Table 1 Responses to research questions based on our findings

What was the socio-political, economic and health system context of the policy / strategy?

High population and high poverty ratio; disparity in development indicators; absence of well-defined hierarchy of public health centers in urban areas; inequity in access of health services; quality of care is a key concern in public health service delivery.

Were there any key groups / actors influencing policy / strategy formulation?

Civil society groups born out of the movement for reproductive rights in the 1990s influenced policy making significantly and added focus on quality, patient rights and dignity.

What was the process of policy formulation?

Text drafted by the Ministry of Health and Family Welfare after multiple rounds of consultation with governmental and non-governmental stakeholders; submitted to a Committee of Parliamentarians for scrutiny, placed on website for public feedback, and final draft approved for financial support by the Cabinet Committee on Economic Affairs.

What were the objectives of the policy / strategy? Which key thematic areas were addressed? Were there any gaps in the content?

Objectives – to bring about fundamental changes in the healthcare delivery system with greater investment, decentralization and community participation. Thematic areas included improved planning, availability, access and quality of health services. Our analysis focused on the quality improvement theme. No gaps in content emerged in the analysis.

What was the implementation plan?

Public health standards were laid out and additional funding provided to help facilities achieve them. Quality certification body set up. District level system established for quality monitoring; non-governmental organizations and private sector engaged in the effort. Guidelines issued for ensuring quality of MNHFP + A care at all levels.

What were the challenges in implementation (such as cost, technical feasibility, acceptability among target populations)?

Persisting challenges included slow pace of structural improvements, availability of human resources and supplies, and lack of adherence to protocols.

Was the policy / strategy evaluated? If yes, then what was the achievement in terms of coverage, effectiveness and equity, among other factors?

No policy /strategy evaluations were available, though individual scheme evaluations and annual program reviews were available. Evidence showed that while financial incentives improved utilization, structural and human resource capacity could not be increased at the same pace, thereby affecting patient-centered care.