Dr Timothy Powell Jackson is a Senior Lecturer in Health Economics at the London School of Hygiene and Tropical Medicine. He is currently involved in a study evaluating social franchising in Uttar Pradesh, India. The study is estimating the impact of social franchising on the quality and coverage of health services. I spoke to Tim about social franchising, equity and the generalisability of their study.
Could you give us a brief overview of social franchising and how it relates to health?
The idea of social franchising in health is to apply the idea of franchising in the private sector to the health sector. For example, McDonalds is a franchise. You have individual owners of a restaurant but they have to abide by certain branding and directives from the franchiser and quality standards. The idea is to use franchising in the health sector so that the franchiser engages with private facilities. The franchisor engages with private facilities, brands them, and works with them to try and meet quality standards. The programme we are studying is in Uttar Pradesh in India and the organisation is called World Health Partners.
WHP is the franchiser, engaging with low level providers in the health sector, many of them informal health providers. They also engage at a higher level in the public sector – these lower level providers where people get antenatal care try and link them with higher level facilities that provide delivery care. While expanding the franchise, they’re also introducing new technologies. For example using telemedicine; if a woman comes in for an antenatal care visit they can use telemedicine to connect with a central location in Delhi where they can link up with a specialist doctor.
What is the previous evidence for social franchising?
There are some good systematic literature reviews on social franchising in health. The evidence pertains mainly to social franchising in family planning, and there is some evidence it increases utilisation. But I think beyond family planning there is limited evidence on whether it is effective. There’s a recent study in Bihar which is a good evaluation of the same franchiser, World Health Partners, we are evaluating. But those findings have not yet been released.
Do you think that social franchising in health works? And do you think your study will contribute to that discourse?
I would say there’s not much good evidence, even though there’s a lot of activity in social franchising. There’s an annual companion on social franchising, and it lists all the countries and what activities are going on in each country. There’s been huge investment in social franchising despite there being very little evidence. Hopefully we’ll contribute to the body of evidence on social franchising. Our particular model we’re evaluating is focused on maternal health care.
Does this study consider the economic impact of social franchising?
In a sense our evaluation doesn’t necessarily pertain to economics. We’re looking at the programme on a range of indicators; we don’t have an RCT so we’re using other methods to tease out the effects of the intervention. The economics will come in when we look at the sustainability and the cost in relation to the benefit. In terms of the evaluation it’s a standard evaluation, which epidemiologists do, economists do, and statisticians do.
It’s important to look at cost effectiveness, but before something can be cost effective it has to be effective in the first place. I think that’s partly why it can get overlooked. So the primary objective of our evaluation is the effectiveness side. But we are collecting cost data; the cost effective data will be interesting to understand whether this intervention is cost effective to do considering the investment in social franchising. It’s interesting as well in terms of sustainability. When providers join the network they’re hoping the branding will increase recognition of their services and increase patient volume and in turn increase revenue. I think that’s why they do it, so it’ll be interesting to see if there is an increase in volume.
What about the issue of equity in social franchising?
The question on equity is a very open question and one that we’ll look into. I think it’s highly debatable that social franchising engaging with the private sector will do anything for equity. And we’ll be looking at that in two respects; the socio-economic status of patients who are coming in using these services, and whether the impact is greater in populations that are more marginalised. Those two ways will get at that equity question. There should be no assumption that this is pro-poor in the first place. The risk is that it draws people away from the public sector to the private sector with potentially no obvious benefit. It remains to be seen if the quality is better in the private sector.
Could this study be replicated in other parts of India, and will the findings be generalisable?
That’s a good question. I think social franchising has more potential in less rural areas where health providers will benefit more from the branding and the additional custom. This study is happening is in Uttar Pradesh which is a poor and very large state. The programme is being implemented in three districts only but still that includes 8 million people. I think the study findings could be generalisable to Uttar Pradesh, which in itself is enough of a generalisation given the size of the state.
Do you have any final thoughts?
I think the findings will be interesting. Social franchising is an example where the enthusiasm and the investment have gone way beyond the evidence. It’s important that the evidence catches up with the ambitions of the donors and whoever is funding these social franchises. It shouldn’t be taken for granted that a private sector model that works for McDonalds and other consumables will be relevant in terms of health. There are definitely some big questions to be answered. I guess the challenge with evaluating something like this, than say a drug, is that every programme is different, the design will be different as will the context in which it’s delivered. Coming to generalisable conclusions, even across many studies, can be challenging.
Social franchising poses interesting questions about equity, and the nature of the competition between public and private health care. The results of this study will provide evidence on whether social franchising is applicable to a health setting and the effect it has on the quality of services provided in Uttar Pradesh, India.
Image: DFID (Department for International Development) accessed via Flickr/Creative Commons