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Clinical Social Franchising: Organising private healthcare providers to address public health priorities

posted Jul 31, 2013, 4:59 AM by Jeff Knezovich   [ updated Jul 31, 2013, 5:10 AM ]
The past decade has seen a growing appreciation of the importance of private healthcare providers as the first, and often only, source of healthcare in many countries. This has led to a range of interventions aimed at engaging these providers to deliver standardized public health goods and services. One partnership modality, called clinical social franchising, applies commercial principles to achieve this goal. This webinar was chaired by David Bishai of Johns Hopkins School of Public Health and provided an overview of progress in franchising and a case study on the Greenstar social marketing initiative in Pakistan. 

Dominic Montagu of UCSF School of Global Health Sciences talked through the history of social franchising. He explained that a common problem in low- and middle-income countries is that there are many private clinics but they have a limited range of services, and the quality of care provided is often uncertain and variable. For public health initiatives to reach a wide array of people, particularly the poor, they need to engage these outlets. However, it is difficult to do this because some of the priority services, for example for family planning or TB are not offered or are of poor quality in these settings. One solution is to group clinics into a network or franchise. As part of a franchise they adopt a standard brand and a standardised set of quality criteria and add on new services to address public health priorities. The providers get a brand which over time gains recognition and an association with quality and diversified services, access to training from the franchising organisations, standard protocols for treatment and quality assured commodities.

The goals of franchise programmes are:
  • to have a health impact (treatment, prevention or management of unintended pregnancies and safe delivery benefit clients); 
  • to assure quality of care (people receive a service or commodity of a particular standard); 
  • in a cost effective way (targeting a particular population at a lower cost than alternative delivery options); 
  • to serve the poor (there is a focus on equity and reaching those within the lowest two wealth quintiles in the country); and 
  • to ensure market expansion (the provision of services to patients who would otherwise received lower quality of care, delayed care-seeking or have gone without care). 

In 2009 UCSF began surveying social franchises around the world to get a sense of their impact. This information is gathered into an annual compendium. The Center for Health Market Innovations also provide regular updates on these programmes. There are over 75,000 people working in these social franchising programmes, many in South Asia. The number of franchise programmes in the world has increased dramatically since the early 1990s, every three to five years the number of programmes and providers has doubled. The number of services offered has also expanded, most programmes focus on family planning but increasingly other maternal, new born and child health services, HIV, sexual and reproductive health and TB services are being included. 20 programmes now offer safe abortion and post abortion care, some are now offering cervical cancer screening.

Originally these programmes developed in urban areas and currently 40% operate in rural areas – which is a dramatic evolution in how franchises operate and who they serve. Funding has diversified. For most services income is generated through patient payments, but now there are third party voucher systems, public and private health insurance, government reimbursements and conditional cash transfers. This is part of a trend to integrating social franchises into the broader health system and try and make them more sustainable.

The programmes are measured in terms of DALYs averted, over 8 million DALYs were averted by the 39 programmes that reported service provision numbers and the greatest impact was through family planning services. There is an increasing trend on couple years of protection (CYPs). More evidence of the impact of these programmes is becoming available, including a systematic review. However, questions remain, and we need to know more about the cost effectiveness and sustainability of programmes. We also need to know how social franchises transition into more formal health systems.

Rehana Ahmed spoke after Dominic in her capacity as Board Director for Greenstar Social Marketing. Greenstar work to enhance the knowledge and increase the skills of private providers so that they can add public health services to their already running businesses. Greenstar is a nation-wide NGO in Pakistan and a member of PSI. Its mission is to serve low income people by increasing access to products, services and information. In Pakistan the private sector is vibrant and provides nearly 70% of health services, but there is little opportunity for them to enhance skills or provide preventative services.

Low-income people believe that the private sector is of higher quality and so working with them to market family planning and other services is a good way of reaching this group. There are now over 51,000 retail outlets and pharmacies which stock socially marketed products and 8540 franchises providing over 21 products and services. These outlets are supported with: teaching and training; Greenstar branding; ongoing, regular supplies of contraceptives; supervision; and monitoring and evaluation to ensure quality.

A variety of contraceptives are available, condoms, injectables, IUDs and also linkages which allow for surgical contraception, post abortion care and maternal care. It is a comprehensive health care menu that is being provided nationally. Greenstar is having an impact. The number of IUD insertions is growing, along with clients served and DALYs averted. Data from the Pakistani Bureau of Statistics show that more than 1 out of 4 couples who use modern contraception use Greenstar.

There are a number of lessons from the Greenstar experience which could have resonance for franchise networks elsewhere. Firstly that there is a need to build on existing infrastructure and use technology like mobiles intelligently. Greenstar uses all kinds of communications to stimulate demand including the electronic and print media. But interpersonal communication is very important, community mobilisation is vital for getting women into the clinic.

35% of franchisees in Pakistan are in rural areas moving forward it will be important to increase service coverage among in these areas. Building strong and enduring links with the public sector is a priority, particularly at provincial level in Pakistan. Whilst Greenstar’s primary focus will remain family planning both the demand and supply side need to be strengthened so that there are adequate contact points for women when they need the services. Commodity security is a critical area and resources are required to expand the network. Advocacy work is needed to push some of the family planning tasks to lower cadre staff. For example, at the moment by law impants can only be inserted by a doctor but this is not necessary.

The private sector will continue growing and so there are opportunities to expand. However, there has to be a separate strategy of how to work towards financial sustainability. Cost efficiency is important but it shouldn’t be prioritised over performance and health impact. But Greenstar face a challenge in that the government is already resource constrained. So it is now for donors to decide whether they wish to support us in expanding this method.

The presentations were followed by a lively question and answer session which you can hear on our audio recording. To learn more please visit the Social Franchising for Health website.