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Bull World Health Organ. 2017 May 1;95(5):343-352E. doi: 10.2471/BLT.16.179556. Epub 2017 Mar 24.

Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India.

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Sanford School of Public Policy, Duke University, 302 Towerview Drive, 128 Rubenstein Hall, Durham, North Carolina, NC 27708, United States of America (USA).
Department of Economics, Queen Mary University of London, London, England.
Department of Anthropology, Johns Hopkins University, Baltimore, USA.
Department of Internal Medicine, Yale University School of Medicine, New Haven, USA.
Indian Institute of Public Health, New Delhi, India.
Sambodhi Research and Communications Pvt. Ltd., New Delhi, India.
Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, USA.
Department of Economics, University College London, London, England.


in English, Arabic, Chinese, French, Russian, Spanish


To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme - the World Health Partners' Sky Program.


We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers' performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models.


The programme did not significantly improve health-care providers' knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered.


Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.

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