The effect of report cards on the coverage of maternal and neonatal health care: a factorial, cluster-randomised controlled trial in Uttar Pradesh, India

Abstract

Background Report cards are a prominent strategy to increase the ability of citizens to express their view, improve public accountability, and foster community participation in the provision of health services in low-income and middle-income countries. In India, social accountability interventions that incorporate report cards and community meetings have been implemented at scale, attracting considerable policy attention, but there is little evidence on their effectiveness in improving health. We aimed to evaluate the effect of report cards, which contain information on village-level indicators of maternal and neonatal health care, and participatory meetings targeted at health providers and community members (including local leaders) on the coverage of maternal and neonatal health care in Uttar Pradesh, India. Methods We conducted a repeated cross-sectional, 2 × 2 factorial, cluster-randomised controlled trial, in which each cluster was a village (rural) or ward (urban). The clusters were randomly assigned to one of four groups: the provider group, in which we shared report cards and held participatory meetings with providers of maternal and neonatal health services; the community group, in which we shared report cards and held participatory meetings with community members (including local leaders); the providers and community group, in which report cards were targeted at both health providers and the community; and the control group, in which report cards were not shared with anyone. We generated these report cards by collating data from household surveys and shared the report cards with the recipients (as determined by their assigned groups) in participatory meetings. The primary outcome was the proportion of women who had at least four antenatal care visits (ie, attended a clinic or were visited at home by a health-care worker) during their last pregnancy. We measured outcomes with cross-sectional household surveys that were taken at baseline, at a first follow-up (after 8 months of the intervention), and at a second follow-up (21 months after the start of the intervention). Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN11070792. Findings We surveyed eligible women for the baseline survey between Jan 13, and Feb 5, 2015. We then randomly assigned 44 clusters to the provider group, 45 clusters to the community group, 45 clusters to the provider and community group, and 44 clusters to the control group. Report cards of collated survey data were provided to recipient groups, as per their random allocation, in October, 2015, and in September, 2016. We ran the first follow-up survey between May 16 and June 10, 2016. We ran the second follow-up survey between June 18 and July 18, 2017. We measured the primary outcome in 3133 women (795 in the provider group, 781 in the community group, 798 in the provider and community group, and 759 in the control group) who gave birth during implementation of the intervention, between Feb 1, 2016, and July 18, 2017 (the end of the second f...

A summative content analysis of how programmes to improve the right to sexual and reproductive health address power

“…For example, several programmes entailed health facility-led efforts to engage communities in expressing their priorities regarding quality of care; some of these had an explicit health facility accountability component 35 37 42 85–88. Other health sector programmes aimed to create change in the way organisations operate, including health facilities89–92; health and allied professional associations and other organisational stakeholders in SRH, including law enforcement93–95; schools96; and factories 97. For example, a school-based programme in Uganda supported teachers to exercise respectful leadership, such as through the practice of non-punitive discipline 96…”

“…Many of the health facility-focused programmes aimed to foster the provision of respectful (maternity) care, such as programmes aiming to improve communication between providers and patients and their families; to ensure that providers do not employ condescending, demeaning or discriminatory language; and to support community monitoring of health facilities to prevent and document disrespect 91 92 101 102. To effect such change, some programmes created mechanisms of communication between health providers/facilities and communities to increase health system responsiveness,35 44 89 103 or introduced a birth companion or care navigator to change the dynamics of power between the patient and providers 104…”

“…Fifty-three of the programmes—almost 60% of the total—addressed the community level; 11 of them focused solely on the community. Some of the analyses sought to compare programmes that engaged the community with those that did not 89 105. Most of the community-focused activities included community mobilisation and/or dialogue 38 42 71 83 87 89 97 103 105–109.…”

“…Some of the analyses sought to compare programmes that engaged the community with those that did not 89 105. Most of the community-focused activities included community mobilisation and/or dialogue 38 42 71 83 87 89 97 103 105–109. In some cases, this mobilisation and dialogue was described as the community component of a programme trying to impel health system responsiveness to community SRH concerns 37 38 42 85–87 89 103 105…”

The effect of community engagement on healthcare utilization and health insurance enrollment in Ghana: Results from a randomized experiment

“…The experiment was set up to test the importance of report card information versus creating an interface between providers and community members. Similarly, a report card study in India (Fabbri et al, 2019) (45 clinics in each of three treatment arms) also found no effected of any of the interventions on the targeted outcome of maternal care. That study was set up to test the importance of discussing the outcomes of the report card in provider groups, community groups or both.…”