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Table 6 T-HOPE framework: comparison of programs using MNCH (three programs)

From: Assessing health program performance in low- and middle-income countries: building a feasible, credible, and comprehensive framework

 

Comparative Features

Program MNCH 1 (South Asia)

Program MNCH 2 (South East Asia)

Program MNCH 3 (South Asia)

Overview

 

A for-profit hospital chain providing health care to women and children.

A not-for-profit network of franchised clinics providing maternal and child health services and family planning, reproductive health and HIV/AIDS services.

A not-for-profit clinic franchise offering services for maternal and child health, family planning and reproductive health, general primary care, tuberculosis and malaria.

Health Output (A2)

Programs MNCH 2 and 3 serve millions of clients a year, while Program MNCH 1 serves about 10,000 patients a year.

Since its inception in 2005 through the summer of 2007, the program served over 21,271 outpatients and 1,810 inpatients, of which 1,043 were there for deliveries. The program has become the largest chain in the region, treating more than 70,000 patients and delivering more than 7,000 healthy babies.

In 2010 alone, the program’s 629 centers, across 40 countries, provided 7 million couples with high quality health services, including: family planning; safe abortion & post-abortion care; maternal & child health care, including safe delivery and obstetrics; diagnosis & treatment of sexually transmitted infections; and HIV/AIDS prevention.

In 2010, the program served 9.5 million clients needing services for diarrhea, pneumonia, immunization, and child delivery in the hospital and at home.

Health Outcome (A3)

Both Programs MNCH 1 and 2 show improvements in health outcomes due to their interventions, with Program MNCH 1’s impact involving changes in healthy prenatal and delivery behaviours, and Program MNCH 2’s showing an impact in reproductive health.

Of all the women who deliver their second or third child at the program, over 50 % had their previous delivery at home or in an under-resourced government hospital; between 2011 and 2012, the average antenatal visits by the pregnant women increased from 2.5 to over 4.

The program provided 49,619 IUDs in 2011, which was the major contributor to its 283,571 CYPs generated during the period.

 

Affordability (B1)

Program MNCH 3 provides free services for the poor, while Programs MNCH 1 and 2 provide services for less than other similar local offerings. Program MNCH 1 provides services for approximately one fifth the cost of similar services elsewhere, while Program MNCH 2 provides services for approximately one third to one sixth the cost of similar services elsewhere.

In 2012, the price of a normal delivery at the program was approximately US$40, compared to the standard US$200, and this includes all doctor and nurse visits, all medicines, and the complete stay in the hospital.

In 2012, the program had both mandatory and recommended pricing. For example, the price for an IUD is set at US$2. Competitive prices for an IUD in private clinics range from US$6.60–US$13. Deliveries by midwives range from US$33–US$77, whereas private doctor and hospital prices for midwives range from US$220–US$330.

In 2012, prices for services ranged between US$0 (for the poor) and US$0.38.

Availability (B2)

Both Programs MNCH 1 and 2 are roughly within walking distance of the communities they serve.

In 2012, families who patronized the hospital typically lived within a 5 km radius of the hospital. Strong word of mouth recommendations extended this radius up to 20 km.

In 2012, 81 % of the program’s facilities were within walking distance for community women.

 

Pro-Poor Targeting (B3)

All programs serve poor clients. For Programs MNCH 2 and 3, approximately one third to one half of their clients are impoverished. Program MNCH 1 serves clients that are disadvantaged but not at the bottom of the pyramid.

The program targets customers from a key tier in the national population: not the very bottom of the pyramid, but those that are low down on the pyramid. Monthly family income of customers is as follows: 40 % earn below US$90 per month; 30 % earn between US$91 and US$130 per month; 20 % earn between US$131 and US$220 per month; and 10 % earn above US$220 per month. The poverty line in the region is US$31 per month.

In 2011, 46 % of the program’s clients were members of households whose incomes fell below the poverty line; 66 % were unemployed; and 78 % had at least 2 children.

One of the primary goals of the program is to serve poor patients and therefore all clinics have what is known as a poorest-of-the-poor fund. Clients that qualify as poor receive a card, which entitles them to receive free services. The official qualification process for the card is based on criteria used by the national public health department to identify lower socio-economic status, but if a client indicates that they are poor, they are provided with the card. The program reports that 27 % of its patients are poor.

Clinical Quality (C1)

All programs show impact in clinical quality in provision of clinical services.

Through the program’s long-standing partnership with a U.S. health care institute, its clinical quality indicators have shown significant improvement. For example, its “culture of safety” ratings increased from 35 % in January 2010 to 77 % in December 2010.

Through the program’s Quality Technical Assessment, 100 % of franchised-midwives were found adhering to service provision standards and having maintained confidence in their delivery of program services.

As of 2011, there were almost 6,000 safe deliveries per quarter. Only one woman had died while giving birth under the care of a franchised facility since the program’s inception.

User Satisfaction (C2)

Programs MNCH 2 and 3 show approximately 60–70 % of patients are satisfied with services. In addition, 98 % of Program MNCH 2’s patients expressed loyalty, suggesting high user satisfaction. Only 0.3 % of Program MNCH 1’s patients have filed complaints regarding services, also suggesting a high level of patient satisfaction.

Only 18 complaints from about 6000 users of inpatient services were received through the program’s complaint registration system between 2011 and 2012.

61 % of the program’s clients identified themselves to be ‘satisfied’ with regard to price and 68 % in regard to the feeling of comfort. In addition, 58 % expressed satisfaction equivalent to that of the evaluation's highest scale in terms of feeling security against conception. 98 % expressed loyalty to the program, which was primarily based on quality of services.

The clients are typically loyal users of the program’s services and the franchise found that that 71 % of customers are repeat users.

Management Quality (C3)

All programs conduct monitoring protocols to ensure high quality management and operations.

The flagship hospital was ISO 9001:2000 certified in 2007. Customer-focused service is embodied in the program’s protocol and approach whereby each employee is expected to be polite, attentive, and respectful to patients.

Clinical compliance audits, business systems audits, and franchisee and customer satisfaction surveys are conducted regularly through site visits at each franchisee. Team members help franchisees correct problems with entering data.

Not-for-profit organizations monitor clinical quality of the clinics and report findings and progress on resolving performance gaps to the program head office. A clinic level quality circle is in place and all clinic staff members are responsible for maintaining the quality of the services they provide. A clinical quality council reviews clinic performance indicators.

Economic Efficiency (C4)

Both Program MNCH 2 and 3 report on cost per CYP, with Program MNCH 3’s costs at less than half that of Program MNCH 2.

 

The cost per CYP generated has dropped to US$16 after 2 years - roughly on par with other franchises at similar stages of development.

The cost per CYP generated is about US$7.

Human Resources Supply (C6)

All programs report on their human resources situation. Program MNCH 1 describes efforts to attract doctors and employ other types of health workers to keep costs low. Program MNCH 2 describes training for franchisees, and Program MNCH 3 describes reasons for staff turnover.

Talent recruitment: doctors earn fixed salaries so they can focus on care of existing patients as opposed to the need to attract new customers. The program typically employs Auxiliary Nurse Midwives who undergo significantly less training than Graduate Nurse Midwives, reducing costs and attrition.

As part of staff training, franchisees must complete a minimum of 10 supervised IUD insertions, 5 IUD removals, and 10 pap smears.

Within the franchisors’ headquarters, 35 % of staff turnover was due to releasing staff for performance reasons, while 65 % of staff turnover was due to career advancement either for opportunities outside the country or in-country promotions.

  1. The text summarizes the implications of these comparisons