Private-Sector Social Franchising to Accelerate Family Planning Access, Choice, and Quality: Results From Marie Stopes International

This research provides analysis of Marie Stopes International (MSI)’s social franchising programme against the 4 intended outputs of access, efficiency, quality, and equity. The programme uses a service delivery approach "in which small, independent health care businesses are organised into quality-assured networks" intended to engage the private sector in improving access to family planning (FP) and other health services.

"Clinical social franchising is a service delivery approach in which small, independent health care businesses are organized into quality-assured networks. Social franchising involves intensive capacity building and support for providers, including clinical training, branding, quality monitoring, and commodity support, as well as marketing and demand generation among potential clients. In addition, franchising programs engage providers and clients through behavior change communication (BCC) and initiatives to ensure access for the lowest-income clients. Social franchising presents an opportunity to engage private providers in health care delivery to increase access to high-quality family planning and other services." This study examines the ability of social franchises: "to increase access to LARCs [long-acting reversible contraceptives] and permanent methods as part of a broad method mix, to improve the quality of services provided, and to reach clients from groups that typically have high unmet need, such as those of lower-income levels."

Data was obtained from routine programme monitoring data, clinical quality audits, and client exit interviews. Routine programme monitoring data came from 17 countries and "comprised 12 countries in Africa (Ethiopia, Ghana, Kenya, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Uganda, Zambia, and Zimbabwe) and 5 countries in Asia (India, Pakistan, the Philippines, Vietnam, and Yemen)" from 2008-2014. Clinical quality audits include external audits complementing the continuous review process and internal audits conducted by the country programme. MSI's quality technical assistance (QTA) programme began with audits in 9 countries in 2011, and, by 2014, 14 countries achieved the standardised sample of 10% of franchisees with a maximum of 25. QTA scoring from 2011-2014 was used in this study. Data from exit interviews measuring client satisfaction was used from the 2013 results from 4,844 clients at 14 of the 17 national social franchise networks. Additional data was obtained from the Progress out of Poverty Index (PPI). "Results from the PPI enable estimation of the proportion of clients living on less than US$1.25/day and those living on less than $2.50/day, two commonly used measures of national poverty."

Analysis and results include:

• "Access was assessed using both estimated numbers of clients and couple-years of protection (CYPs)...." From 2008 to 2014, the MSI social franchise program providing voluntary family planning services increased from an estimated 25,335 clients to an estimated 1,239,727 clients, a 49-fold increase. An estimated 50% of clients in 2008 received LARCs, increasing to 70% by 2014.
• "Efficiency was measured at the national level by dividing annual countrywide CYPs (for the entire franchise network) by the number of franchisees in operation at the end of each calendar year, with the exception of the first year of a franchise’s operation...." Increase in client numbers or CYPs resulted from both greater numbers of franchises and rising numbers of clients per franchise.
• "Quality was assessed using overall clinical audit scores and overall client satisfaction scores...." Scores of audits increased between the first two years and the second two years; client satisfaction was 4.51 or a possible 5.
• "Equity was evaluated using client exit interview data to assess the proportion of clients who were family planning adopters (i.e., those who had not used any modern method during the 3 months preceding the service), youth, or living under US$1.25/day or $2.50/day....The overall proportion of clients aged 15–19 years was 5.0% (95% CI?=?3.9, 6.1), and the overall proportion aged 15-24 years was 26.1% (95% CI?=?23.8, 28.4). In 2013, the overall proportion of clients living on under US$1.25 a day was 15.1% (95% CI?=?13.8, 16.4), and the overall proportion living on under $2.50 a day was 57.4% (95% CI?=?54.9, 60.0).... In 2013, 40.7% of family planning clients reported they had not been using a modern method during the 3 months prior to their visit (i.e., that they were family planning adopters) (95% CI?=?37.4, 44.0)."
• "Outcomes were estimated using MSI’s 'Impact 2' model...in short, the model enables conversion of service data into a variety of estimated health outcomes using the best available data on country demographics, fertility, mortality, and more....Using the MSI Impact 2 model, family planning services provided by MSI’s social franchising program between 2008 and 2014 will avert an estimated 4,958,000 unintended pregnancies and 7,150 maternal deaths."

From the discussion:

• Quality improves with supportive supervision (in Pakistan, a ratio of 1 supervisor to every 10 franschises).
• Adding services, for example, in Kenya and Nigeria, may improve service uptake. 
• Expanding choice can be addressed by "counseling training on all contraceptive methods" - "...qualified providers received training on LARC and permanent method service provision while referral pathways were established for providers not able to provide permanent methods, and providers were supplied with equipment and commodities."
• Equity gaps were bridged most successfully in Pakistan where a network of community mobilisers builds demand in communities, and many of these mobilisers provide vouchers to those unable to afford FP. However, in the absence of clinics located where there is greatest financial need and in the absence of voucher or health financing mechanisms, there remains an equity gap in service provision.