For the past five years, the Global Health Group, at the University of California in San Francisco, has been surveying clinical social franchising programs around the world to learn about who they serve, where and how they work, and their health impact.
Clinical social franchising is a model for organizing networks of private providers to deliver a range of standard-based health services under a common brand. This approach to standardizing the provision of healthcare among disparate private providers is rapidly gaining traction.
This year, after conducting an extensive search to identify new and defunct programs, we learned there were 74 programs in operation. We received program data from 59 of them, and reported findings in the Clinical Social Franchising Compendium, 2013. (You can also learn about our data collection and analysis process there). Some of our key findings are summarized below:
What the data say
The growth in social franchising programs is remarkable. In 2012, there were programs located in 40 countries. By way of comparison, in 2002, there were franchising programs in 15 countries.
There were at least 74 clinical social franchising programs in 2012. However, it's not just the number of programs that have changed. Programs have also grown well beyond the health service areas and implementation models that dominated the landscape just 10 years ago.
In 2008, all programs with available data (n=31) reported that they offered family planning services. 18 (58%) also offered sexual and reproductive health services (not including services for HIV or AIDS), and 13 offered services for maternal, newborn and child health.
In 2012, 50 of 59 programs with available data offered family planning services. 31 offered sexual and reproductive health (SRH) services (not including services for HIV or AIDS), and 24 offered services for maternal, newborn and child health (MNCH).
When the SRH and MNCH data is disaggregated by specific type of service, we find that at least 20 programs offer safe abortion or post-abortion care services, and 12 programs offer cervical cancer screenings and/or treatment. It is very likely that these numbers have been underestimated, as some programs have opted not to report service statistics, and not to specify the type of SRH or MNCH service they offer.
The contributions of family planning services towards the overall health impact of franchised health services is still very significant.
Overall, 7 million disability adjusted life years (DALYs) were averted. This means that 7 million years of healthy life that could have been lost if the services were not provided, have been saved. This can be a complicated metric to understand, but it is sufficient to note that a good deal of morbidity and mortality was avoided as a result of these services, and that family planning services contributed to over three fourths of that impact.
I should however note that the model the SF4Health Metrics Working Group adopted to produce this estimate of health impact (which was produced by MSI and PSI) does not take into account some health services being offered by the franchising programs, including safe delivery and post-natal care services, ART for AIDS, and a few other areas. Therefore, overall health impact is underestimated.
Of the health impact associated with the provision of family planning services, long-term methods accounted for over four fifths of health impact.
We also estimated health impact in terms of Couple Years of Protection (CYPs). CYPs, which only take into account the impact of family planning services, were calculated for 31 programs that reported FP data in 2011 and 2012. In those programs, there was an increase of 1,942,829 in CYPs between 2011 and 2012, or about 30.6%.
Clinical social franchising is notable not only for its adaptability to health service areas and its impact, it is also notable for its scalability.
In 2012, more than 66,000 healthcare providers belonged to social franchising networks. The majority of them were outreach workers or social workers, and most were located in South Asia. Overall, there was roughly a 3.6:1 ratio of outreach/social workers to nurses/midwives, and a 2.4:1 ratio of nurses/midwives to doctors. Thousands of vendors of pharmaceuticals also participated in the networks.
Many programs rely on large numbers of people who are not accredited to provide clinical services to bring clients into the offices of those who are accredited. Building consumer demand is therefore a cornerstone for the programs. The non-accredited people typically function as referral points, vendors of health commodities and providers of some forms of testing and health information.
More than 53,000 outlets belonged to the networks. Interestingly, the majority of them are drug and chemical shops, mostly operating in South Asia.
The field of clinical social franchising is dynamic, and a number of programs are adopting new and context-specific approaches to financing their programs, partnering with the government, adapting technologies for program use, and encouraging demand for services. To learn more, download the Compendium.
My colleagues and I will be contributing insights on topics related to social franchising including demand-side financing, equity and performance indicators, and several other topics. We welcome your comments.