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Health Delivery Models - Franchising |
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Description |
Model |
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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
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. |
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Model Strengths |
Model Limitations |
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Miscellaneous concerns:
Challenges for Franchising in frontier markets - Dalberg Report:12
(Not necessarily Health Focused)
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Research Questions |
Pooled Lessons Learned |
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Franchisees' motivations: What factors might influence private providers to join a franchise over continuing to operated independently?
Franchisers process for selecting new entrepreneurs: What characteristics do they want to see on potential entrepreneurs?
Franchise's economic value:
Customers' perceptions
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From WEF and McKinsey:11
From Dalberg Report:
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Case examples |
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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.
(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 StudyRavindran 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-ExperimentWomen'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 ReviewKoehlmoos 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 | QExperimentNgo 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
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.
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.
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:
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.
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-ExperimentSohail 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.
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.
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.
(11)
World Economic Forum (supported by McKinsey & Company). 2010
(12)
Dalberg December 2009