Clinical Social Franchising: Organizing private healthcare providers to address public health priorities

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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 …

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.

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  • A common problem
  • These numbers are very likely underestimates, as some programs have opted not to specify the type of SRH or MNCH service they offer, or have redacted references to abortion services.
  • 75,400+ persons working in the health industry belong to franchise networks.The majority are outreach workers. Vendors of pharmaceuticals are the second largest group. The networks with the largest numbers of providers are in South Asia.The networks provide services through 53,794 outlets worldwide.The majority of outlets are located in South Asia. Drug and chemical shops make up the largest type of outlet.
  • Programs in which the majority of outlets are located in rural areas are circled in blue.
  • The programs that are running franchises through public sector facilities are located in: Burundi,DRC,Kenya (2), Rwanda,Mali,Nigeria,China,Philippines,South Africa,Sudan,Vietnam (2), andZimbabwe
  • Missing from DALYS averted calculation:Cervical cancer screening (10/39 programs)Antenatal care (2/39)Safe delivery services (6/39)Post-natal care, including breastfeeding support (5/39)Syphilis screening and tx (1/39)Lubricants (2/39)ART (1/39)RDTs (1/39)
  • Long-term family planning methods include 10- and 5-year IUDs; 5-, 4-, and 3-year hormonal implants; and female and male sterilizations. Short-term family planning methods include 1-, 2-, and 3-month injectable contraceptives; oral contraceptives; emergency contraception pills; male and female condoms; Standard Days Method (SDM); lactationalamenor- rhea method (LAM); fertility awareness methods; vaginal ring or patch; and the diaphragm.
  • USAID’s CYP conversion factors were applied for this calculation.
  • The Board has given the directive that Greenstar will remain firm on its mission of providing quality care to the poor through a focus on FP/RH
  • Greenstar is a fractional franchise with 8,540 members in its network.We employ xx medical doctors to support these members, the largest number after any hospital.

Transcript

  • 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