Rose Weeks

Investing In Women: An inside look at Merck’s $3 million commitment to India’s largest maternity care franchise

Since launching in 2007, MerryGold Health Network has unspooled a multi-tiered network of nearly 450 clinics and hospitals providing quality, comprehensive maternal health services in 35 districts of Uttar Pradesh and Rajasthan, two of India’s most populous northern states – and among its poorest.

The USAID-backed network is led by the Hindustan Latex Family Planning Promotion Trust and supported through the Indian government’s State Innovations in Family Planning Projects Service Agency in Uttar Pradesh and Merck for Mothers in Rajasthan. The state has further signaled its support by accrediting MerryGold hospitals to provide free reproductive and child health services and emergency obstetric care for poor women in accredited and MerryGold-branded hospitals through its Janani Suraksha Yojana and Sowbhagyavati schemes.

Now, Merck for Mothers, an initiative focused on reducing maternal mortality with a $500 million commitment over 10 years, is supporting the scale-up of MerryGold in 19 districts of Rajasthan. I recently reached Merck for Mothers Executive Director Dr. Priya Agrawal by phone to discuss their $3 million investment in MerryGold. Dr. Agrawal, an obstetrician and gynecologist who studied medicine at Oxford and public health at Harvard, is fascinated by how simple and scalable innovation can effectively reach women and save lives.

Rose Reis: Why has Merck opted to invest in India’s private health sector?

Priya Agrawal (left): Because India has more maternal deaths than any country in the world (56,000 per year, according to World Bank Development Indicators). And it’s clear that, whether formal or informal, India’s private sector is providing a significant proportion of health care.

According to data from the Planning Commission, 92 percent of health care visits in India at the rural level are to private providers. Yet when we started, we understood that private providers had been in somewhat of a blind spot for both the global community and the local government.

The big question is, is it possible for the local private sector in its many forms to deliver affordable, quality maternal health care?

RR: Merck has invested in several health franchise networks both in India and Uganda – why is that?

PA: Franchising has been used for family planning. Now, we’re exploring whether the model can provide critical maternal health services. With labor and delivery, the business model is more complex – and it’s more high risk.

RR: Why did you decide to partner with MerryGold?

PA: We chose to invest in them based on specific criteria, including their high-quality, comprehensive service package and their openness to learning and sharing results. We considered that they’ve demonstrated both financial and institutional sustainability, in that the government has signaled support.

We also noted their huge emphasis on affordability and transparency in pricing to allow for greater reach. Prices are set at 40-50 percent of market rate and posted in every facility.

RR: Why replicate in Rajasthan, and how will they improve on the model?

PA: Rajasthan’s maternal mortality rate is on par with those of Haiti and Rwanda. But just because MerryGold has been successful in Uttar Pradesh doesn’t mean it will translate in another state.

(Photo courtesy of Merck for Mothers, right)

There have been a lot of useful learnings from MerryGold in Uttar Pradesh. An audit showed that franchisees were too close together – they were cannibalizing each others’ business. They’ll be more spaced out in Rajasthan.

And they are moving quickly to recruit and train providers. By March 2015, they expect to train 1,500 community health workers and approximately 300 medical and paramedical staff from 57 franchised facilities.

RR: How can private innovators like MerryGold best work with government?

PA: You absolutely need government because it is critical for scale and policy change. We take a total market approach to determine where the local private sector is best placed. What are the key roles the local private provider should take on and how does it work with the public sector? Can the private sector improve the affordability and accessibility of maternity care for poor women?

The good news is we’re seeing change in attitudes around the private sector over time within India. For example, our colleagues at the London School (of Hygiene and Tropical Medicine) are studying how patients are passed back and forth between public and private facilities. The government is interested in the findings – they want to ensure better efficiencies by knowing more about what care women are getting in the private sector.

What’s more, training private providers introduces a huge positive spillover effect on the public health system – many providers are the same! MerryGold gives providers business skills, communication skills and technical skills, learning they can apply while working in either the public or private sector.

It’s true that the incentives and contextual environment are different. Providers might see 100 clients a day in the public sector. But if they know more about how to (more effectively) treat people that will spill over to their public practice.

RR: How are you measuring the success of your investment in MerryGold?

PA: MerryGold tracks targets including the number of districts, franchises covered and providers trained – output metrics. In addition, we are planning a robust evaluation of all our social franchise partners with the London School, looking at aspects including cost, efficiency, quality, equity, health market expansion, maternal health impact and a measure that will get at to what extent services are centered on patients and designed around their needs. We hope to conduct an evaluation and develop in-depth case studies of all three of the social franchise networks we are funding in India and Uganda, including MerryGold, the Sky Health Network run by World Health Partners, and ProFam, run by a local affiliate of PSI in Uganda (PACE) that is also focused on labor and delivery.

We used both IRIS and SF4Health metrics to design our evaluation. We will also document the softer stuff – qualitative assessments. For instance, we will want to know, if you’re not serving the very poor, why is that?

Overall, we hope to accelerate progress toward reducing maternal mortality. A decision to help end preventable maternal mortality is just the first step. We act as a catalyst to design, test and advocate for sustainable and scalable solutions for maternal health. Our support for MerryGold is not about charity – it’s an investment in women, both as the patient and often as the provider.

Read more about MerryGold here; read more about Merck’s work in India here.

Rose Reis is a communications officer at the Results for Development Institute.

Environment, Health Care