Table 1 Description of data collection methods

Household surveys (two rounds—Jan 2015 and May 2016)

3600 (round 1) and 3452 (round 2) households in 180 study clusters. Three types of cluster were surveyed. Group A contained clusters with a SkyCare or SkyHealth provider in the three intervention districts. Group B comprised clusters with no social franchisee in the same three districts. Group C was taken from neighbouring districts that did not have any social franchise network operating within them

Eligible respondents included all women aged 15–49 years who gave birth in the previous 24 months (round 1) or 18 months (round 2), including those who had a stillbirth or whose child died since birth. Eligible women were identified through a census of households, conducted 1 month before the household survey

- Source of care received for ANC, delivery care, and family planning

- Whether the woman was accompanied by an ASHA for ANC and delivery care

- Community awareness of the Sky brand

Health provider surveys (two rounds—Jan 2015 and May 2016)

Using a census of all health providers within the study clusters, we randomly selected for interview one private health provider (social franchisee in intervention clusters), one government health provider, and one ASHA in each cluster. In the second round, we sought to re-interview the same providers or, if not available, a random replacement of the same type. Complete interviews were obtained from 454 health providers in round 1 and 446 interviews in round 2

For the purposes of the census, we defined a health provider as any institution or individual whose primary purpose is to provide healthcare. We excluded drug sellers

- Branding of the facility

- Use of the telemedicine and mobile phone consultations

- Training, supervision, and monitoring

- Health provider knowledge of ANC and actual practice of ANC based on respondents’ recall of their most recent ANC consultation

Clinical observations of antenatal care consultations (Feb–Aug 2016)

A purposive sample of six facilities (4 SkyHealth and 2 Franchise Clinics) was selected to reflect variation amongst facilities within the network. This was not intended to be a representative sample that would allow generalisation across the whole network

25 observations of ANC visits using telemedicine

Clinical quality of care as defined by the minimum care package of interventions required during pregnancy recommended by WHO [18, 19]

Social franchise user survey (Apr–Jun 2016)

15 health facilities were selected based on stratified random sampling (9 SkyHealth facilities, 6 Franchise Clinics). 760 women were selected from facility records

Eligible women were those who had received ANC or delivery care from a social franchise facility within the previous year and, in the case of ANC, had given birth by the time of the survey

- Socio-economic characteristics of women and their household

- Pathway of care

- Experience with telemedicine

- Perception of services and costs

Qualitative research: semi-structured interviews and participant observations (including conversations and other interactions) (2016)

From the 15 focal sites that were randomly sampled for the social franchise user survey, we purposively selected 6 “intensive” sites to reflect differences in number of clients and types of services offered: 2 Franchise Clinics and 4 SkyHealth centres

We used a combination of clinic lists and the help of ASHAs to identify women for interview. We purposefully sampled women to reflect a representation of different profiles based on age, parity, level of education, and urban, peri-urban or rural residence

Participant observations and semi-structured interviews with 30 women; 21 ASHAs; 15 SkyCare providers; 11 SkyHealth directors who were still part of the Sky franchise and 5 who had either not joined, left, or been asked to leave; 3 central medical facility staff and 9 franchisor staff

- Topics with franchisees included motivation for joining social franchise, how being part of the social franchise impacted their business and the care they provide, how sustainable the social franchise model is, differences between private and public sectors, and perspectives on their integration

- ASHAs: understanding of social franchise model, traditional responsibilities of an ASHA and how tasks with the social franchise fit into their role, incentives and payment systems, practices of working with public and private sectors

- Women: care-seeking behaviours and decision making in pregnancy and childbirth, perceptions of the interactions with social franchise providers (including telemedicine), ASHAs, and the public sector

- Programme staff: conceptualisation of the model, challenges and successes during implementation, modifications made, financial and sustainability considerations of the social franchise, nature of interactions with stakeholders and partners