Sub committee 4

1. FP Quality & Performance
within Social Franchising and
Voucher Programs
Client with a Tunza Social Franchise Provider, PSK, Kenya
Sub-committee 4
PBF and FP meeting
Institute of Tropical Medicine
Antwerp Sept 2017

2. Session outline
Part 1: Frameworks:
Quality Framework: Human Rights and related principles that apply to FP
Part 2: Franchising:
• Description of franchising model
• Where, when, and how is quality measured in SF (incl. ToC)?
• Limitations of quality measurement in SF
• Metrics routinely captured in SF (quality & quantity)
Part 3: Vouchers
• Description of vouchers model
• Metrics routinely captured in vouchers (quality & quantity)
• Where, when, and how is quality measured in vouchers (incl. ToC)?
• Where is quality not measured in vouchers?
Part 4: What happens to quality in programs that combine SF and vouchers?
Discussion

3. Quality Framework:
Human Rights and
related principles that
apply to FP
Part 1

4. Source: Understanding
Rights-Based FP,
May 23, 2017,
www.familyplanning2020

5. Other sources: WHO, 2014, Rights-based Contraceptive Services; and FP2020, 2014, Rights and Empowerment Principles

6. Source: Understanding Rights-
Based FP, May 23, 2017

7. Social
Franchising &
Quality
Part 2

8. Description of
franchising model
Existing health providers enter into
contractual agreements with the
franchisor to deliver a specified
package of services in accordance
with franchise standards under a
common brand, a far more cost-
effective approach than building
and setting up new facilities

9. Source: SF4Health, UCSF

10. Reasons why social franchising is used
• To expand the offer of priority health services by the
private sector that typically focuses on curative care
• To improve quality and client centred care in the private
sector
• To include private providers in service provision and
demonstrate the role they can play in public health goals

11. Structure and readiness/softer
skills attitude, willingness to serve the
poor, female on staff
Step 2
• Supplies and equipment
• Choice of FP methods
• System to recruit,
motivate and retain staff
• Upgrading health facilities
• Mode of delivery
Franchisee
Branded Name
Step 3
• Assistance in creating
demand for products/
services
• Training (e.g. in clinical
procedures, business
management)
• Protocolised management
• Regular monitoring
Franchisee
Process Effects
Step 1
Select
licensed
providers and
sign contracts
• Continue cycle of quality assurance. Communication of findings, identify & prioritise opportunities for improvement,
define problem, identify who will work on problem, analyse and study problem, chose solution, implement solution
• Providers perform
to standards
• Access, Availability
Quality improved
• FINANCIAL ACCESS
(affordable services
if NGO network)
• Equitable services?
Outcomes
Quality Assurance process
• QA standards + service delivery protocols;
• M&E of routine clinical service data
• Self assessment and Assessment by the
franchisor or the provider-network
• Quality Improvement Surveys – User and
Provider Perception Surveys
• Facility Specific Quality Improvement Plan
• Client
Satisfaction
• Continuing use
• Women get
methods they
want without
barriers or
coercion
• FP needs are
met; demand is
satisfied
Franchisor

12. Where, when, and how is quality measured in SF?
• Different networks apply different methods and indicators to assess different
aspects or dimensions of Quality.
• Holistic vs Targeted Quality Meaurement!
Structure/Readiness
• Initial assessment; usually through external assessment
Process indicators
• Availability contraceptives, adherence to health care delivery standards
• Indicators on provider competence, protocol adherence
• Reliance on franchisee self reporting for routine service stats?
Outcome/Output
• Client service utilization (clinic records)
• Contraceptive continuity or discontinuity
• Client satisfaction (client exit interviews, household surveys)

13. How is Quality assured in SF?
Franchisors provide regulatory oversight role that government plays for all
providers
• Intermittent external Quality Audits/assessment by franchisor
• Clinical audits by internal clinical team (incl. follow up action planning)
• Clinical audits by external clinical teams—typically annual on subset clinics
• Ranking of providers based on quality and quantity of clients
• Providers’ self-assessment of process plays significant role in improving quality
and/or QA teams conduct regular QA (Improvement Plans)
• Benchmarking and setting standards
• Routine clinic monitoring data on method use & discontinuation rate
• Client exit interviews/ Mystery client surveys
• Ensuring feedback loop

14. Limitations of SF in addressing quality?
• Demand side financial barriers not fully addressed, reducing method
choice
• Limited financial gain for providers to improve quality:
• Insufficient evidence on link between SF and improvement knowledge/behaviour.
• SF typically do not work in BCC/ demand creation, except marketing
product awareness.
• Fractional franchise models: have a ‘Method-specific’ focus skewed
to few services (limited in addressing full range of FP services)
resulting in limited client satisfaction.
• Many fractional SF models overlook wider quality issues in provider
skills, i.e. antibiotics dispensing practices

15. Impact of SF on Human Rights and related principles that apply to FP
Rights Element Description of how SF can impact
Accessibility
Geographic: SF expands # outlets offering wider FP method range; Policy (youth!);
contraceptive security: supplies, equipment, training
Availability
Method choice- esp LARC (motivated staff providing counselling + standardized FP services –
direct link to increased use of modern contraceptives)
Acceptability
Private providers have inherent incentive for client centred behaviour. Provider will tailor
facility/services and become more responsive to client’s wishes: cultural/ social; privacy;
choice; opening hours; waiting room/time; etc.
Quality
Standardized FP services, responsive to client’s needs, offering full range (incl. LARC/PM) +
adequate counselling (side effects/misconceptions) – improves contraceptive continuation
Agency/empower
/ autonomy
BCC/Demand Generation elements not always given to support intent to use/agency
Non-discr/Equity Equity impact not always clear
Accountability Private SF providers directly risk reputation for poor practice & gain from satisfied clients
Informed Choice
Part of QA (comprehensive counselling with accurate info and free choice of a wide range of
methods) and because provider tailors to client’s wishes
Privacy/confident
iality
Choice of providers can, in theory, expand privacy, and SF training reinforces importance of
confidentiality, important for clients and providers take this into account/ esp Youth services
Participation n.a.

16. Metrics routinely captured in SF (quality & quantity)
Facility Readiness: including equipment, supplies, medicines, and condition of
clinic’s infrastructure. For FP networks and franchises also standardized
adherence to brand requirements
• Management: Providers’ capacity to plan, organize, implement, and maintain effective
delivery services
• Marketing: Providers’ knowledge of their communities and how effectively they market their
services to retain current clients and attract new ones, pricing strategies
Technical competence and adherence to standards
• Provider knowledge, attitudes and skills
• Service delivery reporting: numbers of FP methods, removals, counselling, etc. (outputs)
Continuity of care: client follow-up, ensure repeat visits with same provider
• Client satisfaction (client exit interviews)
• Return visits (Client loyalty assessed with exit interview)
• Client service utilization reports

17. Vouchers
Part 3

18. What is a voucher?
A token (e.g. piece of paper,
e-code) which can be
exchanged for defined goods
or medical services as a proof
of payment

19. Voucher management agency
Target Population
Health Providers
(public/NGO/private)
Donor/Government
Step 5
Step 1
Step 2
Step 4
Voucher$
Community
workers
Step 3VoucherVoucher
Voucher
$

20. Reasons why vouchers are used
• To accelerate the use of priority health services
– by changing health seeking behaviour and motivating clinics to provide
priority services with quality
• To target underserved populations and address
inequalities
• To include private providers in service provision
• To reduce access barriers by providing additional benefits
• To introduce social health insurance skills:
– accreditation, pricing, contracting, QA, M&E, verification, claims
processing/payment

21. Theory of Change Vouchers
• Financial: vouchers pay for service costs; sometimes transport or other costs
• Mapping identifies most appropriate clinics: private, NGO/FBO or public; near
target group, in relation to cultural/social context etc
• Assessment of quality and readiness identifies best clinics to be contracted
• Periodic assessments ensures quality
• Voucher clinics tailor services and become more responsive to client’s needs
• The voucher income is invested to improve quality/readiness
• During voucher distribution face-to-face information/education/guidance
• The voucher acts as personal invitation, empowers client to seek
services/provides proof-in-hand client is attended (helps to combat
discrimination of marginalised groups such as young and poor)

22. Yemen: work with commnunity; visiting clients at their
homes (IEC/BCC/distribution of voucher)
Workshop local leaders Local women trained as voucher distributors
Distributors gives out voucherBeneficiary receives FP voucher at her home

23. Investments done with voucher income (Yemen)
Autoclave
Ground water tank
Surgical tools Blood pressure meter, stethoscope
Curtains Ambulance

24. How do vouchers impact on Human Rights and related principles that apply to FP
Rights Element Description of how Vouchers can impact
Accessibility
↑ financial (LARC/ PM); geographic (more clinics near clients; evt. transport paid);
policy (youth!); informational; contraceptive security all methods
Availability ↑ readiness and motivated staff to provide all FP methods / contraceptive security
Acceptability
Provider will tailor facility/services and become more responsive to client’s wishes:
cultural/ social; privacy; choice; opening hours; waiting room/time; etc.
Quality
Selection/regular QA: when insufficient then provider not contracted /contract
closed, sometimes training is organised.
Agency/empower/
autonomy
Voucher empowers: proof-in-hand client will be attended to free of charge;
distribution gives face-to-face information on providers and methods
Non-discr./Equity Vouchers mostly used to target underserved groups: ↑equity
Accountability Client exit interviews as part of verification services
Informed Choice
Part of QA (comprehensive counselling with accurate info and free choice of a
wide range of methods) and because provider tailors to client’s wishes
Privacy/confident. Important for clients and hence provider takes into account (esp. youth)
Participation Through community leaders supporting voucher distribution

25. Which indicators are used and when?
• Indicators to identify underserved population – DHS and other
statistical data/FP reports on country/region
• Mapping indicators – distance to target population, indicators related
to client’s needs (e.g. Culture, language, female staff, privacy etc)
• Technical quality – whole series of indicators, often country or SF
specific, such as quality counseling, knowledge FP methods, capacity to
provide each FP method, hygiene etc
• Readiness to provide services– assessed during first assessment
(training of providers, # clients on specific FP method last 3 months,
supplies available etc.)
• Client satisfaction (waiting time, privacy, choice etc)

26. Combination of SF & vouchers?
Part 4

27. Agency
Fund (donor, govt)
Contracted Providers
Clients
Agency
Fund (donor, govt)
Clients
Contracted Providers
Supply-Side
Social Franchise
Vouchers
Vouchers
Marketing
Payment
Demand-Side
Voucher System
Training,Branding,
Supplies,Quality
$

28. Voucher and Social Franchise
Management
agency
Other
clients
Voucher
clients
Contracted
Providers
Fund (donor, govt)
Supply side:
Training, branding,
supplies, quality, and
payment of vouchers
Paying clients
Demand side:
Vouchers and
Marketing
Vouchers

29. Combining vouchers with social franchising programs
Opportunity
- Efficiencies in leveraging SF supply side
quality investments (private sector is
‘ready’ for vouchers)
- Enhances equitable access esp. in out-
of-pocket reliant SF programs
- Separates client method choice from
price factors
- Can enhance provider value proposition
of achieving higher SF quality standards
(e.g. through tiered reimbursement
schedules)
Challenges in practice
- Quality assurance is typically
conducted under the SF program
while vouchers put more emphasis on
compensating FP outputs, which can
risk a disconnect (must be managed)
- Selection strategies are different: SF
on quality potential, vouchers on
quality achieved, yet combined
programs can struggle
programmatically to separate
selection process

30. How does combination of FP and vouchers impact on Human Rights
and related principles that apply to FP
Rights Element Description of how combination SF and Vouchers (V) can impact
Accessibility
↑ Financial (V effect); Geographical (V and SF both increase # of outlets
near clients offering wide range of methods); Policy (SF/V); Informational
(V); Cultural (SF/V); Contraceptive Security (SF/V). Combination of SF/V
strengthens accessibility
Availability
↑ to all methods including LARC/PM: both SF/V ensure readiness and
motivate staff (V tends to increase motivation in SF clinics further)
Acceptability
SF/V: Provider will tailor facility/services and become more responsive to
client’s wishes: cultural/ social; privacy; choice; opening hours; waiting
room/time; etc. When combined SF+V this behaviour is further
strengthened
Quality
Q is important in SF and V and further strengthened when combined, also
because paying for a service reinforces importance of quality

31. How does combination of FP and vouchers impact on Human Rights
and related principles that apply to FP (continued)
Rights Element Description of how combination SF and Vouchers (V) can impact
Agency/empowerme
nt/ autonomy
Voucher empowers: proof-in-hand client will be attended to free of charge;
distribution gives face-to-face information on providers and methods. In SF
not a given, hence in combi SF/V the V ensures this right
Non-
discrimation/Equity
In SF not always clear / in Voucher it is one of the objectives and vouchers
used to target underserved groups: ↑equity
Accountability
Private SF providers directly risk reputation for poor practice & gain from
satisfied clients / V: Client exit interviews as part of verification of services. SF
and V strengthen accountability
Informed Choice
In both SF/V: Part of QA + because provider tailors to client’s wishes, hence
ensuring informed choice is strengthened
Privacy/confidentialit
y
SF/V: Important for clients /provider takes into account. Choice of providers
can expand privacy, and SF training reinforces importance confidentiality.
Combi of SF and V strengthens this right element
Participation
In SF not present. Voucher adds this rights element through involving the
communities when distribution vouchers

32. How does the combination of SF and voucher impacts on
Human Rights and related principles that apply to FP
Rights Element
Description of how Vouchers can impact
SF alone Voucher alone SF and Voucher
Accessibility X XX XXX
Availability X XX XXX
Acceptability X X XX
Quality XX X XXX
Agency/ empowerm/ autonomy - XXX XXX
Non-discrimination/ Equity XXX XXX
Accountability X X XX
Informed Choice XX X XXX
Privacy/confidentiality X X XX
Participation - XX XX

33. Discussion
Part 5