The red and yellow color scheme is evident everywhere you look. Brightly painted lines run along every room and hallway, and a smiling sun adorns window curtains and posters displaying health information. We are at the Surjer Hashi Clinic outside of Dhaka, one of the 325 clinic networked by the Smiling Sun Franchise Program (SSFP), a USAID-funded initiative that has grown to become the largest private healthcare network in the country. The colors and logo are part of the franchise branding, now highly recognizable to the local residents that gradually stream through the clinic’s doors. On the day that we visit, most of the patients are women and children, primarily mothers who bring their babies for much-needed check-ups.
The Surjer Hashi Clinic opened in 1999 and is currently managed by Dr. Nazmul Islam. He tells us that the clinic was converted into a franchise in 2007 and launched in 2008—the conversion process, including the training, branding, and certain infrastructure improvements to assure quality, took a year. The clinic now hosts doctors around the clock and operates its own ambulance services. The ambulance is provided to the poor for free; other patients pay 200Tk (about $2.40) to come to the clinic and 1100Tk (about $13) to be transported from the clinic to the Dhaka Medical College. The clinic has also established agreements with several informal providers in the area, or “quacks”, as they are known by many in Bangladesh, for referrals, particularly for surgical contraception.
Unlike many other franchise programs, where the franchisees are independently-operating providers, Smiling Sun works with a group of local NGOs that enroll the clinics that they manage into the network. The Surjer Hashi Clinic is operated by Swanirvar Bangladesh, one of Smiling Sun’s largest NGO partners. All SSFP clinics offer a set of government-approved primary care services, called the essential service delivery (ESD) package, which includes basic curative care, family planning, and maternal care services. In addition to the static clinics, Smiling Sun also operates over 9,000 satellites, regularly-run mobile clinics that offer a subset of the ESD services.
Patients wait in the reception area of the Surjer Hashi Clinic, a Smiling Sun clinic operated by Swanirvar Bangladesh.
Sustainability is essential to the network. The franchise aims to achieve significant cost recovery across all of its clinics—initially targeting 70%—while maintaining a pro-poor focus. This has proven to be a challenge. A mid-term review carried out in 2010 showed that the average cost-recovery rate that year was 34% across the network. At the time of our visit, the rate has risen to 42%, a promising increase for a network looking to ensure long-term sustainability. To make care affordable to the poor, Smiling Sun prices services according to market conditions, including the clinic location (urban vs. rural) and the existence of competitor facilities. The franchise has also participated in a government voucher scheme aimed at increasing women’s access to ante-natal care and delivery services.
At the Surjer Hashi Clinic, membership in the network has had some tangible benefits. Since adopting the Smiling Sun brand, patient volume has increased significantly, from about 50-55 patients daily and 5-6 delivery per month in 2006 to 120 patients per day and 60 deliveries per month. Dr. Islam says that he particularly appreciates the training provided by the network and the ongoing support made available to franchisees.
But the day-to-day work is also not without its challenges. While the clinic is generally well-lit, the electric supply is often unpredictable. As we make our way through the clinic, the lights flicker and shut off. Staff turnover has also been particularly high—an issue that plagues clinics across the Smiling Sun network—though the franchise has attempted to incentivize qualified providers to remain at its clinics through salary increases and performance-based payments. Furthermore, patients often come expecting free care, a mind-set that is difficult to change in a country dominated by donor-backed NGO service delivery.
But it appears that things are, in fact, changing. Toward the end of our visit, we stop to chat with one of the nurses. The woman has been working at the clinic for eleven years and has observed first-hand the transformation from an individual clinic to a Smiling Sun franchisee. A few minutes into the conversation, we are notified that there is a line of patients waiting to see her. Not wanting to intrude, we say thank you and step aside. And then the lights come back on.