The past decade has seen a growing appreciation of the importance of private healthcare providers as the first, and often only, source of healthcare in many countries. This has led to a range of interventions aimed at engaging these providers to deliver standardized public health goods and services. One partnership modality, called clinical social franchising, applies commercial principles to achieve this goal. In 2012, 74 clinical social franchising programs were operational in 40 countries. The programmes included networks of 66,000+ providers that delivered franchised clinical and health services for family planning; maternal, newborn and child health; and to diagnose and treat TB, malaria and/or HIV. Millions of people received services. The scale and overall health impact of these programs is documented in the Clinical Social Franchising Compendium, 2013 (http://bit.ly/10nVT25). This approach to engaging private purveyors of health and clinical services is gaining traction worldwide. The evidence base for this approach is also increasing, with studies now addressing health impact, quality of care, new usership of formal medical services, cost-effectiveness and equity. This webinar will explain how clinical social franchising works, how it is being adapted in different countries and the evidence for its relevance as a public health approach.

1. Clinical Social Franchising:
Organizing private healthcare
providers to address public health
priorities
An initiative of
the Private Sector in Health Symposium
@psinhealth
#healthmkt
www.pshealth.org
1

2. Symposium: Sydney – 6 July 2013
• Since 2009 a group of researchers and policy analysts
working on health markets in low and middle-income
countries have organised a pre-congress symposium at
the biennial conferences of the International Health
Economics Association
• The aim has been to encourage and disseminate high
quality research on the performance of these markets
and on practical strategies for improving access to safe
and effective services by the poor
• The Future Health Systems Consortium is responsible
for organising the 2013 symposium with financial support
from the Bill & Melinda Gates Foundation, Rockefeller
Foundation, and the USAID-funded SHOPS Project
www.pshealth.org
2

3. Symposium: Sydney – 6 July 2013
• Since 2009 a group of researchers and policy analysts
working on health markets in low and middle-income
countries have organised a pre-congress symposium at
the biennial conferences of the International Health
Economics Association
• The aim has been to encourage and disseminate high
quality research on the performance of these markets
and on practical strategies for improving access to safe
and effective services by the poor
• The Future Health Systems Consortium is responsible
for organising the 2013 symposium with financial support
from the Bill & Melinda Gates Foundation, Rockefeller
Foundation, and the USAID-funded SHOPS Project
www.pshealth.org
2

4. Symposium: Sydney – 6 July 2013
• Since 2009 a group of researchers and policy analysts
working on health markets in low and middle-income
countries have organised a pre-congress symposium at
the biennial conferences of the International Health
Economics Association
• The aim has been to encourage and disseminate high
quality research on the performance of these markets
and on practical strategies for improving access to safe
and effective services by the poor
• The Future Health Systems Consortium is responsible
for organising the 2013 symposium with financial support
from the Bill & Melinda Gates Foundation, Rockefeller
Foundation, and the USAID-funded SHOPS Project
www.pshealth.org
2

5. This webinar series provides
opportunities to set the
scene before the Sydney
meeting and to ensure that
those who may not be
attending the Symposium
have the opportunity to
participate in debates about
strategies for improving the
performance of health
markets in meeting the
needs of the poor.
3

6. Webinar series
• Facilitated by the Future Health Systems
Consortium
• Organised by a number of organizations
• Designed to involve a wide audience
• July 2, 2013: Social franchising webinar
Global Health Group at the University of California
at San Francisco
4

7. Webinar series
• Facilitated by the Future Health Systems
Consortium
• Organized by a number of groups
• Designed to involve a wide audience
• July 2, 2013: Social franchising webinar
Global Health Group at the University of California
at San Francisco
4

8. Webinar series
• Facilitated by the Future Health Systems
Consortium
• Organized by a number of groups
• Designed to involve a wide audience
• July 2, 2013: Social franchising webinar
Global Health Group at the University of California
at San Francisco
4

9. Webinar series
• Facilitated by the Future Health Systems
Consortium
• Organized by a number of groups
• Designed to involve a wide audience
4

10. Organization of webinar
• Chair: David Bishai (Johns Hopkins School
of Public Health)
• Panelists
- Rehana Ahmed (Marie Stopes International)
- Dominic Montagu (Global Health Group at
the University of California at San
Francisco)
• Discussion
5

11. Questions?
How to submit
• Via the ‘Questions’ box in
the GoToWebinar control
panel
• Via Twitter using the
hashtag #healthmkt
Be sure to include your name,
organization and location
with your question.
6

12. The Private Sector Healthcare Initiative
Clinical Social Franchising
Dominic Montagu
Private Sector in Health Webinar - July 2, 2013 12

13. What is Social Franchising?
13

14. SOCIAL FRANCHISING
Problem:
Many private clinics in LMIC, but
each has a limited range of
services and uncertain quality

15. SOCIAL FRANCHISING
Solution:
Grouped into branded franchise.
Still independent, but common
standards and new services.

16. SOCIAL FRANCHISING
Branding
Training
Standards
Commodities
Solution:
Grouped into branded franchise.
Still independent, but common
standards and new services.

17. SOCIAL FRANCHISING - GOALS
+ Health Impact
✓ Quality
$ Cost-Effectiveness
Equity
Market Expansion

18. SOCIAL FRANCHISING - GOALS
+ Health Impact
A summary of health benefits resulting from
avoiding a disease or unintended pregnancy.

19. ✓
SOCIAL FRANCHISING - GOALS
Quality
The ability to treat or refer clients with
complications, and adherence to overall
program protocols

20. $ Cost-Effectiveness
SOCIAL FRANCHISING - GOALS
Able to deliver a service to a target
population at a lower cost than alternative
delivery options.

21. Equity
SOCIAL FRANCHISING - GOALS
The percentage of patients receiving
franchised services that are within the lowest
two national wealth quintiles.

22. Market Expansion
SOCIAL FRANCHISING - GOALS
Provide services to patients in need who
would otherwise receive lower quality care,
delay seeking care, or go without care.

23. • Provides a range of services
• Some existing services are
improved
• Most existing services remain
unchanged
Typical private clinic
Private
Clinic
Services
• Aches, pains, headaches
• Cuts, abrasions
• Stomach problems
• Eye, nose, throat
• Fevers and coughs
• Diarrheal diseases
• Infections
• Chronic illnesses
FRACTIONAL FRANCHISING

24. Typical franchise clinic
• New services are added
• Some existing services are
improved
• Most existing services remain
unchanged
services
• Aches, pains, headaches
• Cuts, abrasions
• Stomach problems
• Eye, nose, throat
• Fevers and coughs
• Diarrheal diseases
• Infections
• Chronic illnesses
• Family planning
• TB diagnosis and Care
Franchise
Clinic
FRACTIONAL FRANCHISING

25. Typical franchise clinic
• New services are added
• Some existing services are
improved
• Most existing services remain
unchanged
services
• Aches, pains, headaches
• Cuts, abrasions
• Stomach problems
• Eye, nose, throat
• Fevers and coughs
• Diarrheal diseases
• Infections
• Chronic illnesses
• Family planning
• TB diagnosis and Care
Franchise
Clinic
FRACTIONAL FRANCHISING

26. Typical franchise clinic
• New services are added
• Some existing services are
improved
• Most existing services remain
unchanged
services
• Aches, pains, headaches
• Cuts, abrasions
• Stomach problems
• Eye, nose, throat
• Fevers and coughs
• Diarrheal diseases
• Infections
• Chronic illnesses
• Family planning
• TB diagnosis and Care
Franchise
Clinic
FRACTIONAL FRANCHISING

27. • Outlets are owner-operated
• Payment is for services delivered
• Services are standardized
• “Clinical” services are provided
DEFINITION

28. In 2009, PSHi launched a global survey to understand the scale, quality, impact,
implementation models, and financing models of clinical social franchising
programs.
 The results were reported in the First Compendium of Clinical Social
Franchising.
• In May 2103, the fifth annual edition was released. It is available at
http://www.sf4health.org/
• Profiles about each of the programs are also available at
http://healthmarketinnovations.org
Global survey of clinical SF programs

29. ...Social Franchising used in many LMICs
Greenstar,
Pakistan
Janani,
India
SQH,
Myanmar
Smiling Sun,
Bangladesh
SSA: 2,341 franchisee
clinics
Asia: 12,772
franchisee clinics
#franchises
50
40
30
20
10
201120102009200820072006200520042003200220012000199919981997199619951994
Total number
of franchises
Salient
Examples
Countries with
social franchises
Source: "Clinical Social Franchising Compendium – An annual Survey of Programs (2011)" -- Global Health Group, UCSF
Growth Worldwide
60
70
2012

30. Countries with programs, 2009
25 countries
40 programs
1 program
2 programs
3 programs
4 programs
5 programs
30

31. Expansion of programs, 2012
40 countries
74 programs
1 program
2 programs
3 programs
4 programs
5 programs
31

32. Number of programs reporting the offer of franchised services for
FP, SRH (excluding HIV/AIDS), HIV/AIDS, MCH, malaria and TB
(2008–2012)
n=59 programs
32

33. Disaggregation of SRH and MNCH service
provision data shows:
• 20+ programs offer safe abortion or post-
abortion care services
• 12 programs offer cervical cancer screenings
and/or treatment
A closer look at SRH/MNCH services

34. Number of franchisees, by profession and region
(2012)
n=60 programs
Number of outlets, by type and region
(2012)
n=60 programs
34

35. Rural versus urban location for outlets (2012)…
35

36. 36

37. Use of demand-side financing mechanisms (2012)
n=60 programs. 19 programs reported the use of demand-side financing mechanisms, and
three of those have reported the use of one or more mechanisms.
37
Vouchers are the most frequently
used third-party financing
mechanism. They are most
commonly linked to the use of FP
commodities or services.

38. Number of programs that have franchised public sector clinics or
outlets (2010–2012)
n=60 programs
13 sites now report that franchised services are offered
through public sector clinics.
38

39. Health impact: DALYs averted,* by service areas (2012)
n=39 programs
Over eight million DALYs, or healthy years of life lost, were averted in 2012 by the 39
programs that reported service provision numbers. The greatest contribution came from the
provision of family planning services.
39

40. Proportion of FP DALYs averted attributable to long-term FP
methods* (2012)
n=39 programs
Long-term family planning methods accounted for over 80% of the health impact
attributable to family planning services.
40

41. Trend in CYPs (2011 to 2012)
n=the same 32 programs across both years
From 2011 to 2012, CYPs in 32 programs increased overall by 23.7%.
41

42. Conclusion
The model of social franchised health service delivery continues to
grow
The principal attractions are:
1. Leverage of existing infrastructure
2. Scalability
3. Quality assurance
Questions are becoming clearer, but a number remain unresolved:
1. Cost-effectiveness
2. Sustainability
3. Defined role in an evolving health system

43. Dr. Rehana Ahmed
Board Director
Greenstar Social Marketing
Pakistan
(Based in Kenya)

44. Greenstar
A Fractional Franchise @Scale
Dr.Rehana Ahmed
PS4Health Webinair
2 July, 2013

45. Greenstar Social Marketing Pakistan
• A nation-wide local NGO and
• An independent member of Population Services
International (PSI).
Greenstar Mission
To improve the quality of life of low income people by
increasing access and use of health products, services, and
information.

46. Social Franchising started with a
question…………..
Q. Can the Intrauterine contraceptive
device (IUCD) be socially marketed?

47. It needs a trained health provider & a
supportive supervisory system.
The IUCD cannot jump out of the
packet into the uterus ……….

48. • Low participation of private sector in
delivering preventive services
• Limited professional development
opportunities for private health care
professionals
Who did Greenstar train?
The private sector provides 70% of
health services in Pakistan and yet
there is ……..

49. Business Model
Social Franchising & Marketing at Scale
Social Marketing
•Coverage 107 out of 135 districts of
Pakistan and expanding….
•33 staff medical detailers
Social Franchising
•Coverage 96 out of 135 districts of
Pakistan and expanding….
•65 staff medical doctors
•42 staff academic detailers
•IPC staff mobilizers
8540 franchisees
21 products and services
•51 ,000 retail outlets
•24,000 pharmacies

50. • Products
– Condoms: 106 million
– Pills: 2.99 million
– Injectables: 1.01 million
– IUDs: 0.31 million
Results 2012 .…
# 1 in all 60 PSI member countries
with…………2.1 Million CYPs

51. Results 2012.… # 1
with 8540 franchisees
Franchise Services: Family planning ; Maternal health,
child survival & TB
IUCD insertions: 216,656
Implants: 2,059
Surgical (VSC) 7,099
PAC (MVA) 23,195
Post MVA FP 22,731
• Total Clients served: 3.4 million
• DALYs averted 1.36 million

52. National Impact
Pakistan Bureau of Statistics 2011
More then 1 out of every 4 couples who
use modern FP methods - use Greenstar.

53. National contribution (CYPs)
30%
5%
6%
59%
Greenstar
Social
Marketing
Commercial
Sector
NGO
Public Sector
CONRACEPTIVE PERFORMANCE REPORT 2010-2011
Pakistan Bureau of Statistics

54. Health Areas
Family Planning
Maternal &
Child Health
TB treatment

55. Scale : Match growth with infrastructure &
technology
• The ratio of number of franchise clinics to
number of supervisory staff should remain
favorable
• Add ICT innovations to complement human
resource and create efficiencies; engage in fast
two way communications
Lessons Learned

56. Scope: broaden to range of services for which there is a
demand , this increases overall uptake of services.
• In Greenstar – additions are provision of ANC, safe
delivery, PNC , newborn care & PAC services ( with
addition of a second brand –Goodlife)
• Performance based vouchers for MNCH , has shown
increase in uptake of FP services, as well.
Lessons Learned (contd)

57. Demand Generation needs interpersonal
communications (IPC)
• Community mobilization
Quality Challenge
• Aim for optimum & realistic quality in the given
context
Lessons Learned (contd)

58. • Greenstar to remain “the organization of choice” for
reaching underserved urban and rural populations in
the post devolution era
• Develop a proactive provincial government
collaboration
• Increase rural coverage
• Work with public sector for longer-term broader
linkages and direct interventions with public
sector facilities
Strategy 2013-2016

59. Primary focus remains family planning
• Supply side: increase access to products/services
and channels
• Demand side: increase awareness about
products/services and channels and improve
provider channel quality
Strategy 2013-2016 Cont......

60. • Explore women’s reproductive life-cycle goals to
better integrate supply and demand
• Present birth spacing as continuum of maternal
and child and the increase the contact points for
family planning products and services
Strategy 2013-2016

61. Build long-term financial sustainability for
Greenstar
Position for cost efficiency but do not
prioritize it over performance and health
impact
Strategy 2013-2016 Cont......

62. • Products security for the harder to reach areas
• Resources to support a network at scale, for the
quality services
• Interventions to reach rural /underserved areas e.g.
mobile services, community volunteers
Future needs

63. Future needs
Advocacy for task shifting to lower cadre for FP
service provision
Demand side financing schemes like vouchers

64. Questions & Comments