October, 2016 - SUPPORT Summary of a systematic review | print this article |

What are the effects of social franchising on health service access and quality in low and middle income countries?

Social franchising adapts ideas and approaches developed and used in commercial franchising to the provision of public health services. While commercial franchising is driven by profit generation,social franchising strives to achieve social benefits. Social franchising has been identified as a way of increasing access to health services rapidly, particularly amongst the poorest populations, while maintaining quality standards in low and middle income countries.In such settings, access to health services is currently inadequate and private health service providers play an important role.

 Key messages

  • No evidence was found regarding the effects of social franchising on access to or the quality of health services in low and middle income countries.We are therefore uncertain of the effects of social franchising.
  • There is a need for well designed experimental studies that are informed by the theoretical and empirical literature.


Background

Social franchising takes place when a franchisee (e.g. an NGO) adopts a defined concept for health service delivery from a franchiser and then implements this under an established brand name.Quality standards and reporting requirements are required to match those set by the franchiser. Examples of social franchising networks include the provision of standardised training, supplies, and case management according to unified protocols.While commercial franchising is driven by profit generation, social franchising strives to achieve social benefits. Social franchising has been identified as a way of increasing accessto health services rapidly in low and middle income countries while maintaining standards of quality. Access to health services in such settings is currently inadequate and private health service providers play an important role.



About the systematic review underlying this summary

Review objectives: To assess the effects of the social franchising of health service delivery on access to and the quality of services and health outcomes in low and middle income countries
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non randomised trials, interrupted time series studies,and controlled before after studies reporting on social franchises delivering health services, driven by seeking social benefits.
No studies meeting the inclusion criteria were identified.
Participants All levels of healthcare delivery, all types of patients and healthcare providers.

Settings Low and middle income countries.

Outcomes Healthcare access, quality of care, health outcomes,adverse effects, equitable access or utilization, cost/service, patient satisfaction

Date of most recent search: October 2007 – March 2008
Limitations: This is a well conducted systematic review with only minor limitations, but the last search for studies was done in 2008.

Koehlmoos TP, Gazi R, Hossain SS, Zaman K. The effect of social franchising on access to and quality of health services in low and middle income countries. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD007136.

Summary of findings

This is a well conducted systematic review with only minor limitations. It failed to identify any studies meeting the inclusion criteria.

  • No studies that met the inclusion criteria were identified, therefore we are uncertain of the effects of social franchising on health service access and quality in low and middle income countries.
As new ways of expanding health services in low income countries are explored, social franchising is attracting increasing interest. However,initial optimistic assumptions and expectations have not been supported by rigorous evidence, and potentially adverse effects have not been carefully assessed.

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
The review did not find any studies conducted in low and middle income countries that met its inclusion criteria.

Although social franchising is currently used and advocated in low and middle income countries, no rigorous evaluations of its impacts (both positive and negative) are available.

EQUITY
Equity (access to, and utilisation of, health services) was a considered outcome.

Social franchising promotes social rather than financial benefits, and therefore its effects on equity could be assumed to be positive. Social franchising, for instance,could help particularly with expanding access to health services amongst the poorest populations. However, there are no rigorousevaluations of its impacts on equity.

 

  • Social franchising can impact negatively on equity in instances where it competes with, or crowds out,equally or better performing approaches to healthcare delivery. Loss of motivation among existing providers is another potential downside of the introduction of new approaches.
 
ECONOMIC CONSIDERATIONS
Cost/service (from a societal perspective or the perspective of the franchiser, fran-chisee or patients) was a considered outcome.

The cost and cost effectiveness of social franchising are unknown.

 

  • The introduction of social franchising might result in competition for resources with existing or alternative approaches to healthcare delivery. This may result in reduced funding levels and overall quality erosion in instances where the existing or alternative ap-proaches offer better cost effectiveness or the effects of scale cannot be realised any longer due to reduced demand.
MONITORING & EVALUATION
The review found an absence of robust evidence from rigorously designed studies.

There is a need for well designed experimental studies informed by theoretical and empirical literature.

 

  • If implemented, social franchising should be accompanied by well designed monitoring and evaluation.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see:www.supportsummaries.org/methods.

 


 

Additional information

Related literature

Beyeler N, York De La Cruz A, Montagu D. The impact of clinical social franchising on health services in low and middle income countries: a systematic review. PLoS One 2013; 8(4):e60669.


Viswanathan R, Behl R, Seefeld CA. Clinical Social Franchising Compendium: An Annual Survey of Programs: findings from 2015. San Francisco: The Global Health Group,Global Health Sciences, University of California, San Francisco, 2016. http://sf4health.org/sites/sf4health.org/files/sf4h-social-franchising-compendium-2016.pdf.


Lonnroth K, Aung T, Maung W, et al. Social franchising of TB through GBs in Myanmar: an assessment of treatment results, access, equity and financial protection. Health Policy and Planning 2007; 22:156–66.


Montagu D. Franchising of health services in developing countries. Health Policy and Planning 2002; 17(2):121–30.


WHO, USAID. Public policy and franchising reproductive health: current evidence and future directions. Guidance from a technical consultation meeting. Geneva: WHO, 2007.

http://apps.who.int/iris/bitstream/10665/43735/1/9789241596021_eng.pdf


This summary was prepared by

Peter Steinmann, Swiss Tropical and Public Health Institute, Switzerland.

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

Acknowledgements

This summary has been peer reviewed by: Tracey Koehlmoos, Catherine Goodman, Vivian Welch, Simon Goudie, and Hanna Bergman.

This review should be cited as 

Koehlmoos TP, Gazi R, Hossain SS, Zaman K. The effect of social franchising on access to and quality of health services in low and middle income countries. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD007136.

The summary should be cited as

Steinmann P. Does social franchising have an effect on access to and quality of health services in low and middle income countries? A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org.

Keywords

evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, social franchising

 



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