Markets, incentives, and health promotion can improve family planning and maternal health practices: a quasi-experimental evaluation of a tech-enabled social franchising and social marketing platform in India.

ABSTRACT

BACKGROUND: Improving family planning and maternal health outcomes are critical to achieving the Sustainable Development Goals. While evidence on the effectiveness of government-driven public health programs is extensive, more research is needed on effectiveness of private-sector interventions, especially in low- and middle-income countries. We evaluated the impacts of a commercial social-franchising and social-marketing program - Tiko Platform - which created a local ecosystem of health promoters, healthcare providers, pharmacies, stockists/wholesalers, and lifestyle shops. It provided economic incentives through discounts and reward points to nudge health-seeking behaviors from enrolled women consumers/beneficiaries. METHODS: An ex-post facto evaluation was commissioned, and we employed a quasi-experimental design to compare outcomes related to the use of family planning, and antenatal and postnatal services between users and non-users who had registered for Tiko in three North Indian cities. Between March and April 2021, 1514 married women were surveyed, and outcome indicators were constructed based on recall. Despite statistical approaches to control for confounding, the effect of COVID-19 lockdown on Tiko operations and methodological limitations preclude inferring causality or arguing generalizability. RESULTS: We found a strong association between the use of the Tiko platform and the current use of temporary modern contraceptives [non-users 9.5%, effect +9.4 percentage points (pp), p-value < 0.001], consumption of 100 or more iron-folic-acid tablets during pregnancy [non-users 25.5%, effect +14 pp, p-value < 0.001], receiving four or more antenatal check-ups [non-users 18.3%, effect +11.3 pp, p-value 0.007], and receiving postnatal check-up within six weeks of birth [non-users 50.9%, effect +7.5 pp, p-value 0.091]. No associations were found between the use of the Tiko platform and the current use of any type of contraceptive (temporary, permanent, or rudimentary). Effects were pronounced when a community health worker of the National Health Mission also worked as a health promoter for the Tiko Platform. CONCLUSION: Commercial interventions that harness market-driven approaches of incentives, social marketing, and social franchising improved family planning and maternal health practices through higher utilization of private market providers while maintaining access to government health services. Findings support a unifying approach to public health without separating government versus private services, but more rigorous and generalizable research is needed. TRIAL REGISTRATION NCT05725278 at clinicaltrials.gov (retrospective); 13/02/2023.