Establishing and Scaling-Up Clinical Social Franchise Networks: Lessons Learned From Marie Stopes International and Population Services International

This article describes social franchising in the health sector. It is a model that organises small, independent health care businesses into quality-assured networks and "has been shown to improve quality, client satisfaction, and access to services, especially preventive services that may be underprovided due to lower profit potential." (Footnotes removed in this summary.)

"The model applies the principles of commercial franchising to achieve social goals. Under the social franchising model, the franchisor is the entity that organizes private clinics into quality-assured networks while providing a comprehensive support package, ranging from training, quality monitoring, and commodities to branding, marketing, behavior change communication (BCC), and demand generation support. Clinic members, called franchisees, retain ownership and management of their facilities but maintain compliance with franchise quality standards and monitoring....This article describes MSI  [Marie Stopes International] and PSI’s [Population Services International] franchising approaches, from launch through scale-up."

"The overall health impact of the family planning services provided by MSI and PSI social franchise networks can be measured in terms of the disability-adjusted life years (DALYs) averted. DALYs are calculated as the sum of years of life lost due to premature mortality in the population and the years lost due to disability for people living with a health condition or its consequences....In 2013, PSI’s social franchising family planning services averted more than 2 million DALYs in Africa, and MSI averted about 1.6 million DALYs in the continent [See Figure 3 in the study]. Similarly in Asia, PSI averted about 2 million DALYs while MSI averted nearly 0.5 million DALYs." 

The model described uses a fractional franchise approach building on the franchisee’s existing basic health care and business infrastructure and the clinic’s existing client base to expand access to services. Like social marketing, which focuses commercial marketing techniques to achieve specific behaviour goals on the client demand side of changing behaviour, clinical social franchising involves BCC - both on the provider and the client sides - and includes clinical training and monitoring, provider recruitment, and skills transfer.

The article describes the growth of franchising family planning (FP) services, including the factors that contribute to success, among these being: underserved clients and an overburdened public sector, a supportive government, clients able to pay for service, and a favourable policy environment. Once the positioning of the franchise model is established, commercial branding is used to define and communicate what is special about the franchise - positive attributes such as quality, choice, and affordability. "A range of traditional marketing approaches may be used - for example, signs and billboards or radio advertisements - but the specific approaches used depend largely on what types of marketing and advertising are permitted for health services in a given country.... Population Services International (PSI) has begun promoting a regional brand strategy, where possible, to enable coordination and economies of scale. The Tunza and ProFam brands are common in East and West Africa, respectively, the Sun Quality Health network operates in Asia, and Red Segura serves Latin America. The approach still allows for local customization -  for example, branding in Swahili in East Africa and in Spanish in Latin America - but equally keeps costs down by allowing new franchises to leverage existing brand strategy, marketing materials, and other inputs."

With this shared branding comes the risk of negative quality being associated with the brand. Thus, quality assurance, improvement, and accreditation schemes are important for franchisee selection and brand management. Franchisee selection can include, for example, female-to-female service and willingness to serve the economically poor and locate where they have access. "When franchise providers own their facility, buy-in and accountability for agreed quality improvements can be more easily ensured. For recruitment, both organizations seek out clinics run by mid-level provider cadres, such as clinical officers, midwives, and nurses. Experience has shown that the behavior and practices of doctors is harder to influence."

Competency-based clinical training, provider certification, minimum standards, a facilitated supply of appropriate commodities, supervision, and ongoing quality assurance with independent audits are components of the schemes.  “Strong communication and effective interaction with providers is key. As a backdrop to all interactions with franchisee providers, PSI field staff use medical detailing or provider BCC techniques and skills. Medical detailing and provider BCC are similar processes (as they relate to franchising) that involve a PSI staff member visiting individual health clinic providers or owners of pharmacies or drug shops to educate them about a particular product or service and to promote that product or service…. PSI’s provider BCC approach addresses the training-to-practice gap by complementing training with follow-up medical detailing but also by managing the overall relationship with the provider effectively and maximizing opportunities to support and influence provider behaviors and provider-client interaction skills. The specialized communications skills of the medical detailers, modeled after those used in the pharmaceutical industry, allow PSI field staff to identify underlying provider needs, motivations, and/or barriers and biases to performing the desired behavior or service. PSI field staff can then offer the provider a variety of relevant and actionable solutions designed to meet the individual provider’s needs and motivations—solutions that are valuable to the provider. The medical detailers distribute resources such as literature, counseling charts, and patient brochures to assist providers in adopting the desired behaviors.”

Helping providers develop sustainable businesses is part of the scale up of social franchising, for example, in “Zimbabwe, MSI’s BlueStar network has created a mentoring program that uses WhatsApp, a free mobile phone application that allows real-time communication and problem solving between new franchisees and more-established clinic mentors.” Tablet computers in PSI’s Nepal programme allows for real-time data collection and access to “a variety of clinical reference guides and behavior change tools.”

Attracting clients using BCC and demand generation includes: PSI’s Latin America franchise, Red Segura visits garment factory floors “to educate young female employees about their SRH choices and how and where to access services through franchisees. In India, PSI’s network conducts door-to-door mapping and household visits, working to reach young married women in their homes. In Pakistan, MSI’s Suraj network takes a similar approach by engaging female health educators to conduct door-to-door visits with information on SRH topics and franchisee locations…. In 2014, MSI combined a voucher program for adolescents with training on youth-friendly services for franchisees.”

Health systems integration can strengthen systems through the collective voice of franchisers for knowledge sharing and advocacy, and, in some countries, private-sector licensing requirements. “For example, in Kenya, the Association of Social Franchising for Health brings together more than 1,000 private providers from 6 franchise networks, with the aim of entering into policy engagement and dialogue with the government and other decision makers.”