The last decade has seen an important expansion of the social franchising model of service delivery, both in terms of the number of brands available and their geographic presence, as well as the scope of services offered. The [2011 Clinical Social Franchising Compendium](http://www.sf4health.org/sites/www.sf4health.org/files/Social-Franchisin...) identifies **50 franchises that are operating in 31 countries** across the world - that is more than double the number of networks in operation just four years ago. The model’s geographic expansion has also been notable. New networks have sprung up in 17 new countries since 2003, covering larger parts of Africa, Southeast Asia, and more recently, Central America.
Although expanding steadily, service delivery through franchising is still in large part small scale, focused on a very specific set of interventions (e.g., primarily family planning and reproductive health), and remains out of reach for the very poor. Additionally, franchise networks continue to rely on donor funding to subsidize services and expect clients to pay out of pocket for care; of the 50 franchises included in the Compendium, out of pocket payment accounts for at least 80% the payment source in over 30. Aiming to reduce financial barriers to care, a number of franchises have begun **employing demand-side financing mechanisms such as vouchers and insurance** to extend care to the poor. Thus far, however, DSF initiatives have been relatively small scale and covered a limited set of services.
Government financing, on the other hand, is able to reach millions of additional clients. If integrated with social franchises or other accredited networks, it has the potential to offer greater access to standardized quality care and cover a more diverse package of services. Government financing has also gained traction in the last decade, with a number of countries undergoing reforms in an effort to achieve universal health coverage. Countries represented by the [Joint Learning Network for Universal Health Coverage](www.jointlearningnetwork.org) have all made important strides in this direction, often networking both public and private providers and offering schemes that specifically target the poor.
Last week, JLN country representatives [met in Mombasa, Kenya]( http://jointlearningnetwork.org/blog/2011/jun/6/ten-country-delegations-...) to discuss expanding coverage to the informal sector. The Workshop gave them an opportunity to participate in a panel discussion that focused specifically on contracting with social franchise networks to expand access and improve care quality. The session generated a great deal of excitement and interest in this topic. For countries looking to **expand coverage beyond inpatient care**, like [Kenya](http://jointlearningnetwork.org/content/national-hospital-insurance-fund), franchises present an important opportunity to contract with an already existing outpatient care network. Where the national scheme already offers a comprehensive set of benefits, such as [Ghana]( http://jointlearningnetwork.org/content/national-health-insurance-scheme...), franchises provide a valuable **avenue to expand access**. For franchises, government financing offers an additional revenue stream that can be leveraged to achieve scale and incorporate additional services.
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Integration, however, is not without its challenges. One of the main barriers identified by workshop participants is scale. Although potentially valuable, individual networks are not yet big enough to be “essential” to national insurers. To address this, it may be possible for multiple networks within a country to come together into a federation – as has been attempted in India – thus raising their collective negotiating power. Another challenge is the limited scope of services provided by most franchises. Here, it may be valuable to focus integration around one specific intervention, for example – deliveries, which is a service most franchises already perform or have the capacity to perform, and one that is prioritized by many national schemes. Beyond scale and scope, **questions remain about integration “in practice”**. How to harmonize accreditation? Who oversees the process? Who disciplines providers and is held accountable for poor quality?
While all of these question remain to be answered, there is undoubtedly unique potential for public purchasers to leverage existing franchises and other accredited networks to provide essential health interventions – expanding both the clientele base and service diversity of franchise networks, as well as increasing the availability of accredited providers for individuals covered by national schemes.
The JLN session was a great opportunity to catalyze initial discussion around franchise and insurance integration, but it was just a first step in encouraging the kind of partnerships, piloting, and political momentum that will result in a workable model. We will be closely following the connections made in Mombasa and pursuing additional opportunities to bring together key players from both sides to further develop and test this concept.