The core research is undertaken by three thematic work packages and four country work packages. The first is focussed on health policy, health financing and health economics (WP2). These are particularly important elements in this proposal, as the intervention is a health financing one, which involves the shifting of costs (in theory) from patients to governments (and donors). Its impact will be heavily linked to the effectiveness of the financing channels. In addition, the analysis of the equity effects of the policy will be critical to understanding its success or failure. This WP will therefore develop the overall causal framework for the analysis and will help to synthesise the end findings on cost-effectiveness of interventions, in particular by collecting cost data, which will be combined with results from other WPs to derive cost effectiveness (understood here in the broadest sense, to include wider health system impacts as well as narrow ones). The health policy component will analyse the way in which policy is driven, and also assist in evaluating the internal innovation of the community of practice component. The second thematic WP is the local health systems (WP3) one. This takes a two-way analysis, considering both what enables successful implementation of the policies at the district level, but also what the effects of the policy are on the health system itself. This will be key to understanding the dynamics of reform (not just the effects, but the processes which contribute to them and which will need to be taken into consideration in generalising from evaluation results). The final thematic WP looks at quality of care and health outcomes (WP4). Neither are easy to measure in the maternal health field, which is why tools will be adapted and piloted which have potential to track quality of care and changes to outcomes without major (and expensive) maternal mortality surveys.

Four focal countries will be involved in research in all three of these thematic areas (though the exact combination of tools varies according to the local needs and the timing of reform – some have had some degree of documentation already; others very little or none). Three are in francophone West Africa – Benin, Burkina Faso and Mali – and one in the Maghreb (Morocco). They are participating in this proposal because they have all introduced policies to remove fees for deliveries and caesareans in the past few years, and have all expressed a strong commitment to evaluating their reforms. None of them has as yet had a full evaluation of their policies. They will work in close collaboration with researchers based in the thematic WPs to develop the tools, conduct the research, disseminate findings, and adapt the tools for other contexts.

The final WP is the dissemination one. This has two parts. The first is a ‘community of practice’, which will set up a regional network of policy-makers, researchers and health partners, to learn lessons from one another during this period of reform (most countries in the region having introduced some version of this targeted cost reduction policy in recent years). The CoP itself is an innovation which we will be evaluating. In addition, more conventional dissemination at the international level will also be supported by this WP, working with all other partners.