Social Franchising for Health

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Feb 13 2012 0

Social Franchising Videos are Here!

By: Anna De La Cruz
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We’re excited to present three short videos: one showcasing highlights from the First Global Conference on Social Franchising, and two about the work of social franchise networks around the world, from both patient and program officer perspectives. The footage was taken at the Tunza Family Health Network and around Mombasa during the conference.

Many thanks to the Bill & Melinda Gates Foundation and PSI for sponsorship, and to What Took You So Long for filming and Strategic Productions for producing the videos.

We hope you circulate them and use them to share what social franchising is about to a wider audience. Below are ways you can promote the videos:

1. Share the videos on Facebook and Twitter.
2. Embed the videos on your blog or website directly from YouTube.
3. Forward the videos on to your colleagues and friends.

Highlights from Social Franchising Conference 2011, Mombasa, Kenya

The Work of a Social Franchise Network – From a Patient’s Perspective

The Work of a Social Franchise Network – From a Program Officer’s Perspective

Categories: Uncategorized
Nov 23 2011 0

Social Franchising: Where to Next?

By: Karl Hofmann
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The following post is by PSI CEO and President Karl Hofmann. 

We are in an era of real concern about costs, of flat or declining budgets for development and value-for-money of development spending. This sort pressure focuses global health NGOs on how to better meet the needs of our target audiences and deliver better value to them.

Social franchising has a proud history and impressive achievements to its name. Today PSI is a large part of the social franchising movement across the world. PSI’s 16,000 social franchisees currently deliver essential health services to an estimated 13.5 million clients in 22 countries worldwide.

It’s time to consider where we are headed and how we can improve. I’d like to propose six key areas for PSI and social franchising going forward.

1.  Social franchise networks should be audience driven in their design and planning.

Health provider behavior is directly linked to social franchise network quality and productivity, so while clients are the primary target audience for a social franchise network, we should systematically focus on health providers as a key audience as well.

2.  Social franchise networks should follow an integration agenda.

Integration is the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money. We should put a greater focus on integrated case management, and development of maternal health service packages, among other things.

3.  Social franchise networks should evolve toward a standardized business model with common characteristics.

For PSI, the ideal franchise models involve: multi-tiered networks integral to the national health system; strategic management of the franchise brand; innovative use of information and communications technology; cost-effective influencing of franchise provider behavior; and creative financing mechanisms.

This franchise model has four key components:

  • Franchise brand – defines and communicates the franchise offerings and value proposition;
  • Franchisee standards and procedures – define what franchisees are expected to do in order for the brand to deliver on its promise;
  • Franchisor operating system – defines what the franchisor does to build and manage franchisees and protect the franchise brand; and
  • Franchise financing mechanisms – define how the franchise will finance care for the resource-poor and use performance-based financing (PBF)  to drive equitable performance.

4.  Social franchise networks should align with the four objectives of social franchising and use standard metrics related to those objectives.

Social franchises must be measured according to their success in terms of access, quality, cost-effectiveness and equity. PSI is proposing validated metrics to assess progress against these objectives to the Social Franchising Metrics Working Group, composed of MSI, Smiling Sun, UCSF, USAID, R4D, the Gates Foundation and JHU. These metrics are currently being assessed by an internal working group.

5.  Social franchise networks should use demand-side and supply-side performance-based financing creatively.

Subsidy of some kind is essential if the private sector is to serve the health needs of the poor and lower their out-of-pocket expenses. PBF interventions and social franchise networks go together. Social franchising increases the ease and reduces the cost of introducing and operating PBF strategies, while PBF strategies make social franchises more attractive to private providers and help the social franchise networks address issues of equity.

6.  We should all be better at telling and selling the story.

We can build the robust community of practice that social franchising merits through advocacy, sparking donor and government interest, sharing experience and best practices.

Moving forward, we should scale up and enhance our work in social franchising. We must systematically monitor the performance of our franchises and ensure that it scores as well as the public sector in terms of volumes, quality, and the poverty- and health-seeking profile of clients. Ultimately social franchises can be an important partner to public sector service provision, and can significantly help countries aiming to achieve universal coverage.

Categories: Social Franchising
Nov 22 2011 0

Realizing the Potential of mHealth: The 7 Steps for Implementing an SMS mHealth Scheme

By: Trevor Lewis
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By Trevor Lewis
Results for Development Institute

The promise of mHealth is quite attractive to many health program implementers, but few know how to actually implement it. That’s why, during the final day of the 2011 Social Franchising for Health Conference in Mombasa, Pam Riley of the SHOPS Project clearly laid out 7 steps for implementing a mass-SMS mHealth program – this could range of blasting out text messages to patients for health education to sending group messages to nurses and doctors to remind them to always dispose of used needles.

  1. Needs Assessment. Pam stressed the importance of identifying a problem for which mHealth is the logical solution and not simply using mobile technology because it is the “hot new thing.” The program manager also has to assess the infrastructure: is mobile penetration sufficient to support this program? Finally, they must ask who their target audience is; are they used to using mobile phones? Are they even literate?
  2. Planning and budgeting. It is crucial to know how much an mHealth plan will cost to know if it is even feasible. Some aspects that will need to be budgeted for include: planning, design, the technology itself, deployment, monitoring and evaluation. In Pam’s experience with an SMS project in Uganda, the planning period was the biggest expense. She also urged implementers not to underestimate the importance of trouble-shooting in the deployment of the strategy.
  3. Technology installation. For this particular type of project, Pam recommended the use of FrontlineSMS because it is free and easy to use. That being said, a program doesn’t have any tech-savvy staff or they are planning to use multiple mobile applications in the work, she recommended the use of a consultant. Depending on the scale and needs for customization, an implementer should also consider engaging the mobile operator itself.
  4. Content development. When choosing the content of the mass-SMS’, one must ask what the desired behavior change is and why the target audience isn’t already behaving that way. Then the tone, the frequency, the language, and the vocabulary of the text must be considered. Finally, Pam stressed that the message should be tested over and over to be sure that it is effective and clear.
  5. Deployment. Once the messages have been adequately tested and the appropriate staff have undergone training and orientation, the mHealth program can be deployed. During deployment of a program using mobile phones, it will be important to find a way to keep the telephone numbers updated.
  6. Monitoring. It is important to keep track of data surrounding the deployment of the program: who is being reached? Who is responding? If the mHealth program is using a quiz style format, who is getting the questions right and who is getting them wrong?
  7. Evaluation. Evaluation is a key step that should not be forgotten, as the mHealth community is in desperate need of knowledge and evidence around what works. What outcomes will be measured? Is the project scalable? 

Implementing an mHealth program is rarely as simple as it looks and programs are likely to encounter a number of challenges along the way. Nevertheless, the potential returns are great, so hopefully, using the 7 steps laid out above, more implementers will be able to incorporate technology and mobile phones into the work. As Pam advised, “Do, learn, iterate, document.”

Categories: Conference Updates, Social Franchising
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Nov 21 2011 1

Chapel of Love: Linking Social Franchises to 3rd Party Financing

By: Maria Belenky
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Participants in the 3rd Party Financing discussion at the Social Franchising Conference last week were treated to a rendition of “Going to the chapel” as they took their seats. The session was rebranded “Marriage Counseling”, alluding to an earlier post by Gina Lagomarsino in which she presented social franchising and national insurance as a potential marital match. True to TV dating game shows, three “date” options were discussed at the session: government contracting, integration with national insurance, and access to provider credit. Which do franchise managers choose? Is it ok to have more than one partner?

First up is contracting. Government contracting of private clinics offers a number of benefits. Governments are often bad managers – contracting out service provision allows government agencies to delegate managerial responsibilities to the private sector and, instead, focus on higher-level tasks such as planning and oversight. For clinics, government contracts bring in a steady funding stream that can be used to update infrastructure and diversify service offerings. But governments can also be challenging to work with and individual providers may find it difficult to manage government contracts. Is there strength in numbers? In India, franchise networks have banded together to form a national federation. As a group, they have garnered the interest of India’s government and have now submitted a proposal to implement franchise networks in five of the country’s northern states. While the federation’s experience with contracting is yet to be defined, it does demonstrate that disparate networks joining forces can command government attention. Lesson 1: Franchise networks should identify opportunities to band together to leverage collective bargaining power.

Now, on to national insurance. While there is general agreement that, where exist, national schemes are key to long-term sustainability, there is still a lot of skepticism toward the practicality of accepting public insurance. Much like contracting, engaging governments may be difficult, particularly for smaller networks, and many providers may not be ready to meet the standards of insurance accreditation. Furthermore, as long as donor funds persist, vouchers may appear to be the more attractive tool to increase demand and improve service quality. But pursuing one option does not preclude the other. Vouchers may indeed be the better short-term option to increase the uptake of key services and build internal capacity for claims administration. Insurance, however, presents a viable long-term funding stream – think exciting fling versus long-term companionship. More importantly, vouchers can target services not covered by national schemes and leverage government agencies to help with administration and monitoring (see Tinh Chi Em’s voucher program), laying important groundwork for future integration.  Lesson 2: Voucher programs can complement public insurance schemes where available and engage governments from the get-go to build the foundation for future integration.

Last, although certainly not least, is provider credit. Access to credit is perhaps one of the largest barriers to scale-up and traditional lenders are weary of investing in the health sector.  Where credit is available, access qualifications and costs may simply be too high. In addition to dispelling myriad misconceptions about lending to health among traditional investors, a greater number of loans should be tailored to small private providers. The Medical Credit Fund, implemented by the PharmAccess Foundation, has stepped in to fill this gap. The Fund provides doctors and clinics in sub-Saharan Africa access to affordable loans to expand their practices and invest in quality; funds are supplemented with technical assistance on business administration and quality improvement. Lesson 3: Provider credit can be used to improve the infrastructure and capacity within franchise networks, giving them the necessary leverage to achieve national insurance accreditation.

Having reviewed the three eligible options – which do franchise managers chose? The trick answer may be all. Supply side financing such as contracting and provider credit may be necessary to build provider capacity to delivery much needed interventions, while demand-side approaches such as insurance – perhaps preceded or supplemented by vouchers – increase patients’ ability to access them. It appears that in health systems strengthening, multiple partners may not only be allowed, but even preferred.

Categories: Conference Updates, Social Franchising
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Nov 17 2011 1

Many thanks from the Global Health Group!

By: Anna De La Cruz
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The Global Health Group at UCSF would like to thank each of the 165 attendees from 35 countries who attended the First Global Conference on Social Franchising in Mombasa, Kenya. The experiences of implementers from around the world, combined with the perspectives of key figures in government, donor, NGO and academic communities, made for an exciting synergy that has helped grow the community of practice and strengthen health systems moving forward.

Those who would like to access the conference presentations can find them here, and we look forward to sharing more resources with you in the near future, including a conference report and video. For now we hope you’ll enjoy this group conference photo taken outside the Whitesands on Friday.

Congratulations to all of you for contributing to a milestone event for Social Franchising and global health!

Categories: Uncategorized
Nov 15 2011 0

Highlights from the 1st Global Social Franchising Conference

By: Jyoti Kulangara
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Day 2 of the 1st Global Social Franchising Conference displayed the successes and failures, insights and concerns, opportunities and risks faced daily by the front-line social franchising program implementers.

PANEL SESSION 1: HISTORY, CONTEXT & OPPORTUNITIES
Social franchising is at a tipping point – a time when it could become a system that is widely adopted and expanded. So we’re well poised to talk about where we are and where we should be headed.

The first speaker, Khama Rogo, rated Africa’s health systems on leadership and governance; service delivery packages and models; human resources for health; health information; and financing, medical products, technologies. We’re currently performing low to moderately.

How can we get to where we have to be? Khama Rogo suggested 8 fundamental changes:
1. Entrench social health franchising into national policies, strategies and laws;
2. Public sector must adopt public-private partnerships;
3. Franchisors must collaborate with the public sector;
4. Look at social health insurance, starting with microfinance;
5. Donor flexibility;
6. Commitment to scaling up;
7. Local ownership; and
8. Inclusion of social health franchises in schools of medicine and health.

The second speaker, Dana Hovig of MSI, took us through the history of social franchising from when it first began in Pakistan with the Greenstar network. He then challenged us to enter social franchising 3.0 – looking beyond supply-side interventions and the dogma of public-private boundaries.

Karl Hofmann of PSI, the third speaker, presented six ideas to focus our social franchising efforts moving forward with social franchising:
1. Being driven by the needs and behaviors of our audience (clients and providers)
2. Integration – the needs of the people we serve are holistic; our solutions should address all of these needs.
3. Innovative business model that works within a total market approach.
4. Standard metrics to measure the four pillars of social franchising.
5. Demand and supply side performance-based financing.
6. Telling and selling the story and sharing our best practices

PANEL SESSION 2: MANAGING TO SCALE
The second panel addressed the challenge faced by all social franchises – taking a program to scale successfully.

Top 5 lessons learned from the 2nd panel:
1. When you scale up, match the infrastructure and complement it with more human resource and technical assistance.
2. Use technology to link rural providers to high-level skills available at metros.
3. Use innovative models to sustain a rural network of community health workers.
4. Focus on sustainable scale.
5. Understand your brand promise, deliver to it and measure it

The small groups sessions in the afternoon addressed a few of the divergent ideas relevant to social franchising:

FOCUS vs. INTEGRATION OF SERVICES:
Top 3 challenges of integration:
• Maintaining the quality of each service.
• Keeping the brand promise. Will integration affect the brand value?
• It’s important to maintaining and/or improving the business skills of providers as the number of services they offer improves – especially in relation to accounting, financial sustainability and financial credit.

Top 3 lessons learned about integration:
1. Don’t position franchising as focused on a particular health area.
2. Focus on smart integration.
3. Focus on the needs and behaviors of the audience (provider and client) when considering integration.

QUALITY METRICS:
Top 3 guidelines on capturing data:
• Ensure that there’s less data that’s more useful.
• Align metrics with government requirements.
• Continue the conversation about developing quality metrics. The Social Franchising Metrics Working Group is developing standardized metrics for each of the four pillars of social franchising, including quality.

TIERED DELIVERY SYSTEMS AND PROVDIER REFERRALS:

Top 3 solutions to the challenges presented by tiered delivery systems and provider referrals:
1. Introduce referral fees.
2. Use mHealth and technology for data collection.
3. Encourage communication between the different networks and systems, through meetings and newsletters.

DEMAND-SIDE FINANCING: VOUCHERS vs INSURANCE SCHEMES
Vouchers could be the first step to build a new program – a long-term way to cover niche areas of your program. They are less bureaucratic than insurance schemes, but insurance schemes are more sustainable.

If you weren’t able to participate in the 1st Global Social Franchising Conference, keep checking out the Highlights series to get the inside scoop into the conversations at the conference. You can also view the PowerPoints at sf4health.org

Categories: Uncategorized
Nov 13 2011 0

1st Global Social Franchising Conference: Implementers Convene as Kenya Embarks on Vision 2030

By: Jyoti Kulangara
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The 1st Global Social Franchising Conference kicked off with a Welcome Dinner where the Hon. Prof. Peter Anyang’ Nyong’o, the Kenyan Minister of Health, Medical Services, set the tone for the rest of the conference with some inspiring words: “We must establish sustainable healthcare delivery…and social franchising can be the answer to improve the scale and quality of our healthcare delivery.”

Kenya is embarking on its Vision 2030, a new development plan for the country that can lead it through 2030 into a middle-income, industrializing nation. Perhaps most exciting to those of us in the social franchising and global health realm is their aim to meet the millennium development goals (MDG’s), and in particular, ensure that every Kenyan has access to quality of health, including reproductive health.

Enter social franchising and the 1st Global Social Franchising Conference. We’re here in Mombasa at a pivotal time, at a time when the Ministry of Health is embracing major changes – embracing the public-private partnership – to meet its Vision 2030.

The Minister stressed that as it reviews it existing laws and policies and debates on the upcoming ones, the Government of Kenya recognizes the important role played by both public and non-state actors in the delivery of healthcare in Kenya.

But instead of focusing on the public-private divide, the Minister focuses on the bigger picture, and the reason we’re all here in Mombasa representing the work that we do: “What matters in the end is not whether the service was delivered in the public or private sector. What matters is that the service was of high-quality, was affordable and was successful.”

If you weren’t able to participate in the 1st Global Social Franchising Conference, keep checking out the Highlights series to get an inside scoop into the conversations at the conference.

Categories: Conference Updates
Nov 11 2011 0

The Promise and Challenges of Referral Systems

By: Trevor Lewis
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During the opening session of the 2011 Social Franchising Conference for Health in Mombasa, Karl Hofmann, the president of Population Services International, argued that the integration of more services should be one of the key steps forward for health franchises in the in the near future. However, this can be difficult due to equipment and human resource constraints, as well as government restrictions on the scope of services that clinics or health workers of a certain level are allowed to offer. In response to this challenge, many franchises have developed referral networks to connect health workers, clinics and hospitals. However, while referral networks are an innovative way to overcome gaps in service, a number of challenges still remain in their implementation.

First, there is the question of why clinics and franchisees would buy in to the referral system? What’s in it for them to refer patients away from their clinics? BlueStar, Vietnam addressed this issue by implementing referral fees. In this case, the clinic that made the referral is entitled to 10% of what the patient pays at the other clinic. The clinics settle these payments to each other at a meeting for all franchised clinics that takes place every 3 months.

But if clinics are paying each other based on the number of referrals, the issue of tracking referrals then becomes very important . While a number of clinics use paper-based forms for tracking, a more reliable method seems to be the use of mobile phones. In this way, clinicians are not only able to record referrals but also warn clinics that a patient has been referred to them, as well as pass along patient data to avoid redundancies during the visit. Programs such as M-Afya Kiosks and Jacaranda Health both aim to do this.

Finally, there is the issue of accessibility. Even when someone is referred to another clinic or hospital for a certain service, who can say if they can actually make it to the clinic, especially if it is located many miles away? To solve this, one program in Kenya has begun providing vouchers to patients who can use them with a certain taxi company. At the end of the month, the taxi company presents the program with the vouchers to get reimbursed. Another program, called Comprehensive Community Based Rehabilitation Tanzania (CCBRT), uses M-PESA to transfer money to remote locations to pay for travel to the clinic.

Referral networks are useful tools but provide a number of challenges. However, as shown above, with proper planning and implementation, solutions can be found. Still, there are other problems that will be even more difficult to solve. For example, many patients want a one-stop shop where they can access any service and buy any drug that they should need, but this idea directly contradicts referral networks. Therefore, referral networks, while promising, still require much thought and debate.

Categories: Social Franchising
Nov 09 2011 7

Tunza Clinic Site Visit

By: Maria Belenky
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This post was written after a site visit to the Tunza Clinic in Mombasa, Kenya on the first day of the 2011 Social Franchising Conference. The authors are: Trevor Lewis, Program Associate, Results for Development Institute and Maria Belenky, Senior Program Associate, Results for Development Institute.

Emily Mbotela opened the St. Hillarias Clinic in 2000 in Mombasa, Kenya to provide basic primary care and maternity services. Then in 2009, Tunza came calling. Tunza, a fractional franchise implemented by Population Services International (PSI), offers standardized and quality-assured family planning and reproductive health services (FP/RH) in 258 outlets across Kenya. While Emily’s clinic offers a broad spectrum of primary care, she was approached by PSI to offer franchised FP/RH services under the Tunza brand.

Why did she join the network? Tunza gives qualified doctors, clinical officers, and nurses access to training, technical assistance and the advantage of being associated with a brand recognized for its quality. Franchisees also receive discounted equipment, some at as much as 1/8 of the original cost, as well as continuous medical education. This is highly valued as these types of trainings are generally only available to public providers in Kenya.

Another advantage of joining Tunza is reliable access to affordable methods of contraception. Many Tunza clinics are able to get most of their contraceptives for free from the government, but when the government has a stock out, the clinicians are able to turn to PSI to fill in the gap. In addition, PSI is the only provider of intra uterine devices (IUDs) to the Tunza franchisees – the devices are delivered in easy to use kits that include the IUD itself, gloves and a sterile pad. With all of these advantages, the Tunza franchise has been able to grow by more than 100 clinics since it launched with 150 clinics in 2009. PSI hopes to incorporate another 30 private clinics per year.

Tunza also employs community mobilization both to educate the community about contraception and family planning and to encourage traffic in Tunza clinics. Mobilizers, who come from the communities in which they work, run 1 to 2 sessions per week, with 15 to 20 people in attendance. To increase interest in the session, the mobilizers will visit areas where men and women already gather, work with local leaders, and go door-to-door. After an open discussion to answer the wide range of questions from attendees, the mobilizers encourage them to visit one of the franchised clinics. They may also hand out vouchers to those who would otherwise be unable to pay for Tunza’s services.

These days, the Tunza branding is visibly displayed alongside the St. Hillarias sign on the front of the clinic. The clinic itself is a modest sized two-story facility that’s marked by the bright orange and purple colors characteristic of the Tunza brand. Six staff – including four full-time nurses – run the clinic around the clock. While St. Hillarias offers 24-hour a day curative services, the Tunza-branded family planning and reproductive health services are available only between 8am and 6pm daily. When asked who make up the majority of her patients, Emily replied that they are mostly women. Male resistance to contraception is still prevalent in the area and women often favor injections as a form of contraception due to its discreet nature.

Since becoming part of the Tunza network, Emily has seen patient volumes increase significantly. As the nearby government facility does not offer IUD insertions, her success has been bolstered by becoming a referral clinic for patients seeking this form of contraception. The brand has become so visible that the Duka la Dawa, or chemist shop, across the street has painted its façade in Tunza colors to make customers believe that they are associated with the franchise. It’s a lucky coincidence that St. Hillarias clinic is looking to create formal partnerships with several drug shops in the area to which they can reliably guide patients to purchase certain medications unavailable at the clinic. While no formal agreement has been reached with the neighboring shop, the clinic’s staff admit that there is a certain benefit to reaching out to them – “they already have our colors!”

Categories: Social Franchising
Nov 08 2011 0

Stories from the field: Using referrals to increase client volume

By: Senanu Arkutu
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By Senanu Arkutu
Social Franchise Manager
BlueStar Ghana

Towards the end of 2009, on a typical day in the BlueStar Ghana office in Accra, I sat at my desk, head in my left hand, staring at our white board of current results. Number of implants inserted, number of IUCDs inserted … and therefore, number of couples whose contraceptive needs had been met. We had made progress, but it still wasn’t looking good enough for the people in my region.

“We need to do more. What are we going to do?” I said to my chief Field Officer Osumanu (now Regional Manager) and Sandra, my Franchise Officer.  Yes, we had a network that allowed us to encourage franchisees to refer to one another, and we had satisfied clients who referred friends and family but it wasn’t enough.

Then it came to me. “We have to do ‘outreach’ within the franchise!”

What I meant was, we needed to adapt Marie Stopes International’s outreach model, which had seen record numbers of women lining up for voluntary long term and permanent family planning methods, to our BlueStar franchise setting. We started looking and asking and found similar successful models in Kenya and Pakistan. We brainstormed, strategized, found a plausible budget line and called the new model ‘Demand Creation’.

The community ‘demand creation’ events we now run are three-week long activities which include a bespoke mix of public announcements, film shows and 13 days of mobilization. Also included are BlueStar Ghana’s own Community Based Educators (CBEs) who – armed with communication skills, detailed information on family planning methods, mini family planning flip charts, and samples of implants and IUCDs – are set loose into a community.

The CBEs walk around the community and surrounding areas, sensitizing and mobilizing house to house, market to market, hair salon to hair salon, youth group to youth group. Members of the community are also told about the two day promotional service delivery days at their nearest BlueStar clinic, at which implant and IUCD services are delivered for only 1 GHS (about 65 cents). CBE BlueStar Referral slips are given to women who are interested, which makes them more likely to attend for services on the day.

Four CBEs refer around 200 women in 3 days. Effective referrals can lead to up to 100 implants and 20 IUCDs being fitted during the two day promotional service delivery. The BlueStar Ghana programme has greatly benefitted from the new ‘demand creation’ model, seeing an increase of over 100% in the uptake of long term and permanent methods from 2009 to 2011.

The information about where the community can get family planning and other sexual health services begins to spread, and this ensures an increasing flow of clients into our BlueStar clinics. Referrals up, volume up!

Categories: Social Franchising
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