Clinical Social Franchising:
Organizing private healthcare
providers to address public health
priorities
An initiative of
...
Symposium: Sydney – 6 July 2013
• Since 2009 a group of researchers and policy analysts
working on health markets in low a...
Symposium: Sydney – 6 July 2013
• Since 2009 a group of researchers and policy analysts
working on health markets in low a...
Symposium: Sydney – 6 July 2013
• Since 2009 a group of researchers and policy analysts
working on health markets in low a...
This webinar series provides
opportunities to set the
scene before the Sydney
meeting and to ensure that
those who may not...
Webinar series
• Facilitated by the Future Health Systems
Consortium
• Organised by a number of organizations
• Designed t...
Webinar series
• Facilitated by the Future Health Systems
Consortium
• Organized by a number of groups
• Designed to invol...
Webinar series
• Facilitated by the Future Health Systems
Consortium
• Organized by a number of groups
• Designed to invol...
Webinar series
• Facilitated by the Future Health Systems
Consortium
• Organized by a number of groups
• Designed to invol...
Organization of webinar
• Chair: David Bishai (Johns Hopkins School
of Public Health)
• Panelists
- Rehana Ahmed (Marie St...
Questions?
How to submit
• Via the ‘Questions’ box in
the GoToWebinar control
panel
• Via Twitter using the
hashtag #healt...
The Private Sector Healthcare Initiative
Clinical Social Franchising
Dominic Montagu
Private Sector in Health Webinar - Ju...
What is Social Franchising?
13
SOCIAL FRANCHISING
Problem:
Many private clinics in LMIC, but
each has a limited range of
services and uncertain quality
SOCIAL FRANCHISING
Solution:
Grouped into branded franchise.
Still independent, but common
standards and new services.
SOCIAL FRANCHISING
Branding
Training
Standards
Commodities
Solution:
Grouped into branded franchise.
Still independent, bu...
SOCIAL FRANCHISING - GOALS
+ Health Impact
✓ Quality
$ Cost-Effectiveness
Equity
Market Expansion
SOCIAL FRANCHISING - GOALS
+ Health Impact
A summary of health benefits resulting from
avoiding a disease or unintended pr...
✓
SOCIAL FRANCHISING - GOALS
Quality
The ability to treat or refer clients with
complications, and adherence to overall
pr...
$ Cost-Effectiveness
SOCIAL FRANCHISING - GOALS
Able to deliver a service to a target
population at a lower cost than alte...
Equity
SOCIAL FRANCHISING - GOALS
The percentage of patients receiving
franchised services that are within the lowest
two ...
Market Expansion
SOCIAL FRANCHISING - GOALS
Provide services to patients in need who
would otherwise receive lower quality...
• Provides a range of services
• Some existing services are
improved
• Most existing services remain
unchanged
Typical pri...
Typical franchise clinic
• New services are added
• Some existing services are
improved
• Most existing services remain
un...
Typical franchise clinic
• New services are added
• Some existing services are
improved
• Most existing services remain
un...
Typical franchise clinic
• New services are added
• Some existing services are
improved
• Most existing services remain
un...
• Outlets are owner-operated
• Payment is for services delivered
• Services are standardized
• “Clinical” services are pro...
In 2009, PSHi launched a global survey to understand the scale, quality, impact,
implementation models, and financing mode...
...Social Franchising used in many LMICs
Greenstar,
Pakistan
Janani,
India
SQH,
Myanmar
Smiling Sun,
Bangladesh
SSA: 2,341...
Countries with programs, 2009
25 countries
40 programs
1 program
2 programs
3 programs
4 programs
5 programs
30
Expansion of programs, 2012
40 countries
74 programs
1 program
2 programs
3 programs
4 programs
5 programs
31
Number of programs reporting the offer of franchised services for
FP, SRH (excluding HIV/AIDS), HIV/AIDS, MCH, malaria and...
Disaggregation of SRH and MNCH service
provision data shows:
• 20+ programs offer safe abortion or post-
abortion care ser...
Number of franchisees, by profession and region
(2012)
n=60 programs
Number of outlets, by type and region
(2012)
n=60 pro...
Rural versus urban location for outlets (2012)…
35
36
Use of demand-side financing mechanisms (2012)
n=60 programs. 19 programs reported the use of demand-side financing mechan...
Number of programs that have franchised public sector clinics or
outlets (2010–2012)
n=60 programs
13 sites now report tha...
Health impact: DALYs averted,* by service areas (2012)
n=39 programs
Over eight million DALYs, or healthy years of life lo...
Proportion of FP DALYs averted attributable to long-term FP
methods* (2012)
n=39 programs
Long-term family planning method...
Trend in CYPs (2011 to 2012)
n=the same 32 programs across both years
From 2011 to 2012, CYPs in 32 programs increased ove...
Conclusion
The model of social franchised health service delivery continues to
grow
The principal attractions are:
1. Leve...
Dr. Rehana Ahmed
Board Director
Greenstar Social Marketing
Pakistan
(Based in Kenya)
Greenstar
A Fractional Franchise @Scale
Dr.Rehana Ahmed
PS4Health Webinair
2 July, 2013
Greenstar Social Marketing Pakistan
• A nation-wide local NGO and
• An independent member of Population Services
Internati...
Social Franchising started with a
question…………..
Q. Can the Intrauterine contraceptive
device (IUCD) be socially marketed?
It needs a trained health provider & a
supportive supervisory system.
The IUCD cannot jump out of the
packet into the uter...
• Low participation of private sector in
delivering preventive services
• Limited professional development
opportunities f...
Business Model
Social Franchising & Marketing at Scale
Social Marketing
•Coverage 107 out of 135 districts of
Pakistan and...
• Products
– Condoms: 106 million
– Pills: 2.99 million
– Injectables: 1.01 million
– IUDs: 0.31 million
Results 2012 .…
#...
Results 2012.… # 1
with 8540 franchisees
Franchise Services: Family planning ; Maternal health,
child survival & TB
IUCD i...
National Impact
Pakistan Bureau of Statistics 2011
More then 1 out of every 4 couples who
use modern FP methods - use Gree...
National contribution (CYPs)
30%
5%
6%
59%
Greenstar
Social
Marketing
Commercial
Sector
NGO
Public Sector
CONRACEPTIVE PER...
Health Areas
Family Planning
Maternal &
Child Health
TB treatment
Scale : Match growth with infrastructure &
technology
• The ratio of number of franchise clinics to
number of supervisory ...
Scope: broaden to range of services for which there is a
demand , this increases overall uptake of services.
• In Greensta...
Demand Generation needs interpersonal
communications (IPC)
• Community mobilization
Quality Challenge
• Aim for optimum & ...
• Greenstar to remain “the organization of choice” for
reaching underserved urban and rural populations in
the post devolu...
Primary focus remains family planning
• Supply side: increase access to products/services
and channels
• Demand side: incr...
• Explore women’s reproductive life-cycle goals to
better integrate supply and demand
• Present birth spacing as continuum...
Build long-term financial sustainability for
Greenstar
Position for cost efficiency but do not
prioritize it over performa...
• Products security for the harder to reach areas
• Resources to support a network at scale, for the
quality services
• In...
Future needs
Advocacy for task shifting to lower cadre for FP
service provision
Demand side financing schemes like vouchers
Questions & Comments
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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 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.
  • Clinical Social Franchising: Organizing private healthcare providers to address public health priorities

    1. 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. 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. 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. 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. 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. 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. 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. 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. 9. Webinar series • Facilitated by the Future Health Systems Consortium • Organized by a number of groups • Designed to involve a wide audience 4
    10. 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. 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. 12. The Private Sector Healthcare Initiative Clinical Social Franchising Dominic Montagu Private Sector in Health Webinar - July 2, 2013 12
    13. 13. What is Social Franchising? 13
    14. 14. SOCIAL FRANCHISING Problem: Many private clinics in LMIC, but each has a limited range of services and uncertain quality
    15. 15. SOCIAL FRANCHISING Solution: Grouped into branded franchise. Still independent, but common standards and new services.
    16. 16. SOCIAL FRANCHISING Branding Training Standards Commodities Solution: Grouped into branded franchise. Still independent, but common standards and new services.
    17. 17. SOCIAL FRANCHISING - GOALS + Health Impact ✓ Quality $ Cost-Effectiveness Equity Market Expansion
    18. 18. SOCIAL FRANCHISING - GOALS + Health Impact A summary of health benefits resulting from avoiding a disease or unintended pregnancy.
    19. 19. ✓ SOCIAL FRANCHISING - GOALS Quality The ability to treat or refer clients with complications, and adherence to overall program protocols
    20. 20. $ Cost-Effectiveness SOCIAL FRANCHISING - GOALS Able to deliver a service to a target population at a lower cost than alternative delivery options.
    21. 21. Equity SOCIAL FRANCHISING - GOALS The percentage of patients receiving franchised services that are within the lowest two national wealth quintiles.
    22. 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. 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. 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. 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. 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. 27. • Outlets are owner-operated • Payment is for services delivered • Services are standardized • “Clinical” services are provided DEFINITION
    28. 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. 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. 30. Countries with programs, 2009 25 countries 40 programs 1 program 2 programs 3 programs 4 programs 5 programs 30
    31. 31. Expansion of programs, 2012 40 countries 74 programs 1 program 2 programs 3 programs 4 programs 5 programs 31
    32. 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. 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. 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. 35. Rural versus urban location for outlets (2012)… 35
    36. 36. 36
    37. 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. 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. 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. 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. 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. 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. 43. Dr. Rehana Ahmed Board Director Greenstar Social Marketing Pakistan (Based in Kenya)
    44. 44. Greenstar A Fractional Franchise @Scale Dr.Rehana Ahmed PS4Health Webinair 2 July, 2013
    45. 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. 46. Social Franchising started with a question………….. Q. Can the Intrauterine contraceptive device (IUCD) be socially marketed?
    47. 47. It needs a trained health provider & a supportive supervisory system. The IUCD cannot jump out of the packet into the uterus ……….
    48. 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. 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. 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. 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. 52. National Impact Pakistan Bureau of Statistics 2011 More then 1 out of every 4 couples who use modern FP methods - use Greenstar.
    53. 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. 54. Health Areas Family Planning Maternal & Child Health TB treatment
    55. 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. 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. 57. Demand Generation needs interpersonal communications (IPC) • Community mobilization Quality Challenge • Aim for optimum & realistic quality in the given context Lessons Learned (contd)
    58. 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. 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. 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. 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. 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. 63. Future needs Advocacy for task shifting to lower cadre for FP service provision Demand side financing schemes like vouchers
    64. 64. Questions & Comments

    ×