The Global Health Group at UCSF recently launched the 2011 Clinical Social Franchising Compendium, the third in a series of annual publications that aim to profile and analyze clinical franchises operating globally. Karen Schlein, the lead author and editor of this year’s Compendium at UCSF, gives us a glimpse into its findings – based on profiles of 50 franchises, 10 new to this publication – touching on the expansion of the model over the last decade, adoption of new funding streams, and ongoing efforts to measure service quality.
The Global Health Group at UCSF has been compiling the social franchising compendia for the past three years, what have you observed in terms of the proliferation of the social franchising model, both in terms of the number of franchisees in the network, as well as geographic presence?
KS: Although social franchising began in the mid-1990’s it is only in the last few years that this model has proliferated. The number of social franchises has actually more than doubled since 2007 when there were 24 franchises. Now there are 50. In terms of geographic expansion, the model began in Asia and quickly spread to Africa. It has, however, also become prominent just in the last year in Latin America where four social franchises now exist. In terms of clients served by social franchises, South Asia accounts for the majority of clients due to the scale of a few programs in particular which serve over one million clients per year; these are Blue Star Bangladesh, Smiling Sun Bangladesh, Sun Quality Health Myanmar, and Greenstar Pakistan.
FP and SRH have traditionally been the most popular service types offered by social franchises, though you note a distinctive increase in number of "other" services offered. What are some of the trends you're seeing in the expansion of the scope of services?
KS: In recent years, the number of services offered by franchises has greatly expanded. Programs realized that integrating multiple services was desirable by clients and also for the cost effectiveness of the franchises. In addition to reproductive health and family planning services, many programs, such as ProFam Benin and MicroClinic International in Ghana, now offer treatment for malaria, TB, diarrhea and pneumonia. Within the realm of reproductive health, programs have expanded their offerings to include safe delivery kits, emergency contraception and misoprostal for post-partum hemorrhage and abortion. Additionally, in the last few years programs have significantly increased their provision of long-term family planning methods such as IUDs.
It's evident that quite a few franchises rely on community health workers - what is their most common role? Does it differ by region?
KS: There are almost 12,000 community health workers providing health services for social franchises around the world. CHWs tend to be involved in a variety of activities including demand creation for the franchise, door-to-door outreach and provision of a limited number of products. In Nicaragua, Red Segura utilizes CHWs to promote the uptake of RH services, provide counseling on FP, and directing patients to its network of providers for further care. Thus, CHWs play an important role in referring clients to the franchise clinic and liaising with the community. Most CHWs are reimbursed for their transport and some are also provided with a stipend.
A number of franchises have implemented demand-side financing mechanisms to make care more accessible, but the majority still rely on out of pocket payments as their primary payment source. Do you see a trend toward the incorporation of additional financing mechanisms? What are the challenges to this?
KS: The majority of payments at franchises are out-of-pocket payments. A limited number of franchises are now offering vouchers that cover long-term family planning methods and a number of other franchises have indicated their plans to introduce demand-side-financing options in 2011. BlueStar Pilipinas, for example, is pursuing integrations with the Philippine’s National Health Insurance Program (NHIP) to provide a Maternity Care Package that includes pre-natal, safe delivery, postnatal and FP services.
Do most franchises rely on donor support to operate? How have franchises addressed the issue of sustainability?
KS: All franchises rely on some form of donor support but many programs are starting to address the issue of financial sustainability. Only four franchises recover 20% or more of their costs [these are: RedPlan Salud Peru, BlueStar Bangladesh, Sangini Nepal, and Smiling Sun Bangladesh] so most programs are still heavily reliant on donor funds. Programs have taken steps to improve cost recovery by increasing the number of patients who can afford to pay for services and also by adding higher revenue-generating services such as emergency obstetric care and diagnostics. Additional innovations to improve the ability of clinics to generate revenue include clinic refurbishment to attract more patients and educating all clinic employees about business practices.
You recently launched a Quality Metrics Support Program to encourage quality measurement, what does the 2011 compendium reveal about the quality assurance mechanisms currently implemented by social franchises?
KS: Social franchises are implementing an impressive range of quality measurement initiatives. Not only are franchises measuring quality, they are using the findings to make improvements to their network. Franchises achieve high quality standards by having strict guidelines for providers and discontinuing association with providers that don’t meet those standards. High quality in a number of programs is encouraged by recognizing providers that consistently deliver high quality healthcare. Many franchises conduct mystery client surveys, exit interviews, unannounced inspections and audits to ensure quality of the facility and the services provided.
The 2009 and 2010 Clinical Social Franchising Compendia are available on sf4health.org.