In 2010, the Population Services International (PSI) program, Sun Quality Health (SQH), and its sister network of village health workers, Sun Primary Health, performed more than 2.1 million client consultations in Myanmar. John Hetherington, who has managed the network since 2007, talked to CHMI about how—in the second-poorest country in the Asia-Pacific region—SQH has assembled one of the broadest service packages of any social franchise network operating today in an attempt to provide high quality, well regulated priority health services to local people.
CHMI: You offer a wide range of services under the Sun Quality Health brand. How do you select the services the brand will include?
John Hetherington: With a backbone of 1200 doctors in more than 200 townships, we can be entrepreneurial. We first ask, is there a need not being met? And is there an opportunity for a network of providers to offer that service? In Myanmar, the largest health concerns – malaria, family planning, pneumonia, diarrheal disease, TB – are either too expensive to treat, or doctors don’t provide the right quality service. As in many places, we started with reproductive health and family planning, where there is a natural fit for social franchising.
Why is it that so many social franchising programs start by offering family planning?
JH: I think family planning is unlike other services because everyone from 15-49 is potentially a client – meaning, they are theoretically all fertile -- and this makes it different than addressing diseases which require many more inputs to be efficient, targeting, testing, etc., particularly in Asia, where many of the big diseases tend to be concentrated epidemics. With FP, you have the potential to offer (almost) anyone you interact with something that can be of service to them. You have the potential for large scale impact without the precise geographical targeting that you would need to treat an epidemic.
Without using the media to market to clients, how does your franchise attract clients?
JH: Advertising for medical services is illegal. Here, as in many countries, there are lots of people who go to their local doctors when they are ill or think they are ill. Many of these doctors have practiced for 20-30 years without continuing medical education. These are the doctors we retrain, so [with their clients] we have a captive audience, in a way.
How do you set prices?
JH: We set prices in a way that they are not a barrier to the poorest person we want to reach in the given target. We make services available at a price people are expecting—50 cents to a dollar for a malaria treatment, versus the five to six dollars it would cost otherwise. If we were not subsidizing these services, doctors would not provide them, or they might give patients the wrong drugs--give an injection, for example.
Speaking of which, how do you ensure quality?
JH: Social franchising is more complex to manage than other channels of social marketing—you need higher levels of training, monitoring and supervision.
On our staff, we have close to 80 doctors that, on average, visit each of the 1200 clinics every six weeks. They observe service delivery and answer the franchisee doctors’ questions. We also send mystery clients to assure that the level of service quality remains intact. We use vignettes in training.
These techniques ensure that [franchisees] are not gauging people with prices or giving the wrong treatment. However, we don’t own these clinics. We hope the training around good hygiene, infection prevention, client relationships, and counseling improves overall practices, since we don’t monitor health areas outside the SQH basket of services.
Is it difficult to get providers to participate?
JH: No – their business increases. Their reputation is better, they have more services to offer, and their customers can get an IUD for 50 cents instead of 50 dollars.
In Myanmar, the public sector is not able to serve the needs of most people; 80-90% of people go to the private sector for health care. This is not unique. The private sector, while used by everyone, is atrocious in most places. With proper management, however, it can be made to do less harm—and even do very good work.
I have had surrealistic conversations with some country officials or [global health policy makers] where someone asks [a policy maker], what is your national protocol for first-line treatment for malaria? Yet, if you look at the data, 99% of people go to a pharmacy and buy drugs off the shelf. Some have to have a philosophical shift to understand this.
Describe your relationship with the Myanmar government.
JH: There is always a give and take between an NGO and the government. We have a longstanding relationship with the government in Myanmar and some of our staff are former civil servants. [Officials] appreciate that we are improving the quality of services by providing continuing medical education where there is none, and reporting on treatments not captured by the national health management information system.
The health minister has also seen the impact of Sun Quality Health. It’s not minor—it’s providing something like 25% of all family planning services, and we are detecting and treating more than 12% of all TB cases nationally.
We heard you are now offering screening for cervical cancer, which is very unusual even though 80% of cases occur in the developing world.
JH: Our franchising director at the time, Dr. Nyo Nyo Mihn learned a couple of years ago at a medical quality conference funded by one of our donors that you can screen [for abnormal cells] with acetic acid and treat abnormal cells with cryotherapy using Co2 in low resource environment, all without electricity. PSI’s innovations fund allows us to be entrepreneurial without massive amounts of money, so we are now beginning training.
Some people in the health ministry are concerned that private sector doctors should be doing something they consider to be a hospital service. But almost no one is doing cervical screenings anywhere, so again, there is a choice of doing nothing, or doing something in partnership with the health facilities that are actually being accessed by people.
We are also piloting a basic package of anti-retroviral therapy with 100 clients, which hasn’t yet been done in social marketing.
You also provide TB screening and treatment.
JH: Starting this intervention in 2004 was our biggest gamble. A recent study showed that the TB prevalence in Myanmar is five to six times higher than what was previously estimated. Now, our franchise does more than 12% of all case detection and treatment in the country.
Recently, in a village meeting, a woman spontaneously came up to us in tears. She told us she had been dying from TB and the treatment she got from a government clinic wasn’t working for her. A PSI health worker told her to go to a [Sun Quality Health] doctor. She said, ‘I’m healthy now and you saved my life’. I was thinking, that’s one person, and there are 17,000 people every year getting that service that would otherwise die, and give TB to eight other people.
Yet, you still have people outside the country saying you can’t work ethically inside the country, and the regime here can also be xenophobic. We can negotiate between those two things—the government doesn’t see [the program] as impinging on their sovereignty and the opposition doesn’t see it as giving succor to the regime. This model would be interesting to use in other difficult political situations, perhaps in Zimbabwe.