How did we get here?
At Merck for Mothers, we are committed to saving women’s lives and bringing fresh thinking to the age-old problem of maternal mortality. One of the most important areas of our work is rather unorthodox for the maternal health field: exploring how the local private health sector can be leveraged to strengthen the overall health system.
From our early visits to countries like Nigeria, India, Uganda and Kenya, we saw that private, community-based doctors, midwives, pharmacists and other providers were playing important, often critical roles in delivering healthcare to pregnant women, yet they remain largely overlooked by the global health community. We heard from women and experts alike that these private providers were often where women turned for care because they were close to home, attuned to local needs and customs, open longer hours and perceived to offer high-quality services.
It soon became clear that if we really want to ensure women get the care they need for a healthy pregnancy and a safe childbirth we must improve the services they receive wherever they seek care. From our experiences to date, we have learned a tremendous amount that we believe could be valuable for the maternal health field. We have outlined some of those learnings here.
What are we focusing on?
We began with three-year investments inUganda and India – countries that continue to struggle with maternal mortality and where large portions of the population seek care from the private health sector. We set out to design and test new solutions in maternal healthcare that have the potential to be scaled and sustained, such as social franchising and accreditation. We also built in a rigorous evaluation plan to learn which interventions work, whether they are cost-effective, how likely they are to be sustainable given market dynamics and their potential impact on maternal mortality.
Leveraging private care to improve maternal health in Uganda
In Uganda, we’ve partnered with Population Services International and its local affiliate, PACE, on a project called MSD for Ugandan Mothers (MUM). We’re working with PACE to ensure that pregnant women – particularly those in remote and low-income communities – have access to affordable, quality maternal health products and services through the ProFam network of private franchise clinics. This comprehensive project is also working beyond the clinic setting, helping women overcome common barriers to care, such as cost, transportation and limited supplies. To date, MUM has expanded the ProFam social franchise to more than 140 health facilities and improved access to quality care for more than 100,000 women and counting.
Leveraging private care to improve maternal health in India
In India, we’ve partnered with leading health organizations to expand women’s access to affordable, quality maternal healthcare in Jharkhand, Rajasthan and Uttar Pradesh – three states with some of the highest rates of maternal mortality in the country. With Pathfinder International and World Health Partners, we created a novel partnership that links and strengthens the public and private health sectors through social franchising, telemedicine, capacity building and referrals. We’re working with Jhpiego and the Federation of Obstetric and Gynaecological Societies of India (FOGSI) to develop standards of quality care and help providers meet those standards through training, continuous quality improvement and accreditation. And finally, we’re working with Hindustan Latex Family Planning Promotion Trust (HLFPPT) to expand a sustainable social franchise network of private hospitals – identifying the right incentives to ensure quality maternal health and family planning services.
What have we learned about the local private sector’s role in maternal health?
Private providers are a diverse group. Private care is offered by midwives, drug shop owners, and formal and informal providers, most of whom work independently, making it difficult to standardize the care they deliver. India, for example, has more than 80 types of private providers.
Given their diversity, some private providers are better placed than others to offer comprehensive maternal health services. Private providers who want to extend their services beyond antenatal/postnatal care and family planning must first develop the capacity to take on labor and delivery services. The latter are more complex and expensive to offer because they require specialized training, equipment, supplies and referral systems, especially when it comes to managing childbirth emergencies. It can be a particular challenge to provide labor and delivery care in rural areas where infrastructure is more limited and there are fewer skilled providers.
Volume of deliveries is an important consideration in determining where to invest in capacity building. Many providers see relatively few deliveries and even fewer complications and emergencies, making it difficult to maintain their skills so they can consistently and effectively manage these rare cases. In some contexts, it may be more efficient to support capacity building efforts in peri-urban areas where there are more private providers, greater numbers of deliveries and high maternal mortality. It’s also important to ensure that providers with relatively few deliveries offer high quality antenatal and postnatal care and make timely, appropriate referrals.
Assuring the quality of private maternal care requires a different approach. Time is money for private providers. They have limited availability to take on complex quality assurance and quality improvement efforts. If we want to encourage them to deliver high quality services, we need to develop more efficient and tailored strategies for training, meeting standards and measuring performance. Private providers will engage in delivering higher quality care as long as incentives are aligned.
Social franchising may be an effective way to expand the availability of private maternal healthcare while assuring its quality. Social franchising has been successful in expanding access to affordable family planning and primary healthcare. We are hopeful that Merck for Mothers’ programs in India and Uganda will demonstrate that it is possible to extend the franchise model to maternal health, increasing the availability of quality pregnancy and childbirth-related services.
Accrediting health providers may be another effective way to ensure quality care, but new approaches are needed. In India, we’ve heard from private providers that the current accreditation system is cumbersome and does not offer sufficient incentives to encourage them to participate. As governments and independent bodies develop accreditation structures, they must address the barriers preventing private providers from participating. And to truly assure quality, accreditation standards should be comprehensive enough to capture the actual care delivered, not just a clinic’s infrastructure or a provider’s qualifications.
Examining private maternal healthcare provides valuable lessons for countries striving to strengthen their health systems. As countries like India and Uganda begin to take on the worthy challenge of achieving universal health coverage, we believe the local private health sector should be an important part of the equation. We hope that the models we are testing — social franchising, accreditation and linking public and private care — will prove successful and provide a way forward for governments to leverage high quality private care to meet their national health goals. Working together, we’re optimistic that we can ensure women receive affordable, quality care wherever they seek it.
Dr. Priya Agrawal
Executive Director, Merck for Mothers