16. Agha S., A.M. Karim, A. Balal and S. Sossler   (2003), ‘A Quasi Experimental Study to Assess the Performance of a Reproductive Health Franchise in Nepal’, Commercial Market Strategies (CMS), Country Research Series Paper No.14, Washington DC.

In 2001 the Commercial Market Strategies (CMS) project established a nurse and paramedic franchise in Nepal to increase utilization of reproductive health services and client satisfaction with service quality. To assess the impact of the intervention, CMS used a quasi-experimental study design, with baseline and follow-up measurements on non-equivalent control groups. Three instruments were administered to study participants: client exit interviews, provider interviews, and household interviews. Baseline surveys were conducted during April and May 2001. Follow-up surveys were conducted during December 2002 and January 2003. Multi-level random-effect models were used to estimate clinic/cluster-level variances. Civil unrest in Nepal caused major delays in project implementation: The evaluation presented in this report covers about 10 months of actual implementation. CMS found that at the clinic level, client satisfaction increased at intervention clinics, but not at control clinics. Client loyalty, measured by return visits, also increased at intervention clinics, but not at control clinics. The increase in client loyalty was explained, in part, by the increase in satisfaction with service quality. At the population level, CMS did not find consistent increases in utilization of various reproductive health services, possibly because (1) providers were not proactive in informing clients who came for general health services about the reproductive health services being offered; (2) mass media activities had limited impact on increasing awareness of reproductive health services being provided by the nurse and paramedic franchise; and (3) the intervention was implemented for too short a period of time for it to have had a measurable impact. While utilization of other reproductive health services did not change, an increase in contraceptive use may have been associated with use of the nurse and paramedic network. CMS concluded that a franchiser that provides training to franchised clinics in reproductive health service delivery and in client–provider interaction and that monitors the quality of care provided at these clinics can help increase client satisfaction at network clinics.