clinical social franchising: organizing private healthcare providers to address public health...

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

An initiative ofthe Private Sector in Health Symposium

@psinhealth#healthmkt

www.pshealth.org

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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

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

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

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

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

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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

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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

Webinar series

• Facilitated by the Future Health Systems Consortium

• Organized by a number of groups

• Designed to involve a wide audience

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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

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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.

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The Private Sector Healthcare Initiative Clinical Social Franchising

Dominic MontaguPrivate Sector in Health Webinar - July 2, 2013 12

What is Social Franchising?

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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, but common

standards and new services.

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 pregnancy.

✓

SOCIAL FRANCHISING - GOALS

Quality

The ability to treat or refer clients with complications, and adherence to overall program protocols

$ Cost-Effectiveness

SOCIAL FRANCHISING - GOALS

Able to deliver a service to a target population at a lower cost than alternative delivery options.

Equity

SOCIAL FRANCHISING - GOALS

The percentage of patients receiving franchised services that are within the lowest two national wealth quintiles.

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.

• Provides a range of services• Some existing services are

improved• Most existing services remain

unchanged

Typical private clinic

PrivateClinic

Services

• Aches, pains, headaches• Cuts, abrasions• Stomach problems• Eye, nose, throat • Fevers and coughs• Diarrheal diseases• Infections• Chronic illnesses

FRACTIONAL FRANCHISING

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

FranchiseClinic

FRACTIONAL FRANCHISING

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

FranchiseClinic

FRACTIONAL FRANCHISING

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

FranchiseClinic

FRACTIONAL FRANCHISING

• Outlets are owner-operated

• Payment is for services delivered

• Services are standardized

• “Clinical” services are provided

DEFINITION

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

...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

# f

ran

chis

es

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 Worldwide60

70

2012

Countries with programs, 2009

25 countries40 programs

1 program

2 programs

3 programs

4 programs

5 programs 30

Expansion of programs, 2012

40 countries74 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 TB (2008–2012)n=59 programs

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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

Number of franchisees, by profession and region (2012)n=60 programs

Number of outlets, by type and region (2012)n=60 programs

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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 mechanisms, and three of those have reported the use of one or more mechanisms.

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Vouchers are the most frequently used

third-party financing mechanism. They are

most commonly linked to the use of FP

commodities or services.

Number of programs that have franchised public sector clinics or outlets

(2010–2012)

n=60 programs13 sites now report that franchised services are offered through public

sector clinics.

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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.

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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.

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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%.

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ConclusionThe model of social franchised health service delivery continues to grow

The principal attractions are: 1. Leverage of existing infrastructure 2. Scalability3. Quality assurance

Questions are becoming clearer, but a number remain unresolved:4. Cost-effectiveness5. Sustainability6. Defined role in an evolving health system

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

Greenstar

A Fractional Franchise @Scale

Dr.Rehana AhmedPS4Health Webinair

2 July, 2013

Greenstar Social Marketing Pakistan

• A nation-wide local NGO and • An independent member of Population Services

International (PSI).

Greenstar MissionTo improve the quality of life of low income people by increasing access and use of health products, services, and information.

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 uterus ……….

• 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 ……..

Business Model

Social Franchising & Marketing at ScaleSocial 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

• 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

Results 2012.… # 1 with 8540 franchisees

Franchise Services: Family planning ; Maternal health, child survival & TB

IUCD insertions: 216,656Implants: 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

National Impact

Pakistan Bureau of Statistics 2011

More then 1 out of every 4 couples who use modern FP methods - use Greenstar.

National contribution (CYPs)

30%

5%

6%

59%

Greenstar Social Marketing

Commercial Sector

NGO

Public Sector

CONRACEPTIVE PERFORMANCE REPORT 2010-2011Pakistan Bureau of Statistics

Health Areas

Family PlanningMaternal &Child HealthTB treatment

Product & Services

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

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)

Demand Generation needs interpersonal communications (IPC)

• Community mobilization

Quality Challenge• Aim for optimum & realistic quality in the given

context

Lessons Learned (contd)

• 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

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......

• 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

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......

• 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

Future needs

Advocacy for task shifting to lower cadre for FP service provision

Demand side financing schemes like vouchers

Questions & Comments