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J.biosoc.Sci, (2007) 39, 341354,  2006 Cambridge University Press doi:10.

1017/S002193200600174X First published online 11 Dec 2006

CHANGES IN PERCEPTIONS OF QUALITY OF, AND ACCESS TO, SERVICES AMONG CLIENTS OF A FRACTIONAL FRANCHISE NETWORK IN NEPAL
SOHAIL AGHA, ANASTASIA GAGE ASMA BALAL Department of International Health and Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA

Summary. With declining levels of international donor funding for nancing reproductive health programmes, developing country governments and international donors are looking towards private sector strategies to expand the supply of quality reproductive health services. One of the challenges of a health franchise is to improve the quality of services provided by independent private practitioners. Private providers are more likely to abide by the quality standards set by a franchiser if they see a nancial benet resulting from franchise participation. This study was conducted to measure whether (a) there were improvements in perceived quality of care and perceived access to health facilities once these facilities became part of a franchise and (b) improvements in perceived quality and perceived access were associated with increased client loyalty to franchised clinics. Franchisees were given basic reproductive health training for seven days and services marketing training for two days. Exit interviews were conducted with male and female clients at health facilities. A pre-test measurement was taken in April 2001, prior to the start of project activities. A post-test measurement was taken in February/March 2002, about 9 months after the pre-test. Multilevel regression analysis, which takes the hierarchical structure of the data into account, was used for the analysis. After taking provider-level variation into account and controlling for client characteristics, the analyses showed signicant improvements in perceived quality of care and perceived access to services. Private provider participation in a franchise network helps improve client perceptions of quality of, and access to, services. Improvements in client perceptions of quality and access contribute to increased client loyalty to franchised clinics. Once increased client loyalty translates into higher client volumes, providers are likely to see the benets of franchise participation. In turn, this should lead to increased provider willingness to remain part of the franchise and to abide by the standards of quality set by the franchiser. 341

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S. Agha, A. Gage and A. Balal Introduction

The resources currently available to meet the reproductive health (RH) needs of women in developing countries are inadequate. This is due to a greater demand for RH services arising from there being (a) a larger number of women of reproductive age than ever before, and (b) the need to provide a wider range of RH services to women. At the same time, donor funding for RH services is stagnating (Indacochea & Vogel, 2001; Ross & Bulatao, 2001). To meet the greater need for RH services, various models of service provision through the private sector are being tested (Mills et al., 2002). One particular service delivery model involves establishing a private provider franchise, with each provider delivering the same package of services under an umbrella brand. Because of the abundance of small-scale independent private sector providers in many developing countries, the franchise model has the potential to increase substantially the provision of RH services. When a franchised set of services is added to existing general health services that are not franchised, this model is referred to as a fractional franchise. In a fractional franchise, providers are trained to provide the new services by a franchiser/controlling organization that monitors the quality of services provided by franchisees. Franchisees have the right to provide franchised services under the umbrella brand as long as they are able to meet the quality standards set by the franchiser (Commercial Marketing Strategies Project, 2002; Montagu, 2002). Key elements of a fractional health franchise include making new services available, assuring the quality of services, increasing awareness of services among potential clients and raising the level of utilization of services. These elements are interrelated: services have to be available in order to be used; non-use of services may lead to services being discontinued; improvements in perceived service quality may lead to continued or increased use of services (Haddad et al., 1998; Montagu, 2002). The equity of the franchise brand name and the eventual success of a franchise depend on franchisees motivation to meet the quality standards of the franchise. Franchisees may be quite motivated to maintain the quality standards of a franchise once the franchise is established and the benets of franchise participation are visible. However, provider motivation to maintain the prescribed standards of quality may be lower in the initial stage of a franchises establishment. Hence, it is especially important that providers remain motivated to continue providing services at the expected quality standard before the franchise develops a recognized brand name. The motivation to remain part of the franchise helps providers overcome the cost of changing behaviour in terms of providing services at a higher level of quality than before. However, increased clientele at the clinic can serve as an important incentive for providers. This study examines whether there were changes in perceived quality and perceived access to health facilities that became part of a fractional franchise network in Rupandehi district, Nepal, and whether client perceptions of quality and access were associated with higher levels of client loyalty to franchised clinics. The franchise network The SEWA nurse and paramedic franchise was launched on a pilot scale in Rupandehi district in May 2001. Rupandehi district had few trained physicians, since

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trained physicians tend to establish practices in Kathmandu Valley. Rupandehi district did have a number of nurses and paramedics. Sixty-four nurses and paramedics, including sta nurses, health assistants, auxiliary nurse midwives, auxiliary health workers and community medical assistants, from the 120 such providers in Rupendehi district, were recruited to be part of the SEWA franchise. A contractual agreement was developed that clearly dened the roles and responsibilities of both the franchisee and the franchiser the Nepal Fertility Care Center. Franchisees were expected to pay a one-o registration fee of US$14. In addition, an annual membership fee of US$9 was to be paid in monthly instalments. To be selected as a member, providers needed to (a) have completed their professional training at a registered training institution, (b) own or rent a certied private facility, (c) have been previously trained to provide injectable contraception. In addition, franchisees had to be willing to comply with the clinic monitoring protocols established by the Nepal Fertility Care Center. All franchisees were given a seven-day basic training in reproductive health (RH). A subset of eligible female providers was given additional training for IUD insertion. The basic RH training included the following elements: (1) supply of non-clinical contraceptive methods, provision of information about clinical contraceptive methods, referrals for clinical methods, counselling techniques, screening, management of side-eects, and infection prevention; (2) antenatal care training included identication of high-risk pregnancy (related to blood pressure, urine sugar/ albumin, weight or anaemia), referral for high-risk pregnancy, provision of tetanus toxoid immunization, nutritional counselling, family planning counselling and referral for safe delivery; (3) identication of STI symptoms, syndromic management of STIs, and individual and couple counselling for the prevention of STIs/AIDS. A separate two-day session was conducted on services marketing. Training was organized around the following elements: (1) how promotional activities such as mass media, outreach and IEC are used to generate demand for services (external marketing); (2) how the development of trust, bonding, empathy and reciprocity builds loyalty with a client (relationship marketing); (3) how quality of services is important in increasing clients perceptions of the value of the services oered; (4) how word-of-mouth is important in increasing client ow. The sessions used a combination of lectures, role-plays and group exercises. As part of their training session in service marketing, all franchisees were asked to develop marketing plans using what they had learnt during the training. The franchisees were supported by an external marketing campaign revolving around a brand name and logo. These were developed after a series of focus groups with the client population and with providers. Planned marketing activities included creating awareness and demand for the franchise services through radio advertisements, brochures, leaets, a door-to-door campaign, hoarding boards, clinic open houses, promotional booths in local farmers markets, and advertisements in print media. However, political and civil unrest in Nepal caused major delays in the implementation of the external marketing campaign and most marketing activities, including mass media advertising and outreach activities, began just before the implementation of the post-test exit survey in February 2002. Referral linkages were established to strengthen the franchise. The internal referral system allowed providers to refer clients to trained female providers for IUD insertion

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or removal. For the referral of more complicated health problems, external linkages were established with private physicians and government health facilities in the district. This mechanism was established to facilitate client access to an integrated package of services. A eld coordinator made monthly quality monitoring visits to the franchisees. The main purpose of these visits was to ensure that service quality protocols, which are based on the elements of quality dened by Judith Bruce (1990), were being followed. The eld coordinator observed service delivery at the clinic and administered a detailed quality checklist to assess the providers compliance with quality protocols. The coordinator shared the results of her assessment with the service provider and suggested corrective action to improve areas of weakness. The eld coordinator assessed provider performance relative to specic aspects of providerclient interaction that were covered in the service marketing training. She emphasized various aspects of relationship marketing such as positive clientprovider interaction and informing clients about services oered at the clinic. The franchiser helped establish a relationship between the local social marketing company and SEWA providers. Although no special discounts were given to franchise members, this relationship enabled providers to have a steady supply of subsidized family planning products. Finally, a monthly newsletter was circulated to all franchise members to keep them informed of franchise activities and to reinforce their aliation to the network.

Methods Study design A pre-test/post-test cross-sectional non-experimental design was used for the study. Measurements were taken at two points in time from exit clients at health facilities staed by nurses and paramedics. The exit clients were not necessarily the same at these two points in time. For the pre-test measurement, 24 of the 70 health facilities identied as potential franchise members were selected through stratied random sampling. Strata were determined by geographic location and provider qualication. For the post-test measurement, 24 facilities were selected using the stratied sampling procedure used for the pre-test. Of these 24 selected providers, two could not be contacted. Hence, the post-test client exit interviews were conducted at 22 facilities. All post-test interviews were conducted at clinics that became part of the SEWA franchise. Female interviewers were given four days of training on how to administer the questionnaire. Two female interviewers were stationed at each clinic from 8 am to 7 pm for two full days. Except for a few clients who had come to purchase drugs in an emergency, interviewers were trained to interview all male and female clients who exited an outlet. Pre-test interviews were conducted during April 2001. A total of 205 male and 286 female clients were interviewed for the pre-test. Post-test interviews were conducted after about 9 months, during February/March 2002. A total of 323 male and 294 female clients were interviewed for the post-test. Because of the non-experimental study design and the absence of a control group, it was not possible to determine whether the changes observed during the study period

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were due to the intervention. Thus, changes in client perceptions of quality may be a reection of improvements in provider behaviour resulting from the intervention or they may be a reection of secular change. Changes over time may also be a reection of uncontrolled dierences between the two cross-sectional samples that were used for this analysis. However, it is unlikely that the changes observed were due to the eects of other interventions: we are not aware of any other interventions that focused on improving the quality of care oered by providers in Rupandehi during the 9-month study period. The questionnaire and measures The questionnaire collected information on socio-demographic variables: age, gender, marital status and education. It collected information on service utilization: whether the visit was for reproductive health or general health reasons; whether it was a rst or return visit to the outlet. The questionnaire collected information on perceived quality and perceived access to services. A previous study in Nepal showed that client perceptions of the quality and accessibility of services were the most commonly cited reasons for choice of provider (Center for Research on Environment, Health and Population Activities, 2000). Pre-tests of the exit survey instrument conrmed that perceived quality and perceived accessibility were the most commonly cited reasons for choice of provider. The questionnaire was designed to measure clients overall perceptions of the quality of services oered. For the principal outcome measures, the study relied on clients unprompted responses to the question Why did you choose to visit this facility? Coded response options included the providers caring manner, the providers expertise or reliability, the clients personal knowledge of the provider, the proximity of the facility and the convenient location of the facility. An alternative approach would have been to measure client perceptions of the quality of specic franchised services. Overall perceptions of quality were preferable for two reasons: clients tend to generalize their perceptions of the quality of a particular providers services without dierentiating categories of services oered; clients nd it dicult to separate franchised services from other provider-oered services since the same space is shared for examination and equipment (Montagu, 2002). A methodological diculty related to measuring perceived quality is that clients are usually unwilling to express negative opinions about providers (Bernhart et al., 1999; Williams et al., 2000). This type of problem arises from courtesy bias. Several approaches have been used to reduce or eliminate the eect of the courtesy bias in client responses. One approach has relied on assessing changes in perceived quality by relying solely on clients negative opinions of service quality (Williams et al., 2000). Since only a small percentage of clients tend to evaluate the quality of services negatively, this approach is most useful when the number of respondents to this question is large. A second approach measures perceived quality in relation to events or behaviours. For example, to determine privacy, a patient is asked whether only the care-giver was present rather than being directly asked if privacy was observed (Bernhart et al., 1999). This study uses the second approach to assess client perceptions of the overall quality of services: the instrument measures attributes of

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services that are of value to clients and may be expected to inuence clients utilization of these services in the future. A similar approach has been used elsewhere (Bernhart et al., 1999; Agha et al., 2004). Client loyalty was another important outcome variable of interest. A proxy measure was used for client loyalty, based on whether the clients visit was a rst visit or a return visit. This information was collected from the following question: Is this your rst visit to this facility or have you visited here before? Statistical analysis The exit survey data have a hierarchical structure, with respondents nested within providers. Variation is possible both at the individual and provider levels. Indeed individuals may choose providers with certain attributes (including but not limited to their participation in the network). A standard regression analysis using hierarchical data would produce biased parameter estimates because of a failure to take the non-independence of error terms at dierent levels into account. Multilevel analysis was conducted to take the hierarchical data structure into account and to control for non-independence of error terms at the provider and the individual levels. The general equation to be estimated is: ln

S D
pij 1 pij

kj

Xkij

0j

eij qj,

where pij is the probability of occurrence for case i in sample j, k the xed component of the regression coecient for variable k, kj the random component of that regression coecient, 0 and 0j the xed and random components, respectively, of the intercept, Xkij the observed value for variable k for case i in survey j, eij the error term for the case and qj is the provider-level variable identifying the type of provider. To estimate this equation MlwiN version 21 was used (Rasbash et al., 2002). This multilevel analysis program allows for binomially distributed dependent variables. In a rst model the signicance of the random components was checked (kj). The random components of regression coecients were not signicant at =5% for any equation. This indicates that the eects of the independent variables do not vary signicantly over the providers, and that there is no interaction between the client and provider levels. In the nal model, only the xed components for all coecients were estimated, and all random components except for 0j were set to 0. The term 0j was signicant at =5% for all equations in Table 2, indicating signicant variation at the provider level. The nal models, shown in Tables 2 and 3, were estimated using the following equation: ln

S D
pij 1 pij

Xkij

0j

eij qj,

Presentation of findings Odds ratios from multilevel logistic regression analysis predicting reasons for choice of health facility are shown in Table 2. Models that predict perceived quality

Perceptions of fractional franchise network in Nepal Table 1. Distribution of client characteristics and type of provider visited
Pre-test Gender Male Female Mean age Education Less than secondary Any secondary or higher Distance > 10 min < 10 min Provider type Sta nurse Health assistant Auxiliary nurse Auxiliary health worker Reason for visit Reproductive health General illness *p < 005; **p < 001. Post-test

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418%** 582% 328 515% 485% 615%* 385% 102%** 381% 149% 369% 134% 866%

524% 476% 322 511% 489% 687% 313% 282% 130% 159% 429% 146% 854%

as reasons for choice of facility are presented rst, followed by models that predict perceived access as reasons for choice of facility. Odds ratios from multilevel logistic regression analysis predicting client loyalty are shown in Table 3. Condence intervals are presented in parentheses for both tables.

Results Table 1 shows the distribution of socio-demographic characteristics of clients and the type of providers visited. Females comprised a higher proportion of clients at pre-test (58%) than at post-test (48%). The mean age of clients was about 32 years. Nearly half the clients had secondary or higher education. The proportion of clients who were within 10 minutes walk of the facility declined from 39% at pre-test to 31% at post-test. There was a change in the composition of the sample in terms of clients visiting dierent types of providers: at pre-test, clients who were interviewed at facilities with a sta nurse comprised 10% of the sample while clients who were interviewed at facilities with a health assistant comprised 38% of the sample; at post-test, 28% of the clients were interviewed at facilities with a sta nurse and 13% at facilities with a health assistant. Fewer than 15% of respondents came to the health facility for a reproductive health reason. These compositional dierences between pre-test and post-test measurements necessitate the use of multivariate regression analysis.

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Fig. 1. Percentage of respondents who gave reasons for choice of facility. All increases were signicant at p < 001.

Figure 1 shows unadjusted percentages of clients who gave perceived quality and perceived access-related reasons for visiting the facility. Clients reported signicant increases (at p < 001) along all dimensions of perceived quality and perceived access. At post-test, 69% of clients reported that the providers caring manner was a reason for their choice of outlet. At pre-test, only 34% of clients reported providers caring manner as a reason for their choice of provider. The proportion of respondents who reported providers expertise/reliability as the reason for their choice of facility rose from 63% to 73%. Personally knowing the provider as a reason for choosing the provider increased from 31% to 43%. Proximity became a more important reason for choosing the facility: 60% of clients reported proximity as a reason for their choice at post-test, compared with 47% at pre-test. There was also an increase in the proportion of clients who reported convenient location of the clinic as reason for their choice of facility: 35% of clients at post-test compared with 10% at pre-test reported that the facilitys convenient location was a reason for their choice. Table 2 shows odds rations from multilevel logistic regressions predicting reasons for choice of health facilities. These odds ratios have been adjusted for the compositional dierences between pre-test and post-test samples. Condence intervals are presented in parentheses. Model 1 shows that, at post-test, a client is 18 times as likely as at pre-test to select a facility based on the perceived expertise/reliability of the provider. Females are more likely than males and older respondents are more likely than younger respondents to choose a facility because of the providers expertise/reliability. The model also shows that there is a trade-o between the quality of care provided and distance to a facility: a client whose residence is less than 10 minutes walk from a

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Table 2. Odds ratios from multilevel logistic regressions predicting reasons for choice of health facilitiesa
Model 1 Expertise/ reliability Survey round Pre-test Post-test Gender Male Female Age Education < Secondary Any secondary Distance > 10 min < 10 min Provider type Sta nurse Health assistant Model 2 Caring manner Model 3 Personal knowledge Model 4 Proximity Model 5 Location

100 100 100 100 100 181 953 159 233 504 (107, 308) (418, 2176) (104, 242) (142, 380) (155, 1639) 100 100 100 100 161 158 087 164 (120, 215) (115, 217) (066, 113) (123, 219) 102 100 102 101 (101, 103) (099, 101) (101, 103) (101, 102) 100 100 100 100 113 079 200 136 (086, 149) (057, 109) (153, 263) (102, 180) 100 080 (054, 119) 099 (098, 101) 100 101 (069, 148)

100 100 100 100 100 071 119 101 726 087 (053, 096) (087, 165) (077, 132) (513, 1027) (059, 130) 100 108 (018, 659) 073 (014, 397) 191 (041, 881) 327 269 179%

100 100 100 100 143 147 080 070 (065, 314) (028, 760) (042, 152) (032, 150) Auxiliary nurse 105 133 176 097 (048, 228) (031, 560) (089, 347) (044, 213) Auxiliary health worker 146 123 169 075 (076, 281) (034, 4,48) (096, 300) (040, 141) Variance Constant only 044 326 044 072 Full model 044 213 028 051 % reduction 16%b 345% 355% 294%
a

Condence intervals are presented in parentheses. The reduction in variance calculation is based on data to three decimal points.

health facility is less likely to choose that provider because of the providers expertise/reliability. The only provider-level variable in the model provider type is not associated with choosing the provider because of their perceived expertise. The full model explains about 2% of the provider-level variance. Model 2 shows that the odds of a client choosing a health facility because of a providers caring manner are 95 times as high at post-test as at pre-test. The odds of a female choosing a health facility because of a providers caring manner are 16

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times as high as the odds of a male choosing a health facility for this reason. A clients age, education and distance to a facility are not associated with choosing a facility because of a providers caring manner. Provider type is also not associated with the choice of facility. The full model explains 34% of provider-level variance. In Model 3, a client is 16 times as likely at post-test as at pre-test to select a facility based on personally knowing a provider. An older client is more likely than a younger client to choose a facility because they personally know the provider. A client with any secondary education is twice as likely as a client with less than secondary education to choose that provider because of personally knowing them. About 35% of the provider-level variance is explained by the full model. Model 4 shows that a client became more than twice as likely to choose a provider on the basis of their perceived proximity at post-test as at pre-test. Females are 16 times as likely as males to choose a facility because of its proximity. This nding is consistent with restrictions to female mobility in Nepal (Tuladhar, 1997). Older women and clients with secondary or higher education are also more likely to choose a facility because of its proximity. Compared with clients who live further away, clients who live within 10 minutes of a facility are more likely to choose that facility because of its perceived proximity. About 29% of the provider-level variance is explained by the full model. In Model 5, the odds that a client chooses a facility because of its convenient location are 5 times as high at post-test as at pre-test. This is probably because of hoarding boards that were placed outside facilities. Clients who had seen the franchise hoarding boards were twice as likely as clients who had not seen the franchise hoarding boards to choose a facility because of its location (not shown). No other independent variable was associated with choice of facility because of its convenient location. The full model explains about 18% of the provider-level variance. Table 3 shows odds ratios from a multilevel logistic regression predicting reasons for a clients return visit. Variables for gender, age, education and distance to the facility are introduced in Model 1. Females are more likely than males to make a return visit to a facility. Older clients were more likely than younger clients to make a return visit. Secondary or higher education or being within 10 minutes walk of a facility also increased the likelihood of a return visit. Variables measuring client perceptions of quality of, and access to, services are introduced in Model 2. Clients who give the providers caring manner as a reason for choosing a facility are 44 times as likely as other clients to make a return visit. Clients who are attracted to the facility because of the providers expertise/reliability are 113 times as likely as other clients to make a return visit. A clients personal knowledge of the provider is also positively associated with the likelihood of a return visit, with a client who knows the provider personally being nearly 6 times as likely as another client to make a return visit. Finally, proximity to a provider makes a client 43 times as likely as another client to make a return visit. Discussion Although reproductive health (RH) franchising is considered a potentially important mechanism for delivery of family planning through the private sector, there has

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Table 3. Odds ratios from a multilevel logistic regression predicting a clients return visit to a clinica
Model 1 Survey round Pre-test Post-test Gender Male Female Age Education < Secondary Any secondary Distance > 10 min < 10 min Reason for choice of provider Caring manner Expertise/reliability Personal knowledge Proximity Location Model 1

100 113 (075, 172) 100 148 (104, 212) 102 (101, 104) 100 174 (124, 245) 100 148 (103, 213)

100 061 (031, 119) 100 102 (066, 159) 102 (101, 103) 100 165 (108, 252) 100 104 (064, 168) 436 (259, 734) 1129 (708, 180) 581 (335, 1008) 434 (267, 706) 164 (088, 303)

Condence intervals are presented in parentheses.

been little documentation of the eects of clinic participation in a franchise network on client outcomes (Stephenson et al., 2004). This study examined changes in perceived quality and perceived access to services after health facilities run by nurses and paramedics became part of a RH fractional franchise in Nepal. The study found that perceived quality of, and access to, services improved during a short period of time: the pre-test and post-test surveys were conducted within a period of nine months and the implementation of the external marketing campaign was delayed due to civil unrest. Since mass media can be an important element in building brand equity for a franchise, the limited implementation of the external

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marketing campaign is likely to have inuenced the outcomes measured in this study. Mass media is also eective in raising awareness of RH service provision, which may lead to trial use of franchised clinics. Thus, the full implementation of the mass media campaign will have implications for client volumes. Improvements in perceived quality and access indicate that services marketing is an eective strategy for building a stronger clientprovider relationship. There was no signicant overall increase in client loyalty during the study period, which may be explained by the fact that the full intervention (including the marketing component) was not implemented as planned. Perceived quality and perceived access indicators were signicant predictors of client loyalty. This suggests that signicant improvements in client loyalty may occur once the project is fully implemented. Once the external marketing campaign gains momentum and there is more trial use of the franchise, increased client loyalty to clinics will probably translate into higher client volumes, thereby increasing private providers motivation to remain active members of the franchise and to maintain the quality standards set by the franchiser. Several other important ndings emerged from the regression analysis. Women were more likely than men to choose a franchised clinic based on their perceptions of quality and accessibility of services. This is consistent with the fact that the fractional franchise oered RH services that tend to be focused on women. The focus of RH services on women also explains why women were more loyal than men to franchised clinics. Moreover, womens loyalty to franchised clinics was a result of their perceptions of quality of, and access to, the services provided. While improving client perceptions of quality by training providers in services marketing techniques is likely to increase womens loyalty to franchised clinics, services may have to be targeted more directly at men to increase their loyalty to clinics. An explicit goal to reach men with RH services may be necessary to increase the eectiveness of RH franchises. The study found no signicant relationship between provider qualication and client perceptions of quality of services. However, the use of multilevel regression analysis did reveal signicant provider-level random eects, suggesting unobserved inuences at the provider level. One constraint of this study was the limited information available on provider characteristics. Studies of the eects of franchise networks on client outcomes would benet greatly by collecting detailed information on provider and facility characteristics. One of the potential constraints of the fractional franchise model is that RH services comprise only a fraction of total services oered. In the case of the SEWA franchise, less than 15% of clients visited franchised providers for RH reasons. That a relatively small proportion of the total provider business is comprised of RH service provision may suggest an upper limit to how willing providers may be to change their behaviour and improve the quality of RH service provision. If provider habits regarding the provision of general health services are poor, the motivation to change behaviour for a fraction of total business volume may not be high. A fractional franchise that oers a wider range of services than RH will have greater implications for a providers business and may be a more eective way of motivating providers to maintain the quality standards set by the franchiser.

Perceptions of fractional franchise network in Nepal Acknowledgments

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This research was conducted as part of the Commercial Market Strategies Project and was made possible through support provided by the Bureau for Global Health, Oce of Population and Reproductive Health, US Agency for International Development, under the terms of Contract No. HRN-C-00-98-00039-00. The views and opinions of the authors expressed herein do not necessarily state or reect those of USAID or the US Government. The authors are grateful to Ronan Van Rossem, Ruth Berg, Amy Tsui, Rob Stephenson, Lily Kak, Dana Hovig and Craig Carlson for reviewing an earlier draft of this report and to Matthew Carney for assistance with formatting tables and gures. During 2002 Sohail Agha was Deputy Director of Research and Asma Balal was Program Ocer under the Commercial Market Strategies Project (CMS), which provided funds for implementation of the franchise network evaluated in this paper. The CMS project ended in the rst half of 2004, prior to the completion of this paper.

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