)00228-X.

Other outputs

• Policy brief 
• Mystery shoppers for healthcare providers: risky or rewarding in measuring quality of care?

• How much healthcare is wasted? A cross-sectional study of outpatient overprovision in private-for-profit and faith-based health facilities in Tanzania

People

• Catherine Goodman
• Timothy Powell-Jackson
• Jessica King

Ifakara Health Institute: Christina Makungu, Abdallah Mkopi

PharmAccess Foundation: Nicole Spieker, Peter Risha

Dates

Until end of June 2020

HERA – Healthcare Responding to Violence and Abuse

The HERA research study – Healthcare Responding to Violence and Abuse – aims to help health care systems in low-and-middle-income countries (LMIC) to respond effectively to women who experience violence. By strengthening research capacity and conducting research on training and support programmes as well as working with existing services (to strengthen and/or develop their responses to violence against women, VAW), the project will ensure women and their children receive appropriate care by doctors and nurses in primary care (including sexual and reproductive health settings), leading to better health outcomes.

A multi-country study conducted in Brazil, the Occupied Palestinian Territories (West Bank), Nepal and Sri Lanka, HERA is funded by two research grants:

• the Medical Research Council (MRC) Global Challenges Research Fund (GCRF) Foundation Award (2017 to 2019)
• the NIHR Global Health Research Group Award (2018 to 2021)

Through multi-disciplinary research we aim to:

• evaluate the readiness of the Brazilian, Occupied Palestinian Territory/West Bank (oPT/WB),
• Nepalese and Sri Lankan sexual and reproductive health services to identify VAW, respond to the needs of women experiencing violence, and offer referral to VAW services
• conduct research studies with patients and providers to inform the development of the intervention
• develop a tailored training and support intervention for health care professionals with stakeholder involvement
• pilot the intervention in reproductive and sexual health and primary care settings

Capacity strengthening in research is integral to our global partnership and we have used a co-production approach to developing the capacity strengthening programme within HERA which has been independently evaluated.

Papers

• Hawcroft C, Hughes R, Shaheen A, Usta J, Elkadi H, Dalton T and Feder G. Prevalence and health outcomes of domestic violence amongst clinical populations in Arab countries: a systematic review and meta-analysis. BMC Public Health. 2019;19(1):315.
• Manuela Colombini, Abdulsalam Alkaiyat, Amira Shaheen, Claudia Garcia Moreno, Gene Feder, Loraine Bacchus. Exploring health system readiness for adopting interventions to address intimate partner violence: a case study from the occupied Palestinian Territory, Health Policy and Planning

People

• Loraine Bacchus, Co-Director
• Manuela Colombini, Co-Investigator

Outputs

• https://www.bristol.ac.uk/primaryhealthcare/researchthemes/hera/
• Twitter: @HERA_VAW, @LoraineBacchus, @manuelacolombin

Dates

Until March 2021

The PINTAR project - Protecting Indonesia from the threat of AMR (2018-22)

Improving the dispensing of antibiotics by private drug sellers in Indonesia is the missing tactic in the fight against antimicrobial resistance (AMR). Despite the prominence of private drug sellers (PDS) in Indonesia’s health system, little is known about their practices or how to improve governance of this sector.

The goal of this mixed-methods study is to develop and test strategies to improve antibiotic dispensing by PDS in Indonesia. Specific aims are to:

• Understand the economic and social factors that influence the antibiotic dispensing practices of PDS
• Determine the proportion of consumer visits to PDSs for common clinical conditions in which antibiotics are dispensed without a prescription;
• Design and evaluate the effect and cost-effectiveness of a multi-faceted intervention to reduce inappropriate dispensing of antibiotics without prescription by PDS;
• Design a strategy for intervention expansion and monitoring across Indonesia;
• Build capacity in health systems research and evidence-based strategies for improving PDS governance and public-private collaboration (see criteria 2 for details).

Publications

• Wiseman V, Lagarde M, Kovacs R, et al. Using unannounced standardised patients to obtain data on quality of care in lowincome and middle-income countries: key challenges and opportunities. BMJ Global Health 2019;4:e001908. doi:10.1136/ bmjgh-2019-001908

People involved

• Virginia Wiseman
• Mishal Khan
• Shunmay Yeung
• Marco Liverani
• Johanna Hannefeld
• Probadari A
• Wibawa T
• Jan S
• Kaldor J
• Law M
• Guy R
• Batura N
• Schierhout G
• Parathon H
• Heaney A

Dates

2019 – 22

Understanding the role of community pharmacies and drug stores during the COVID-19 outbreak in Indonesia (a sub-study of the PINTAR project) (2020-2021)

This is a sub-study of the 'Protecting Indonesia from the Threat of Antimicrobial Resistance' (PINTAR Study). 

Research to date from the PINTAR study has revealed widespread inappropriate use of antibiotics amongst private drug sellers (PDS) in Indonesia. There is a real and present danger that the COVID-19 pandemic may further exacerbate problems of unnecessary self-medication and spark irrational use and hoarding of antimicrobial drugs such as antivirals, antimalarials and antibiotics. Our team are undertaking a national survey of all registered 
community pharmacies and drug stores across Indonesia to explore their  understanding of the COVID-19 pandemic and the different advice and medicines given to clients in relation to COVID-19. We are also seeking to identify immediate actions that could be taken to improve COVID-19 management practices by private drug sellers, who are the first source of care for the vast majority of patients in Indonesia.

We already have strong engagement with PDS and the Indonesian Pharmacy Association through Phase 1 of the PINTAR study. It is our intention to capitalise on this existing collaboration to undertake research
on the impact of COVID-19 on the practices of PDS in Indonesia.

We are proposing to undertake a mixed-methods study among PDS in Indonesia to explore the following issues:

• PDS knowledge and understanding of COVID-19 including information sources;
• Current advice and medicines given to clients in relation to COVID-19;
• PDS interactions with patients and client expectations of PDS;
• Measures taken by PDS to protect pharmacy and outlet staff from COVID-19
• Any immediate actions that could be taken to improve COVID-19 management practices by PDS

We will explore these issues through a nationwide online survey of all registered PDS and telephone interviews with a sub sample of survey participants. To best of our knowledge, this would be the first study in Indonesia exploring such issues. 

This study will provide vital evidence on the types of advice given and medicines dispensed by community pharmacies and drug stores to suspected COVID-19 patients. This evidence will inform the design of interventions and policies to improve the quality of care offered by private drug sellers during the pandemic. 

Principal investigator: Professor Virginia Wiseman 

Project funder: This research is being funded by a grant from the Indo-Pacific Institute for Health Security (DFAT) under the ‘Stronger Health Systems for Health Security’ Scheme 

Project collaborators:

• Professor Tri Wibawa (Universitas Gadjah Mada, Indonesia)
• Associate Professor Ari Probandari (Universitas Sebelas Maret, Indonesia)
• Associate Professor Virginia Wiseman (Kirby Institute, University of New South Wales, Australia)
• Dr Mishal Khan (London School of Hygiene & Tropical Medicine, UK)
• Doctor Liverani, Marco (London School of Hygiene & Tropical Medicine, UK)
• Professor Stephen Jan (George Institute for Global Health, Australia)
• Associate Professor Shunmay Yeung (London School of Hygiene & Tropical Medicine, UK)
• Professor John Kaldor (Kirby Institute, University of New South Wales, Australia)
• Professor Matthew Law (Kirby Institute, University of New South Wales, Australia)
• Professor Ric Day (Medical Faculty, University of New South Wales, Australia)
• Doctor Neha Batura (University College London, UK)
• Professor Rebecca Guy (Kirby Institute, University of New South Wales, Australia)
• Associate Professor Johanna Hanefeld (London School of Hygiene & Tropical Medicine, UK)
• Ms Aine Heaney (NPS MedicineWise, Australia)
• Doctor Harry Parathon, Harry (Chair Antimicrobial Resistance Control Committee, Indonesian Ministry of Health, Indonesia)
• Doctor Gill Schierhout (Kirby Institute, University of New South Wales, Australia)
• Dr Luh Putu Lila Wulandari, MPH (Kirby Institute, University of New South Wales, Australia)
• Dr Astri Ferdiana (Pusat Kedokteran Tropis, Universitas Gadjah Mada, Indonesia)
• Dr Yusuf Ari Mashuri (Universitas Sebelas Maret, Indonesia)

An implementation trial of continuous quality improvement for antenatal syphilis and HIV detection and treatment in Indonesia: The MENJAGA (protection) Study (2021-2022)

The MENJAGA (protection) Study (2021-2022)

The dual elimination of mother-to-child transmission (EMTCT) of HIV and syphilis through screening and treatment of pregnant women has been identified as a global public health priority. Indonesia, the 4th most populous country in the world, has a national HIV prevalence rate among pregnant women of around 0.3% (15,900 women) with some provinces (e.g. Jakarta) close to the 1% threshold for a generalised epidemic. Comparable estimates for syphilis in pregnancy are unavailable but thought to be similar to those for HIV. The country also has the lowest rate of antenatal screening and treatment for HIV/syphilis in South-East Asia. Despite 98% of pregnant women attending antenatal care at least once during pregnancy, only 10% are tested for HIV and 1% for syphilis (using a mixture of rapid tests and laboratory-based testing). Only 48% of those testing positive for HIV and 30% for syphilis receive treatment.

This poses a formidable challenge and is recognised as one of the most significant gaps in antenatal care in Indonesia. Persistent barriers to antenatal screening for HIV/syphilis include (but are not restricted to): limited awareness among health workers of the need for universal screening; some women are fearful of the test; lack of local standard operating procedures at the clinic level; supply chain gaps in tests and treatments; problems with the referral processes; and difficulties tracking women as they move across the health system. Context-specific interventions to better support the integration of HIV and syphilis testing and treatment into the ANC platform are urgently needed in Indonesia.

Continuous Quality Improvement (CQI), which involves local ANC teams systematically collecting and reflecting on local data to inform the design and implementation of service delivery, has been effectively used to strengthen ANC services in a number of Sub-Saharan African countries. This approach holds considerable promise for Indonesia, a highly populous and diverse country where a ‘one size fits all’ approach to the delivery of quality ANC rarely applies. Using a cluster-randomised design, we will evaluate the effectiveness, cost-effectiveness, acceptability, fidelity and reach of a multi-faceted CQI intervention to improve antenatal testing and treatment of HIV/syphilis in ANC clinics in 6 districts across 3 Provinces (West Java, South Sumatra and South Kalimantan).

This 3-year multi-disciplinary trial will involve clinicians, epidemiologists, economists, social scientists, health services reserachers and policy-makers from the London School of Hygiene & Tropical Medicine, the University of Gadjah Mada, the Indonesian Ministry of Health, World Health Organization and the Kirby Institute. Stakeholders from each study site will also be engaged in the research process including development of a scale-up strategy. This research has the potential to contribute significantly to improved maternal and child health in Indonesia while also strengthening the underlying health system.

Principal investigators:

Professor Virginia Wiseman

Professor Ari Probandari (Universitas Sebelas Maret, Indonesia)

Professor Shunmay Yeung (London School of Hygiene & Tropical Medicine, UK)

Project funder: MRC UK

Project collaborators:

• Professor John Kaldor (Kirby Institute, University of New South Wales, Australia)
• Professor Yanri Subronto (University of Gadjah Mada, Indonesia)
• Doctor Liverani, Marco (London School of Hygiene & Tropical Medicine, UK)
• Professor Matthew Law (Kirby Institute, University of New South Wales, Australia)
• Professor Rebecca Guy (Kirby Institute, University of New South Wales, Australia)
• Professor Rosanna Peeling (London School of Hygiene & Tropical Medicine, UK)
• Dr Ignatius Praptoraharjo (Gadjah Mada University)
• Dr Shita Dewi (Gadjah Mada University)

The DOMINO Study: Measuring and mitigating the indirect effects of COVID-19 on TB and HIV care in Indonesia (2020-2022)

The global health community has made urgent calls for countries to find solutions to minimising the impact of COVID-19 on programs targeting long-standing health problems such as TB and HIV (1). Indonesia, with a population of around a quarter of a billion people, currently has the highest number of COVID-19 infection cases in Southeast Asia, averaging 1000-1300 new infections each day since the 15th June and a case fatality rate of around 6.6% (2). It is also ranked third in TB burden globally (3) and one of a few countries where the number of new HIV infections is rising (4). In recent years Indonesia has strengthened its commitment to controlling these two important diseases. However, the diversion of health resources to the pandemic along with social distancing policies is creating new vulnerabilities and exacerbating existing ones for TB and HIV programs and affected populations.

Our team is partnering with the Indonesian government and community organisations to conduct an observational cohort study across all TB and HIV facilities in the major cities of Bandung (N=62) and Yogyakarta (N=30) to assess clinical outcomes before and during the pandemic. We will analyse routinely collected data to measure linkage to care, retention in care and treatment outcomes along TB and HIV cascades of care. Qualitative methods will be used to explore the experiences of TB and HIV patients and their health care providers during the pandemic, including changes to treatment seeking and actions to minimise disruptions. Out-of-pocket health spending by TB and HIV patients and their families during the pandemic will be measured using structured diaries. Wider health system impacts of COVID-19 on stocks of medicines/tests and health facility funding levels will be assessed using facility records and interviews with health authorities and facility staff. Our findings will generate recommendations on how to minimise disruptions to HIV and TB services in the face of the pandemic.

Principal investigators:

Professor Virginia Wiseman

Professor Ari Probandari (Universitas Sebelas Maret, Indonesia)

Project funder: UKRI

Project collaborators:

• Professor John Kaldor (Kirby Institute, University of New South Wales, Australia)
• Doctor Liverani, Marco (London School of Hygiene & Tropical Medicine, UK)
• Professor Matthew Law (Kirby Institute, University of New South Wales, Australia)
• Professor Yanri Subronto (University of Gadjah Mada, Indonesia)
• Professor Hasbullah Thabrany (USAID Indonesia)
• Professor Riris Ahmad (University of Gadjah Mada, Indonesia)

Completed projects

The rise of chain pharmacies in India and implications for public health

For her PhD, Rosalind Miller studied private retail pharmacies in India. In many communities in low- and middle-income countries (LMICs), pharmacies are widely utilised for obtaining medicines and seeking health advice, but their practice is often poor. Insufficient history taking, a lack of adherence to treatment guidelines, and inappropriate dispensing of medicines are commonplace. In recent years, pharmacy chains have been emerging in South America, Africa and Asia. Chains may have the potential to improve quality, but this has been little studied in LMICs. Miller used mixed methods, including a standardised patient survey and key informant interviews, to understand the effect of chain pharmacies in Bangalore, India on the quality of case management for two tracer conditions.

The management of childhood diarrhoea and suspected tuberculosis was similarly substandard in chains and independents for most areas of assessment. However, chains were found to sell significantly fewer harmful and prescription-only medicines for the diarrhoea patient. In-depth interviews explored a set of hypotheses regarding how being organised in a chain may affected key behaviours relating to quality failures. In practice, few differences were identified in:

• employment of qualified staff
• regulation of firms are regulated
• financial incentives faced by staff

Rosalind is now undertaking an ESRC-funded post-doctoral fellowship which seeks to address shortcomings in pharmacy practice in LMICs. She is working with the International Federation of Pharmacists (FIP) to survey national pharmacy associations to learn more about what guidelines, specifically written for pharmacies, are currently in existence. The ultimate aim of this project is to work towards the creation of a set of global level, pharmacy-specific guidelines for the management of key conditions.

Chains were found to exert strong influence over their staff but the potential to exploit this has not been realised.

Papers

• Miller, R; (2018) The rise of chain pharmacies in India: implications for public health. PhD (research paper style) thesis, London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.17037/pubs.04650724
• Miller, Rosalind; Hutchinson, Eleanor; Goodman, Catherine; (2018) 'A smile is most important.' Why chains are not currently the answer to quality concerns in the Indian retail pharmacy sector. Social science & medicine, 212. pp. 9-16. ISSN 0277-9536 DOI: https://doi.org/10.1016/j.socscimed.2018.07.001
• Miller, Rosalind; Goodman, Catherine; (2017) Do chain pharmacies perform better than independent pharmacies? Evidence from a standardised patient study of the management of childhood diarrhoea and suspected tuberculosis in urban India. BMJ global health, 2 (3). e000457-. ISSN 2059-7908 DOI: https://doi.org/10.1136/bmjgh-2017-000457
• Miller, Rosalind; Goodman, Catherine; (2016) Performance of retail pharmacies in low- and middle-income Asian settings: a systematic review. Health policy and planning, 31 (7). pp. 940-953. ISSN 0268-1080 DOI: https://doi.org/10.1093/heapol/czw007
• Miller, R.; Goodman, R. Cheaper Medicines for the Better Off? A Comparison of Medicine Prices and Client Socioeconomic Status Between Chain and Independent Retail Pharmacies in Urban India. International Journal of Health Policy and Management. 2020. DOI: https://doi.org/10.34172/ijhpm.2020.214

People

• Rosalind Miller
• Catherine Goodman, primary supervisor
• Eleanor Hutchinson, secondary supervisor

Outputs

• Cheaper Medicines for the Better Off? A Comparison of Medicine Prices and Client Socioeconomic Status Between Chain and Independent Retail Pharmacies in Urban India

Effect of a multifaceted social franchising model on quality and coverage of maternal, newborn and reproductive health-care services in Uttar Pradesh, India

How can we harness the private sector to improve population health in low-income and middle-income countries? One strategy, heavily supported by the donor community in recent years, is social franchising. In this quasi-experimental study, we evaluated 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 found that the programme did not have a measurable effect on the proportion of women giving birth in a health-care facility, nor did it improve any other individual outcome. We measured a wide range of pre-specified outcomes along the continuum of care for maternal, newborn and reproductive health, and found consistent results of no measurable effect. The findings should place a higher burden of proof on policy makers and funders looking to invest in social franchising for maternal health.

Find out more on the Maternal Healthcare Markets Evaluation Team website.

Publications

Sarah Tougher, Varun Dutt, Shreya Pereira, Kaveri Haldar, Vasudha Shukla, Kultar Singh, Paresh Kumar, Catherine Goodman, Timothy Powell-Jackson, (2018) 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, Lancet Global Health

Penn-Kekana, L., Powell-Jackson, T., Haemmerli, M. et al. (2018) Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India, Implementation Science

Pereira, S.K., Kumar, P., Dutt, V. et al. (2015) Protocol for the evaluation of a social franchising model to improve maternal health in Uttar Pradesh, India, Implementation Science

People

• Timothy Powell-Jackson
• Sarah Tougher
• Catherine Goodman