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IS4D: Health Delivery Models

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Model Evaluation Frameworks
Health Financing Models
Health Delivery Models

 

 


 

Health Delivery Models

 

Franchise Model

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)
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 evidence, but mixed reports of higher quality, possibly at a higher cost, or unaffordability to the poorest
Replicability
 
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

  • 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
  • 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
  • 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

 

 

 

  • Difficulties in recruiting franchisees and significant attrition are reported2

  • Application of quality assurance standards and protocols are often low2

 

Miscellaneous concerns:

  • 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

 

Pooled Lessons Learned Research Questions
  • 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
  • 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
 
Case examples
  • Sun Quality Health network in Myanmar. LINK1

 

Resources


 

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.

 

 

Reference


 

(1) O’Connell K, Hom M, Aung T, Theuss M, Huntington D (2011) Using and Joining a Franchised Private Sector Provider Network in Myanmar. 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) Ravindran and Fonn. (2011). "Are social franchises contributing to universal access to reproductive health services in low-income countries?" 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) Nirali M Shah, Wenjuan Wang, and David M Bishai. (2011) 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? 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. 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) Koehlmoos TP, Gazi R, Hossain SS, Zaman K. The effect of social franchising on access to and quality of health services in low- and middle-income countries. 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.

 

 

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