Many women and girls in low- and middle-income countries rely on private sector providers for their healthcare. For example, the private sector delivers more than 60 percent of all family planning services in Nigeria and provides approximately 45 percent of modern contraceptives in Uganda.
But challenges remain and those of us who work on strengthening health systems must focus on answering key questions, including: How can we ensure that private sector health services and products are of the highest-quality and that they are available to those who are most in need? And finally, how can we ensure that these enterprises will be sustainable
Social franchise networks provide some of these answers. In this model, franchisors support their private sector franchisees by providing subsidized or free commodities and quality assurance services. Franchisors also target low-income clients through health education and behavior change communication activities. However, social franchise networks face challenges of their own, including:
- Declining donor support. Social franchise networks are largely donor funded, which threatens their long-term viability.
- Limited service offerings. Networks typically support a limited set of high-impact services, including family planning and maternity care, rather than a broad range of primary care services.
- Dependence on out-of-pocket payments. Private healthcare providers that are part of social franchise networks are typically located in urban and peri-urban areas and dependent on out-of-pocket payments—which means that poor and vulnerable populations may be excluded.
Results for Development (R4D) and Population Services International (PSI) have pioneered a new approach to help social franchise networks address these challenges and become more financially sustainable, while improving against specific service delivery goals, such as quality, equity, additionality, cost-effectiveness, and health impact.
The PSI Tanzania and R4D teams deliberate over the opportunities, threats and social impact associated with advancing health financing and coordination partnerships with local government bodies in Tanzania.
The approach combines external analysis and internal participation. We leverage the extensive knowledge of the social franchise networks by hosting a series of collaborative workshops where we present our research and co-create and assess ideas together.
In the past 18 months, we have piloted this approach with PSI Tanzania, Programme for Accessible health, Communication and Education (PACE) in Uganda, and Society for Family Health (SFH) in Nigeria.
In each case, we’ve seen that the approach can help identify strategies to increase service and client volumes for private sector healthcare providers while also identifying new revenues for the franchisor itself, including the public sector. Importantly, it can also position franchisors as government partners.
Government planners are primarily concerned with using public resources efficiently to improve overall health outcomes, and with aligning health care services provided by private and donor actors with the government’s own strategies. Limited public sector resources and abilities in developing countries mean there is an opportunity for private sector intermediaries—such as social franchise networks—to help government planners improve coordination among health system actors, identify and address market failures, and target public sector investments so they yield the best value for money. As a result, there is an opportunity for social franchisors to complement the planning and delivery of primary health care services by governments and become vital partners in promoting universal health coverage.
For instance, in Uganda, during the closure of a large government hospital for renovations, we found that a partnership between PACE and the Kampala Capital City Authority (the government body responsible for health care delivery in Kampala) could help fill a severe gap in maternal health care service delivery. Through the partnership, franchise providers could deliver much-needed antenatal, delivery and postnatal care services to women across Kampala for free—easing the burden from secondary and tertiary care public hospitals. These private providers would be assured of payment for services through the government, and refer more complicated cases to higher level public facilities. This partnership will be a means for the government to improve health outcomes, contain costs by maintaining primary care facilities as first point of contact, and ensure that private providers support public health goals while systematically reporting data for improvements in planning and delivery.
Similarly, as governments scale up health insurance programs to promote Universal Health Coverage, franchise networks can be effective partners for registering the population, ensuring governments purchase services that offer the best value for their investment, and referring and tracking patients for continuity of care. Stepping up coordination among public and private sector actors, therefore, can potentially improve the overall coverage and quality of health care services in “mixed” delivery settings.
Already, the franchise platforms in Tanzania and Uganda are exploring new health financing options with government counterparts that will promote them as intermediaries and private sector organizers. These incremental steps toward more effective and more equitable health systems can ensure women and girls access reproductive and family planning services without financial burden; providers access more clients and surer revenues; franchisors better deliver on goals such as equity and quality in health care; and governments enhance coordination and efficiency in their health care response.
The work described in this blog is funded by the U.S. Agency for International Development (USAID) under Support for International Family Planning Organizations (SIFPO2) program, which aims to support private sector channels for family planning and broader primary health care services—particularly social franchise networks—in designated “priority reproductive health countries.” USAID partners with Population Services International, Marie Stopes International, and the International Planned Parenthood Foundation to implement SIFPO2 globally. Within this overarching structure, R4D works to develop strategies to enhance the financial sustainability of PSI’s global social franchise networks.
Photo © Lindsay Mgbor/Department for International Development