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HDM - Franchising

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Model Evaluation Frameworks
Health Financing Models
Health Delivery Models

 

 

  1. Health Delivery Models - Franchising
    1. Description
    2. Model Strengths
    3. Model Limitations
    4. Research Questions
    5. Pooled Lessons Learned
    6. Case examples
      1. Sun Quality Health network in Myanmar.1
      2. DKT International. Social Franchising
      3. R4D Innovative Pro-poor Healthcare Financing and Delivery Models
      4. SF4H Social Franchising Compendia 2012 | 2011 | 2010 | 2009
      5. PSI Social Franchising programs
  2. Resources
    1. General Reviews
    2. Research articles
      1. Using and Joining a Franchised Private Sector Provider Network in Myanmar  | Observational Study
      2. Are social franchises contributing to universal access to reproductive health services in low-income countries? | Observational Study
      3. Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost? | Observational Study 
      4. Effects of Social Franchised Reproductive Health Services on Access to Care | Q-Experiment
      5. The effect of social franchising on access to and quality of health services in low- and middle-income countries | SysLit Review
      6. The impact of social franchising on the use of reproductive health and family planning services at public commune health stations in Vietnam | QExperiment
      7. Social Franchising to Improve Quality and Access in Private Health Care in Developing Countries. | Q-Experiment
      8. Can working with the private for-profit sector improve utilization of quality. | SysLit Review
      9. Changes in perceptions of quality of, and access to, services among clients of a fractional franchise network in Nepal | Q-Experiment
      10. Social franchising evaluations: a scoping review | SysLit Review
      11. Realising the full potential of Innovative Solutions in Healthcare Delivery - WEF-McKinsey | Synthesis
      12. Franchising in Frontier Markets: What's Working, What's Not, and Why - Dalberg | Synthesis

 

 

 

Health Delivery Models - Franchising

Description

Model

Defined as "an arrangement whereby a manufacturer or marketer of a product or service (the franchiser) grants exclusive rights to local independent entrepreneurs (franchises) to conduct business in a prescribed manner in a certain place of a specified period."1

 

The elements that typify a social franchising package are:5

  • Training (e.g. in clinical procedures, business management)
  • Protocolized management (e.g. for antenatal care, childhood diarrhoea);
  • Standardization of supplies and services (e.g. birthing kits,HIV tests);
  • Branding (e.g. use of a logo on signs, products, or garments);
  • Monitoring (e.g. quarterly reports to franchiser, reviews);
  • Network membership (e.g. more than one franchisee in the organization)

 

WORD OF CAUTION: There have been no rigorous assessment of causality of impact.5 So, the conclusions below are at best case-specific generalizations and not necessarily scientifically rigorous evidence.

Services
  • Typically focused more on sexual and reproductive health services but also malaria and TB)1
  • Often provide a full range of primary health care services, both curative and preventive
Revenue Model
  • For-profit model
  • Payment using locally determined means (3rd party of direct use fees)
  • Often fee-caps are often placed on franchised products/services
Social Impact
  •  No reliable evidence5, but mixed reports of higher quality, possibly at a higher cost and potential for being too expensive for the poorest
Economic Viability
  • Have been reliant on external grant subsidies. They haven't been largely profitable by themselves.12
Replicability & Growth
  • The growth  has been limited because of the requirement to raise grant capital to grow scale and social impact. The external grant subsidies may have inhibited an aggressive search for more creative and locally sustainable alternatives12 
  • The simplicity of the business model meeting an underserved market need is key for replication success.12
  • Typically high, but issues surrounding attrition of franchisees are reported3
  •  

Model Strengths

Model Limitations

  • Standards and protocols for quality assurance are in place1,2

  • Evidence shows they have higher quality of care compared to non-franchised models1,3,4,7

  • Customers are normally satisfied with the services1,2
  • Providers are often motivated by non-monetary benefits1
  • Providers have opportunities to improve their clinical skills by courses offered and from practice1
  • Providers have access to a regular supply to more efficacious medicines (i.e. branded products)1
  • Some preliminary evidence shows that franchising is associated with increasing utilization of health services6
  • Mixed evidence on affordability -
    • Measures taken to ensure sustainability lead to unaffordable fees for low-income women and full costs had to be paid out of pocket2
    • Customers' favorable perception of service quality, lower prices, and provider knowledge1
    • Franchised private facilities are found to be more costly per client served than private non-franchised clinics in Ethiopia, but not in Pakistan.3
    •  Franchised private facilities are found to serve fewer patients from bottom quintile in Ethiopia, but it was same proportion in Pakistan.3
    • Franchised clinics can produce improved service quality at lower cost than private non-franchised4
    • There was no statistically significant association between attending franchised services and monthly household income in a study from Bihar8
    • The Green Star and Green Key interventions in urban Pakistan did not benefit relatively poor groups. Clients with income of $101– $250/month and with income greater than $251 were more likely to use franchised services than those earning less than $60/month.8  
    • Evidence for the Ray of Hope intervention in Ethiopia was mixed. Clients with income of $101–$250/month were less likely to attend franchised services than those earning less than $60/month. However clients with primary education were more likely to attend franchised services compared to clients with the least education.8
    • The Nepali study examined client satisfaction with quality of care. Clients at intervention clinics 'very satisfied' with cleanliness increased from 37% to 65%, and with the availability of essential equipment from 35% to 62%. Clients were also reported to be more satisfied with the range of services offered in the intervention clinics (40% to 71%) and with privacy (38% to 72%). The Nepali franchise network clearly benefited a generally poor population, with an estimated income per capita of $125.8,9
  • Mixed evidence on quality
    • Application of quality assurance standards and protocols are often low2
    • Association between franchise status (i.e. franchised v not-franchised) & perception of quality was found to be not statistically significant8
  • Mixed evidence on services range - 
    • Having an assortment of different types of health products and providers was valued by patients who participated in FGD1
    • Franchises have not widened the range of reproductive health services, but have mainly focused on contraceptive services, and to a lesser extent, maternal health care and abortion. Coverage had not been extended to new areas2

 

Miscellaneous concerns:

  • Difficulties in recruiting franchisees and significant attrition are reported2
  • Franchisee's inability to attend training programs2
  • Use of lay health workers to deliver services without support or supervision2
  • Social impact on universal access to reproductive health services appears to be uncertain2
  • Costs and Quality tradeoffs - i.e. higher costs due to higher quality compared to non-franchised3

 

Challenges for Franchising in frontier markets - Dalberg Report:12

  • Lack of profitability can be attributed to:
    • Problematic sector economics in health and education, due to limited tradition and/or ability to pay and competition from subsidized alternatives
    • Elevated overhead costs, and a location and product-market strategy that assigns priority to social impact over financial returns
  • Scaling up through franchising too early (before establishing financial profitability and sustainability) causes: 
    • Untenable demands for fundraising and grant-financing, which inhibit the scale of social impact that can be achieved.
    • An increase in potential conflicts between franchisees and franchisor, especially with regard to how to grow, improve, and expand the business model.
    • Subsidized competition for other entrants who might otherwise be able to serve the market profitably

 

(Not necessarily Health Focused)

  • Franchising creates the opportunity to leverage the entrepreneurial skills and local adaptation required for frontier markets.
  • Franchising requires, rather than generates, a profitable business model. The lack of purchasing power and market density in frontier markets are thus a limiting factor.
  • Business format franchising requires a complex ecology to flourish. This ecology includes the availability of reasonably priced capital for franchisees, sophisticated legal and regulatory frameworks, technical and legal advisory services, and the availability of qualified franchisees. The lack of such ecology in frontier markets significantly increases the risk and (agency) costs of franchising, thereby impeding a franchising strategy.
  • The lack of relative profitability and scalability, as well as the perceived risks with regards to legal and regulatory environment, has resulted in very few Western chains expanding into frontier markets. For example, outside of South Africa, only 4 of the 10 top international franchise chains in 2008 have expanded into Sub-Saharan Africa (SSA), with approximately 30 outlets between them.
  • Within frontier markets there is wide variability of “franchise friendliness,” driven by the provision of finance, the ease of entrepreneurship, and the sophistication of contractual, intellectual property (IP), and regulatory frameworks. For example, Mauritius, Namibia, and Botswana score significantly higher than other countries in Sub-Saharan Africa on franchising friendliness.

 

Research Questions

Pooled Lessons Learned

Franchisees' motivations: What factors might influence private providers to join a franchise over continuing to operated independently?

  • How are 'Franchise Constraints' (fee-caps, service limitations, "formal" operation) & 'Franchise Benefits (reputation)' are weighed?
  • How about customer perception?
  • Price (fees) v volume of sale? assuming being part of franchise may attract larger volume of customers due its perceived quality
  • Monetary v social impact v non-pecuniary benefits?

Franchisers process for selecting new entrepreneurs: What characteristics do they want to see on potential entrepreneurs?

  • Of existing entrepreneurs in a new region? Proven business success, networks?
  • Of new entrepreneurs (those who have limited experience of running businesses?)
  • Technical qualifications - management, medical care, financial planning, etc.

Franchise's economic value:

  • Profits? Is that more than in an independent practice? Other models?

Customers' perceptions 


From Dalberg Report:

 

  • What is the impact of franchising on profitability?
  • What are the conditions for franchising friendliness across industries, across market segments (for example urban/rural and income strata), and across geographies?
  • What is the relative impact of international franchise chains on homegrown franchise growth and development? In the case of traditional format micro-franchising, are concepts developed in Western countries more successful than indigenous models?
  • What are the relative merits of grant subsidized franchise models vs. purely commercial franchise business models for the delivery of public goods and services?
  • How can franchising be best used to deliver public goods and services at scale?
  • What is the role of alternative forms of financing to support franchising?
 
  • Customers prefer to use franchises if -
    • lower fees than private clinics1
    • Assortment of services and products1
    • Information on services and fees presented clearly outside1
    • Quality of products ("better quality," "safer," "effective") compared to those sold at medicine stalls in markets1
    • Privacy when providing services (ex: in sexual health)1
    • Availability of educational material1
    • Providers are friendly and promote "family-like" relationship1
    • Referred by family or friend member1
    • Providers competency is also highly regarded by patients1
  • Providers choose to join franchise if -
    • Non-monetary incentives may be valued more highly - (solidarity with the poor, providing affordable medicines)1
    • Increased self-confidence in their clinical skills (believed their skills to diagnose and treat improved)1
    • Reliable access to branded products1
    • Course offered to improve their skills1
  • Higher quality can be achieved through:
    • trainings for providers1,2,3
    • inspections by franchisers3
    • but it is important to understand cost-implications of higher quality3,4

 

From WEF and McKinsey:11

  • Get close to the patient and follow established behavior patterns: E.g., Aravind has engaged in out-reach strategies – taking care straight to the villages
  • Reinvent the delivery model by using proven technologies disruptively: E.g., MinuteClinic’s IT platforms under-pinning clinical procedures and decision making
  • Confront professional assumptions and right skill the workforce: E.g., The use of community health workers at HealthStores reduces expenditure
  • Standardise operating procedures wherever possible: E.g., Aravind, HealthStores, MinuteClinic and PSI have all standardised their procedures
  • Borrow someone else’s assets: E.g., HealthStores relies on already established sites to base their micro-clinics
  • Open new revenue streams across sectors: E.g., PSI has shown its possible to cross sector boundaries to create new market opportunities in franchising

 

From Dalberg Report:

  • Companies franchise to overcome financing and monitoring challenges and to leverage entrepreneurial skills and incentives, while individuals become franchisees because of the perceived lower risk and greater rewards.
  • Successful businesses build and manage a hybrid network of franchised and company-owned outlets.
  • Successful franchised chains grow in a predictable manner
    • Successful franchises first develop a profitable, sustainable, and scalable business model
    • The path to franchise success is long, typically requiring 5-10 years of proving and customizing a concept and business model before attempting to franchise it
    • Successful franchised chains are subsequently able to grow exponentially over time
  • A number of misconceptions about franchising exist, especially those related to the risk profile and the franchisee profile:
    • Franchising is not the only way to achieve rapid scale
    • Franchisors often choose a mixed-model approach, including both company owned and franchised units in order to maximize system wide profitability.
    • Franchising does not automatically create first-time business owners; in frontier markets, franchisees are often established businesspeople and entrepreneurs with access to the capital necessary to own and operate a franchise.
    • Business risks for franchisees are not necessarily lower than for independent growth; risks vary considerably in franchising. For a franchisee, franchising risks are higher than for independent entrepreneurship when the chains are smaller and newer, and lower when the chains are mature.
  • Investors and donors considering franchising in frontier markets should consider that:
    • Achieving profitability and sustainability from the first outlet is a critical first step before any attempt to franchise is made
    • The impact of franchising on the overall profitability of the business is limited
    • Franchising is not the optimal choice for all expansion trajectories, with timing, sector, and geography each playing an important role in evaluating whether franchising is the appropriate option.
    • Franchising in frontier markets does not always entail lower risk than independent growth and entrepreneurship profile.  

Case examples

 

Resources


 

General Reviews

 

Dimovska et al. (2009) Innovative Pro-poor Healthcare Financing and Delivery Models. Results for Development Institute and Rockefeller Foundation. PDF

This report describes 33 innovative financ-ing and delivery programs selected based on their relevance to broader health systems and potential to achieve positive impact for poor people. While these programs range from donor-driven initiatives to large-scale government-subsidized efforts to for-profit businesses, they all involve active participation by the private health sector. These descriptions are not evaluations, as no rigorous third-party analysis of the impact of the profiled models has been conducted or commissioned, but most model descriptions have been reviewed by the implementing organization to ensure its accuracy.

 

 

Research articles

 

(1)

Using and Joining a Franchised Private Sector Provider Network in Myanmar  | Observational Study

O’Connell K, Hom M, Aung T, Theuss M, Huntington D (2011) PLoS ONE 6(12): e28364. doi:10.1371/journal.pone.0028364 PDF

 

Background: Quality is central to understanding provider motivations to join and remain within a social franchising network. Quality also appears as a key issue from the client’s perspective, and may influence why a client chooses to use a franchised provider over another type of provider. The dynamic relationships between providers of social franchising clinics and clients who use these services have not been thoroughly investigated in the context of Myanmar, which has an established social franchising network. This study examines client motivations to use a Sun Quality Health network providerand provider motivations to join and remain in the Sun Quality Health network. Taken together, these two aims provide an opportunity to explore the symbiotic relationship between client satisfaction and provider incentives to increase the utilization of reproductive health care services.

Methods and Findings: Results from a series of focus group discussions with clients of reproductive health services and franchised providers shows that women chose health services provided by franchised private sector general practitioners because of its perceived higher quality, associated with the availability of effective, affordable, drugs. A key finding of the study is associated with providers. Provider focus group discussions indicate that a principle determinate for joining and remaining in the Sun Quality Health Network was serving the poor.

 

 

(2)

Are social franchises contributing to universal access to reproductive health services in low-income countries? | Observational Study

Ravindran and Fonn. (2011). Reproductive Health Matters. Volume 19, Issue 38 , Pages 85-101, November 2011.doi:10.1016/S0968-8080(11)38581-3 LINK 

 

ABSTRACT: A social franchise in health is a network of for-profit private health practitioners linked through contracts to provide socially beneficial services under a common brand. The early 21st century has seen considerable donor enthusiasm for promoting social franchises for the provision of reproductive health services. Based on a compendium of descriptive information on 45 clinical social franchises, located in 27 countries of Africa, Asia and Latin America, this paper examines their contribution to universal access to comprehensive reproductive health services. It finds that these franchises have not widened the range of reproductive health services, but have mainly focused on contraceptive services, and to a lesser extent, maternal health care and abortion. In many instances, coverage had not been extended to new areas. Measures taken to ensure sustainability ran counter to the objective of access for low-income groups. In almost two-thirds of the franchises, the full cost of all services had to be paid out of pocket and was unaffordable for low-income women. While standards and protocols for quality assurance were in place in all franchises, evidence on adherence to these was limited. Informal interviews with patients indicated satisfaction with services. However, factors such as difficulties in recruiting franchisees and significant attrition, franchisees' inability to attend training programmes, use of lay health workers to deliver services without support or supervision, and logistical problems with applying quality assurance tools, all raise concerns. The contribution of social franchises to universal access to reproductive health services appears to be uncertain. Continued investment in them for the provision of reproductive health services does not appear to be justified until and unless further evidence of their value is forthcoming.

 

 

(3)

Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost? | Observational Study 

Nirali M Shah, Wenjuan Wang, and David M Bishai. (2011). Health Policy and Planning 2011;26:i63–i71. doi:10.1093/heapol/czr027  PDF

 

ABSTRACT: Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. We propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. We apply this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing (1) independent private sector providers; (2) social franchises of private providers; (3) non-government organization (NGO) providers; and (4) government providers on these three factors. Franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. Our results highlight that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific.

 

 

(4)

Effects of Social Franchised Reproductive Health Services on Access to Care | Q-Experiment

Women's & Children's Health (Topic) 06/2007. LINK

 

Abstract: The key social goals in health service provision are quality and accessibility to the poor. Social franchises are one mechanism to achieve both goals, but little is known about their performance. The objective of this paper is to compare the cost per each percentage point increase in the proportion of poor clients for social franchises as compared to government providers. The study uses data from the Carolina Population Center Alternative Business Models (CPC-ABM) Surveys conducted in Pakistan, Ethiopia and the Indian states of Bihar and Jharkhand. There were two rounds of data collection and three survey modules directed towards establishments, providers and clients of family planning facilities. Baseline interviews occurred in 2001 prior to phasing in social franchised systems. Follow up interviews occurred in 2004. Exit interviews and facility inspections provided measures of service quality. Client interviews provided measures of socioeconomic position of clients at each facility. In Ethiopia, India, and Pakistan the respective numbers of facilities enrolled in the study were: 369, 1297, and 993. We model costs as a function of the price of inputs and the quantity of outputs, focusing on 3 specific outputs: numbers of visits, quality of facilities, and percent of clinic attendances by patients in the lowest socioeconomic quintile. Difference in difference estimators are used to identify the effects of social franchising on a facility's efficiency in reaching the poor. Preliminary results show that franchised clinics can produce improved service quality at lower cost than private non-franchised.

 

(5)

The effect of social franchising on access to and quality of health services in low- and middle-income countries | SysLit Review

Koehlmoos TP, Gazi R, Hossain SS, Zaman K. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD007136. DOI: 10.1002/14651858.CD007136.pub2.  PDF

 

Background: Social franchising has developed as a possible means of improving provision of health services through engaging the non-state sector in low- and middle-income countries.
Objectives: To examine the evidence that social franchising has on access to and quality of health services in low- and middle-income countries.
Search strategy: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (up to October 2007), Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3), MEDLINE, Ovid (1950 to September Week 3 2007), EMBASE, Ovid (1980 to 2007 Week 38), CINAHL, Ovid (1982 to September Week 3 2007), EconLit, WebSPIRS (1969 to Sept 2007), LILACS, Science Citation Index Expanded and Social Sciences Citation Index (1975 to March 2008), Sociological Abstracts, CSA Illumnia (1952 September 2007), WHOLIS (1948 November 2007). Selection criteria: Randomized controlled trials, non-randomized controlled trials, controlled before and after studies and interrupted time series comparing social franchising models with other models of health service delivery, other social franchising models or absence of health services.
Data collection and analysis: Two review authors independently applied the criteria for inclusion and exclusion of studies to scan titles and abstracts. The same two
review authors independently screened full reports of selected citations . At each stage, results were compared and discrepancies settled through discussion.
Main results: No studies were found which were eligible for inclusion in this review.

Authors’ conclusions: There is a need to develop rigorous studies to evaluate the effects of social franchising on access to and quality of health services in low and middle-income countries. Such studies should be informed by the wider literature to identify models of social franchising that have a sound theoretical basis and empirical research addressing their reach, acceptability, feasibility, maintenance and measurability.

 

(6)

The impact of social franchising on the use of reproductive health and family planning services at public commune health stations in Vietnam | QExperiment

Ngo et al. (2010). BMC Health Serv Res. 2010; 10: 54.2010 February 28. doi:  10.1186/1472-6963-10-54 

 

Background: Service franchising is a business model that involves building a network of outlets (franchisees) that are locally owned, but act in coordinated manner with the guidance of a central headquarters (franchisor). The franchisor maintains quality standards, provides managerial training, conducts centralized purchasing and promotes a common brand. Research indicates that franchising private reproductive health and family planning (RHFP) services in developing countries improves quality and utilization. However, there is very little evidence that franchising improves RHFP services delivered through community-based public health clinics. This study evaluates behavioral outcomes associated with a new approach - the Government Social Franchise (GSF) model - developed to improve RHFP service quality and capacity in Vietnam's commune health stations (CHSs).

Methods: The project involved networking and branding 36 commune health station (CHS) clinics in two central provinces of Da Nang and Khanh Hoa, Vietnam. A quasi-experimental design with 36 control CHSs assessed GSF model effects on client use as measured by: 1) clinic-reported client volume; 2) the proportion of self-reported RHFP service users at participating CHS clinics over the total sample of respondents; and 3) self-reported RHFP service use frequency. Monthly clinic records were analyzed. In addition, household surveys of 1,181 CHS users and potential users were conducted prior to launch and then 6 and 12 months after implementing the GSF network. Regression analyses controlled for baseline differences between intervention and control groups.

Results: CHS franchise membership was significantly associated with

    • A 40% plus increase in clinic-reported client volumes for both reproductive and general health services.  
    • A 45% increase in clinic-reported family planning service clients related to GSF membership was marginally significant (p = 0.05).
    • Self-reported frequency of RHFP service use increased by 20% from the baseline survey to the 12 month post-launch survey (p < 0.05). However, changes in self-reported usage rate were not significantly associated with franchise membership (p = 0.15).

Conclusions: This study provides preliminary evidence regarding the ability of the Government Social Franchise model to increase use of reproductive health and family planning service in smaller public sector clinics. Further investigations, including assessment of health outcomes associated with increased use of GSF services and cost-effectiveness of the model, are required to better delineate the effectiveness and limitations of franchising RHFP services in the public health system in Vietnam and other developing countries.

 

 

(7)

Social Franchising to Improve Quality and Access in Private Health Care in Developing Countries. | Q-Experiment

David M. Bishai et al.(2008) Harvard Health Policy Rev 2008. PDF

 

Method: A recent survey of 1718 family planning and reproductive health service facilities was conducted in Pakistan.  Data were collected by the Carolina Population Center’s Alternative Business Models initiative, in a multi-stage cluster sample of health facilities, providers and clients in urban areas of Pakistan.  Two waves of data collection in 2001 and 2004 resulted in a total sample of 19801 clients and 2667 health providers in 1718 facilities.  More information on the sampling strategy and data are available elsewhere. Four types of facilities were surveyed: Green Star franchised providers, public providers, non-franchised private providers, and NGO providers. Cost of service provision included total salary and rent.  Service quality was determined by identifying items in client, facility and provider surveys which fit within the Bruce framework for quality in reproductive health services, and creating a summative index for each facility. Household poverty status was determined by rank of monthly income, with those households in the twentieth percentile or below classified as poor.

Results: Analysis shows that Green Star franchised facilities provided higher quality services (mean total quality = 24.9) than other private facilities surveyed (mean total quality private for profit = 15.2; private not for profit = 18.1). The quality score was calculated as the sum of Bruce’s six domains of quality: Choice of methods; Information given to clients; Technical competence; Interpersonal relations; Mechanisms to encourage continuity; Appropriate con-stellation of services. Each domain was constructed from variables collected during facility surveys and exit interviews. Variable selection was decided strictly by using principal components with varimax rotation analysis to identify variables with factor loads greater than 0.4. Cronbach’s alpha for the measurement of each domain ranged from 0.72 to 0.94, indicating strong correlation within the domain.

 

(8) 

Can working with the private for-profit sector improve utilization of quality. | SysLit Review

Edith Patouillard et al (2007).  Int J Equity Health 2007

 

Background: There has been a growing interest in the role of the private for-profit sector in health service provision in low- and middle-income countries. The private sector represents an important source of care for all socioeconomic groups, including the poorest and substantial concerns have been raised about the quality of care it provides. Interventions have been developed to address these technical failures and simultaneously take advantage of the potential for involving private providers to achieve public health goals. Limited information is available on the extent to which these interventions have successfully expanded access to quality health services for poor and disadvantaged populations. This paper addresses this knowledge gap by presenting the results of a systematic literature review on the effectiveness of working with private for-profit providers to reach the poor.

Methods: The search topic of the systematic literature review was the effectiveness of interventions working with the private for-profit sector to improve utilization of quality health services by the poor. Interventions included social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out. The search for published literature used a series of electronic databases including PubMed, Popline, HMIC and CabHealth Global Health. The search for grey and unpublished literature used documents available on the World Wide Web. We focused on studies which evaluated the impact of interventions on utilization and/or quality of services and which provided information on the socioeconomic status of the beneficiary populations.

Results: A total of 2483 references were retrieved, of which 52 qualified as impact evaluations. Data were available on the average socioeconomic status of recipient communities for 5 interventions, and on the distribution of benefits across socioeconomic groups for 5 interventions.

 

Six interventions were identified, "Green Star" and "Green Key" in Pakistan, "Ray of Hope" in Ethiopia, "Janani" in Bihar State, India, "Sewa" in Nepal and "Top Reseau" in Madagascar. Evidence of impact on utilization or quality of health services was mixed:

 

    • Effectiveness of the Pakistan, Ethiopia and Bihar interventions was documented in a single study that used exit interviews to examine client satisfaction at franchised and non-franchised outlets [48]. Effectiveness of the "Green Star" and "Green Key" franchises implemented in Pakistan was jointly evaluated. Clients attending franchised private services were significantly more likely to report that they would return than those attending non-franchised services in Pakistan and significantly less likely in Ethiopia, with no statistically significant difference in Bihar. In all three settings there was no statistically significant difference between the franchise status of the clinic and perceptions of quality (that the service was better than others available) or in citing affordability as a preferred feature of the service [48]. The Green Star and Green Key interventions in urban Pakistan did not benefit relatively poor groups. Clients with income of $101– $250/month and with income greater than $251 were more likely to use franchised services than those earning less than $60/month. Clients with at least secondary schooling were also more likely to use franchised services compared to illiterate clients [48].

 

 

    • The Nepali study examined client satisfaction with quality of care [49]. Clients at intervention clinics 'very satisfied' with cleanliness increased from 37% to 65%, and with the availability of essential equipment from 35% to 62% [49]. Clients were also reported to be more satisfied with the range of services offered in the intervention clinics (40% to 71%) and with privacy (38% to 72%) [49]. The Nepali franchise network clearly benefited a generally poor population, with an estimated income per capita of $125 [49].

 

    • The Top Réseau study reported that coverage of modern contraceptives was higher for women with high exposure to the intervention (have accessed a franchised clinic and have been exposed to the IEC activities) than those with low or medium exposure [50]. Only general SES information was provided for the Top Réseau study.

 

Data on average SES of the recipient population was provided for one of the six interventions. The Nepali franchise network clearly benefited a generally poor population, with an estimated income per capita of $125 [49]. Evidence on the socioeconomic distribution of benefits within the recipient community was provided for the franchise networks in Pakistan, Ethiopia and Bihar State.

 

    • Evidence for the Ray of Hope intervention in Ethiopia was mixed. Clients with income of $101–$250/month were less likely to attend franchised services than those earning less than $60/month. However clients with primary education were more likely to attend franchised services compared to clients with the least education [48].

 

    • The evidence from Bihar was also mixed. There was no statistically significant association between attending franchised services and monthly household income [48]. Clients with no education were more likely to attend franchised services compared to clients with education [48].

 

Conclusion: Few studies provided evidence on the impact of private sector interventions on quality and/or utilization of care by the poor. It was, however, evident that many interventions have worked successfully in poor communities and positive equity impacts can be inferred from interventions that work with types of providers predominantly used by poor people. Better evidence of the equity impact of interventions working with the private sector is needed for more robust conclusions to be drawn.

 

 

(9) 

Changes in perceptions of quality of, and access to, services among clients of a fractional franchise network in Nepal | Q-Experiment

Sohail Agha et al. J Biosoc Sci. 2007.

AKA: Agha, S; A M Karim; A Balal; and S Sossler. 2003. A Quasi-Experimental Study to Assess the Performance of a Reproductive Health Franchise in Nepal. Washington, DC: USAID/Commercial Market Strategies Project 

 

Abstract: With declining levels of international donor funding for financing reproductive health programmes, developing country governments and international donors are looking towards private sector strategies to expand the supply of quality reproductive health services. One of the challenges of a health franchise is to improve the quality of services provided by independent private practitioners. Private providers are more likely to abide by the quality standards set by a franchiser if they see a financial benefit resulting from franchise participation. This study was conducted to measure whether (a) there were improvements in perceived quality of care and perceived access to health facilities once these facilities became part of a franchise and (b) improvements in perceived quality and perceived access were associated with increased client loyalty to franchised clinics. Franchisees were given basic reproductive health training for seven days and services marketing training for two days. Exit interviews were conducted with male and female clients at health facilities. A pre-test measurement was taken in April 2001, prior to the start of project activities. A post-test measurement was taken in February/March 2002, about 9 months after the pre-test. Multilevel regression analysis, which takes the hierarchical structure of the data into account, was used for the analysis. After taking provider-level variation into account and controlling for client characteristics, the analyses showed significant improvements in perceived quality of care and perceived access to services. Private provider participation in a franchise network helps improve client perceptions of quality of, and access to, services. Improvements in client perceptions of quality and access contribute to increased client loyalty to franchised clinics. Once increased client loyalty translates into higher client volumes, providers are likely to see the benefits of franchise participation. In turn, this should lead to increased provider willingness to remain part of the franchise and to abide by the standards of quality set by the franchiser.

 

 

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Social franchising evaluations: a scoping review | SysLit Review

Koehlmoos T, Gazi R, Hossain S, Rashid M (2011). London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London

 

Background: Social franchising developed as a possible means of improving the provision of non-state sector health services in low- and middle-income countries. The objective of this systematic review was to examine the scope and nature of existing research literature on social franchising interventions, including reach, implementation, sustainability and goals, in health service delivery.
Methods: A rigorous search strategy was run in nine major databases, including Medline, Embase and
CINAHL. Grey literature was also searched. All types of evaluative study designs were eligible for inclusion. Existing data abstraction and analysis tools were used. The AMSTAR measurement tool was applied to assess the quality of included systematic reviews. Framework analysis was chosen for synthesising qualitative and quantitative research.

Results: Twelve studies were included in this review: three systematic reviews and nine primary studies. Social franchising has been evaluated in Asia and Africa, particularly from lowincome countries. Most studies focused on reproductive health and family planning. We found a paucity of rigorous study designs, so the evidence supporting social franchising is weak. Across settings, the government continues to have the highest volume of clients for family planning and other services; however, franchises do better than non-franchised private providers in terms of client volume. The clients of social franchises are satisfied with the quality of care and consistently report an intent to return.

    • Seven studies addressed aspects of reach primarily through access to services. Social franchising was not related to increases in client volume across settings or to increased use of STI (sexually transmitted infection) treatment. However, there were mixed outcomes for changes in unmet need for family planning.
    • Five studies addressed quality of care issues. The studies showed that franchise providers were more likely to be trained than non-franchise private providers but that training was associated with government service rather than the franchise. Patient perceptions of quality of care were mixed, although in one post-intervention survey, franchise providers were more likely to be described as having a caring manner.
    • Six of the studies attempted to measure the impact of social franchising on health and health-related behaviour outcomes. Three studies showed an improvement in knowledge and use of modern family planning methods among franchise clients.
    • Seven studies contained elements of equity analysis. They presented mixed results for franchises reaching the young, the poor and the illiterate across settings. Also, clinics set in low-income urban areas did not necessary serve the target low-income group. 

Conclusions: Given that social franchising remains an area of great interest and investment, we recommend evaluations of implementation processes and sustainability, and more rigorous evaluations of the effects of different models.

 

 

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Realising the full potential of Innovative Solutions in Healthcare Delivery - WEF-McKinsey | Synthesis

World Economic Forum (supported by McKinsey & Company). 2010

 

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Franchising in Frontier Markets: What's Working, What's Not, and Why - Dalberg | Synthesis

Dalberg December 2009

Edith Patouillard et al (2007).  Int J Equity Health 2007

 

 

Background: There has been a growing interest in the role of the private for-profit sector in health service provision in low- and middle-income countries. The private sector represents an important source of care for all socioeconomic groups, including the poorest and substantial concerns have been raised about the quality of care it provides. Interventions have been developed to address these technical failures and simultaneously take advantage of the potential for involving private providers to achieve public health goals. Limited information is available on the extent to which these interventions have successfully expanded access to quality health services for poor and disadvantaged populations. This paper addresses this knowledge gap by presenting the results of a systematic literature review on the effectiveness of working with private for-profit providers to reach the poor.

Methods: The search topic of the systematic literature review was the effectiveness of interventions working with the private for-profit sector to improve utilization of quality health services by the poor. Interventions included social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out. The search for published literature used a series of electronic databases including PubMed, Popline, HMIC and CabHealth Global Health. The search for grey and unpublished literature used documents available on the World Wide Web. We focused on studies which evaluated the impact of interventions on utilization and/or quality of services and which provided information on the socioeconomic status of the beneficiary populations.

Results: A total of 2483 references were retrieved, of which 52 qualified as impact evaluations. Data were available on the average socioeconomic status of recipient communities for 5 interventions, and on the distribution of benefits across socioeconomic groups for 5 interventions.

 

Six interventions were identified, "Green Star" and "Green Key" in Pakistan, "Ray of Hope" in Ethiopia, "Janani" in Bihar State, India, "Sewa" in Nepal and "Top Reseau" in Madagascar. Evidence of impact on utilization or quality of health services was mixed:

 

    • Effectiveness of the Pakistan, Ethiopia and Bihar interventions was documented in a single study that used exit interviews to examine client satisfaction at franchised and non-franchised outlets [48]. Effectiveness of the "Green Star" and "Green Key" franchises implemented in Pakistan was jointly evaluated. Clients attending franchised private services were significantly more likely to report that they would return than those attending non-franchised services in Pakistan and significantly less likely in Ethiopia, with no statistically significant difference in Bihar. In all three settings there was no statistically significant difference between the franchise status of the clinic and perceptions of quality (that the service was better than others available) or in citing affordability as a preferred feature of the service [48]. The Green Star and Green Key interventions in urban Pakistan did not benefit relatively poor groups. Clients with income of $101– $250/month and with income greater than $251 were more likely to use franchised services than those earning less than $60/month. Clients with at least secondary schooling were also more likely to use franchised services compared to illiterate clients [48].

 

 

    • The Nepali study examined client satisfaction with quality of care [49]. Clients at intervention clinics 'very satisfied' with cleanliness increased from 37% to 65%, and with the availability of essential equipment from 35% to 62% [49]. Clients were also reported to be more satisfied with the range of services offered in the intervention clinics (40% to 71%) and with privacy (38% to 72%) [49]. The Nepali franchise network clearly benefited a generally poor population, with an estimated income per capita of $125 [49].

 

    • The Top Réseau study reported that coverage of modern contraceptives was higher for women with high exposure to the intervention (have accessed a franchised clinic and have been exposed to the IEC activities) than those with low or medium exposure [50]. Only general SES information was provided for the Top Réseau study.

 

Data on average SES of the recipient population was provided for one of the six interventions. The Nepali franchise network clearly benefited a generally poor population, with an estimated income per capita of $125 [49]. Evidence on the socioeconomic distribution of benefits within the recipient community was provided for the franchise networks in Pakistan, Ethiopia and Bihar State.

 

    • Evidence for the Ray of Hope intervention in Ethiopia was mixed. Clients with income of $101–$250/month were less likely to attend franchised services than those earning less than $60/month. However clients with primary education were more likely to attend franchised services compared to clients with the least education [48].

 

    • The evidence from Bihar was also mixed. There was no statistically significant association between attending franchised services and monthly household income [48]. Clients with no education were more likely to attend franchised services compared to clients with education [48].

 

Conclusion: Few studies provided evidence on the impact of private sector interventions on quality and/or utilization of care by the poor. It was, however, evident that many interventions have worked successfully in poor communities and positive equity impacts can be inferred from interventions that work with types of providers predominantly used by poor people. Better evidence of the equity impact of interventions working with the private sector is needed for more robust conclusions to be drawn.

 

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