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Social Franchising for TuberculosisDiagnosis and Treatment: GlobalExperienceMay Sudhinaraset and Dominic MontaguPPM-DOTS Subgroup MeetingLille, 2011
Social Franchising “ is an attempt to use franchising methods toachieve social rather than financial goals, influencingthe service delivery systems of the private sectorsimilarly to the way in which social marketing hasadapted traditional outlets for commodity sales.”
For Profit Franchising
Social Franchising
Common SituationPrivateClinicNGO orHospitalPrivateClinicPrivateClinicProblem:Many private clinics but limited range ofservices, uncertain quality
Social Franchise Membership fectivenessFranchiseePrivateClinicQualityEquity
Fractional FranchisingTypical private clinicservices Aches, pains, headachesPrivateClinic Cuts, abrasions Stomach problems Eye, nose, throat Fevers and coughs Provides a range services Diarrheal diseases Infections Chronic illnesses Family planning TB diagnosis and Care
Fractional FranchisingTypical franchise clinicservices Aches, pains, headachesFranchiseClinic Cuts, abrasions Stomach problems Eye, nose, throat Fevers and coughs New services are added Some existing services areimproved Most existing servicesremain unchanged Diarrheal diseases Infections Chronic illnesses Family planning TB diagnosis and Care
What do we know? Growth and expansion Increase diversification Preliminary Data
GrowthThe number of social franchises has doubled since 2006
Social Franchise Programs 2011
Diversification
Balancing Equity and Cost Recovery*Cost recovery % of program expenditure recovered by program income (self-reported)
Social Franchise Programs 2011 – TB ServicesPakistan GreenstarBangladesh Smiling Sun5959 Completed2700 initiated on DOTSSMCWorld Health Partners9451 Referrals8 on treatment, 4 referralsIndia Operation AshaGhana MicroClinicsSQH Laos3000 Completed?Nigeria Hygeia264 initiated on DOTS26 ReferralsKenya CFW ClinicsReferrals OnlyGoldstar Network837 tested and referredZimbabwe New StartSouth Africa Broadreach70 initiated on DOTS7500 tested2200 initiated on DOTSSun Quality Health16820 tested16400 initiated on DOTS
Social Franchise Programs 2011 – TB ServicesSMC9451 ReferralsSQH Laos26 ReferralsKenya CFW ClinicsReferrals Only
Social Franchise Programs 2011 – TB ServicesPakistan GreenstarBangladesh Smiling Sun5959 Completed2700 initiated on DOTSSMCWorld Health Partners9451 Referrals8 on treatment, 4 referralsIndia Operation AshaGhana MicroClinicsSQH Laos3000 Completed?Nigeria Hygeia264 initiated on DOTS26 ReferralsKenya CFW ClinicsReferrals OnlyGoldstar Network837 tested and referredZimbabwe New StartSouth Africa Broadreach70 initiated on DOTS7500 tested2200 initiated on DOTSSun Quality Health16820 tested16400 initiated on DOTS
What do we know? Myanmar– Quality (Lonroth et al., 2007) Increases case detection 84% treatment success for new sputum smear-positive Minimize treatment delay (median time from symptomto start of treatment 3.7 weeks)
Trend of DOTS case notification rates of all newsmear-positive cases in SQH townships andcontrol townships (PSI/Myanmar)Lonnroth, Tin Aung, Win Maung, Kluge, and Uplekar, 2007. Social franchising of TB care through private GPs in Myanmar:an assessment of treatment results, access, equity and financial protection. Health Policy and Planning
What do we know? Myanmar– Quality Increases case detection 84% treatment success for new sputum smear-positive Minimize treatment delay (3.7 weeks)– Equity
Reaching the Poor?Equity Analysis of SQH Myanmar TBtreatmentUrban Sample: Wealth Quartile Distribution comparingSQH Franchise vs. General TB PatientsRural Sample: Wealth Quartile Distribution comparing SQHFranchise vs. General TB 25201510500PoorestChi2 p 0.05PoorRichRichestPoorestPoorRichRichestChi2 p 0.130National SampleSudhinaraset, M., Lwin, T., Montagu, D., Onozaki, Z Win, T Aung, 2011Sun Quality Health Sample
What do we know? Myanmar– Quality Increases case detection 84% treatment success for new sputum smear-positive Minimize treatment delay (3.7 weeks)– Equity In urban areas, SQH clinics more likely to serve poorestpatients compared to general TB patients (p 0.05) In rural areas, no difference in wealth scores betweenSQH clinics and general TB patients (p 0.130)
New activities TB to be added to expansion of three largefranchise programs in Ghana, Nigeria, andKenya Indian Franchise Federation created in April2011 Franchises in India propose joining forces toexpand both DOTS and MDR TB detection
Future Directions(What Don’t we know?) Standardization across programs Cost effectiveness Scalability– Expensive– Other services have more priorities when it comesto donor funding– Political support– Provider incentives/disincentives
Quality
Quality of care: TB follow-up survey (SQH Myanmar)100%90%80%70%History taking60%Physical examination50%Sputum check40%Offer HIV test30%Correct treatment20%Counseling10%0%Mar, 2010sep, 2010
DefinitionDefinition of a Social Franchise Outlets are operator-owned Payment is for services delivered Services are standardized
Cost-effectiveness Quality Equity . Fractional Franchising Typical private clinic . Goldstar Network 70 initiated on DOTS 9451 Referrals 16400 initiated on DOTS . Social franchising of TB care through private GPs in
