Objective To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India of a large-scale, social franchising and telemedicine programme– the World Health Partners’ Sky Program.

Methods We investigated changes associated with the Sky Program in the knowledge and performance of health-care providers by assessing a representative sample of 810 providers in areas where the Program was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after Program implementation in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models.

Findings The Sky Program did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. The large gap between knowledge of appropriate care and the care actually delivered persisted.

Conclusion Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.