School-based fluoride varnish programmes are a mainstay of caries prevention in low-resource settings, yet their effectiveness depends on delivery fidelity, which is rarely measured and almost never modelled as a multilevel phenomenon. The framework treats delivery fidelity as a mediating construct operating at the level of the individual varnish application, nested within provider, school and district levels, and specifies the mechanisms through which task-shifting among dental hygienists, chairside assistants and teachers, and through which stock-outs and cold-chain failures, alter the probability that a varnish application is delivered at the intended dose, interval and coverage. Using the DHS Program indicator 'Place of delivery: Public sector' (RH_DELP_C_PUB) for 36 African countries between 1990 and 2025, comprising 433 country-survey observations with a mean of 49.365 and a standard deviation of 20.892, the paper illustrates the kind of population-level variation against which programme-level fidelity must be interpreted. The contribution is a testable multilevel specification that links provider mix and supply-chain disruption to child-level caries outcomes through fidelity, together with a set of identification conditions and measurement recommendations for programmes that cannot afford randomised designs.
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Nabirye et al. (2026) studied this question.
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