Background
Evidence on social franchising
Social franchise model
Organising delivery | Programmes that reduce fragmentation and informality of health care delivery and that may enable financing, regulation, training and new business models | |
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Franchise | A group of providers that operates under the same brand but where outlets are operator-owned and services are standardised by a central franchisor | SkyCare/SkyHealth (stand-alone franchises); franchise clinic/franchise diagnostic (fractional franchises) |
Chain | A group of providers that operates under the same brand but where operators are paid employees of a sponsoring organisation | Three franchisor-owned clinics (also called mini-clinics) |
Network | A group of providers that are loosely joined to deliver services to specific population groups. Each provider is a separate entity and retains its own branding. Membership in the network may entitle the provider to payments, patient volume, central services or training | Franchisees are linked to a network of shops selling drugs which receive socially marketed products |
Regulating performance | Programmes that set standards and enforce or incentivize higher quality care or increased access for target populations | |
Quality enforcement/monitoring | Programmes that mandate specific clinical practice guidelines, and/or monitor providers over time to ensure quality | Monitoring and supervision of quality standards in franchisees, exit surveys and encourage feedback from competitors |
Price regulation | Programmes or regulations that specify prices that must be charged to users for services | Fixed prices for below the poverty line clients at Sky Centres; fixed prices for franchised services at franchised clinics |
Financing care | Programmes that mobilise funds for health care and align provider incentives to increase access for targeted groups of patients or to support select health interventions | |
Links to government health financing mechanisms | Initiatives that link private providers to existing government health financing mechanisms that can contract and reimburse private providers for care provided to specified patient groups | Plan to facilitate linking franchisees and beneficiaries to government cash incentive and insurance schemes. Training of community health workers to link with government schemes |
Cross subsidisation | Programmes that charge full-fees for services to patients that are able to afford them and use the profits to subsidise services for the poor | Subsidies for telemedicine for clients below the poverty line off-set to some degree by franchise fee paid per client above the poverty line |
Changing behaviours | Programmes designed to change the behaviour of individuals involved in health care transactions | |
Social marketing | Programmes that aim to change consumer care-seeking behaviours through marketing/advertisement techniques, with or without a branded and/or subsidised product | Branding, advertising, SMS messages, provision of SkyMeds |
Community health workers | Programmes that use community health workers to generate demand for products or services | Government community health workers refer women to public and franchised facilities |
Provider training | Programmes that seek to improve the quality and/or efficiency of services by training health care workers and/or building the internal capacity of organisations | Training of SkyCentre staff, franchise clinic staff, community health workers and public sector staff. Sky centre staff also trained on telemedicine technology |
Other health awareness/education | Programmes that create social awareness and educate the public about specific health topics such as disease prevention and treatment, healthy behaviours, correct use of pharmaceuticals, etc. | Community system to give health messages |
Organising delivery | Programmes that reduce fragmentation and informality of health care delivery and that may enable financing, regulation, training and new business models | |
Enhancing processes | Processes, technologies, or products that facilitate increased efficiency, lower costs, higher quality, and/or improved access | |
Information and communications technology | Programmes that utilise technology to enable remotely delivered care, communication and exchange of medical information (e.g. telemedicine, call centre, cell phone technology, biometric system, etc.). | Cell phone/smartphone/tablet/telemedicine services through franchisees, including remote diagnostics |
Innovative operational processes | Programmes that improve quality, reduce costs or enhance efficiency of services through new business or care processes (e.g. high-volume/low-cost operational models, process standardization). | Telemedicine; getting auxiliary nurse midwives to insert intrauterine devices in rural areas |
Mobile health | Programmes that utilise various models of transportation to deliver services to rural and remote populations. (e.g. ambulance services, health worker transport, travelling clinics/products, etc.) | May have Sky ambulance and link to “108” ambulance |
Supply chain enhancements | Programmes that reduce costs and improve efficiency of supply chains that move medical products from manufacturer to retailer | Last mile outriders (SkyMeds and diagnostics) |
Innovative medical products and equipment | Programmes that design, manufacture and sell new products such as rapid testing kits, nutritional supplements or other medical supplies that reduce costs, improve quality or enable remote care | Non-pneumatic anti-shock garment; stabilisation procedures at lower levels; remote diagnostics; safe delivery kits |
Theory of change
Methods
Study setting
Study design
Data collection
Outcomes
Indicator | Type of indicator |
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1. ANC utilisation | |
Received at least three ANC visits (%) | Use of healthcare |
Received ANC visit in first trimester (%) | Use of healthcare |
Number of ANC consultations (visits) | Use of healthcare |
Received visit from ASHA during pregnancy (%) | Use of healthcare |
2. ANC content of care | |
Fully immunised with tetanus toxoid (%) | Process of care |
Received iron supplementation during pregnancy (%) | Process of care |
Took iron supplementation during pregnancy for at least 100 days (%) | Process of care |
Received test results for syphilis received (%) | Process of care |
Abdominal examination during ANC (%) | Process of care |
Received a drug for intestinal worms during pregnancy (%) | Process of care |
Received a drug to prevent malaria (%) | Process of care |
Multiple birth pregnancy detected during ANC (%) | Process of care |
ANC content of care score of six items (index 0 to 1) | Process of care |
3. ANC knowledge and preparedness | |
Mother knowledge of pregnancy complications (index 0 to 1) | Patient knowledge |
Mother knowledge of signs of delivery complications (index 0 to 1) | Patient knowledge |
Birth preparedness (financial, transport, blood donor, attendant, safe delivery kit) (index 0 to 1) | Healthy behaviour |
Indicator | Type of indicator |
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1. Delivery care utilisation | |
Gave birth in a health facility (%) | Use of healthcare |
Gave birth with a doctor, nurse or midwife (%) | Use of healthcare |
Had a caesarean section (%) | Use of healthcare |
2. Recommended delivery care practices | |
Delivery attendant used gloves (%) | Process of care |
Delivery attendant washed hands with soap (%) | Process of care |
Woman had her BP measured (%) | Process of care |
Mobility during labour (%) | Process of care |
Oral fluids during labour (%) | Process of care |
Heart rate of baby monitored with intermittent or continuous auscultation (%) | Process of care |
Use of anti-shock garment (%) | Process of care |
3. Harmful or ineffective delivery care practices | |
Shaving pubic hair (%) | Process of care |
Enema given (%) | Process of care |
Lithotomy position during labour (%) | Process of care |
Intravenous fluids during labour (%) | Process of care |
4. Delivery care practices frequently over used | |
Urinary catheter (%) | Process of care |
Pain control by epidural analgesia (%) | Process of care |
Oxytocin augmentation (%) | Process of care |
Episiotomy (%) | Process of care |
5. Disrespect and abuse | |
Support during labour (%) | Patient experience |
Medical procedure performed without consent (%) | Patient experience |
Shouted, scolded or humiliated by health worker (%) | Patient experience |
Slapped, pinched or hit by health worker (%) | Patient experience |
Gave birth with privacy (%) | Patient experience |
Refused care for inability to pay (%) | Patient experience |
Kept in facility for inability to pay (%) | Patient experience |
Felt disrespected or abused during facility stay (%) | Patient experience |
6. Economic consequences | |
Out-of-pocket spending on delivery care (NRS) | Financial strain |
Borrowed money to pay for delivery care (%) | Financial strain |
Household in debt to pay for delivery care (%) | Financial strain |
Received JSY cash incentive (%) | Financial strain |
Indicator | Type of indicator |
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1. Postpartum care | |
Received postpartum care within 48 h of birth (%) | Use of healthcare |
Newborn received postnatal care within 48 h of birth (%) | Use of healthcare |
2. Newborn content of care | |
Clean cord care (clean instrument to cut and tie the cord, and nothing put on cord) (%) | Process of care |
Thermal care (immediate drying, wrapping, skin to skin and delayed bathing) (%) | Process of care |
Baby weighed at birth (%) | Process of care |
Baby registered and received certificate (%) | Process of care |
3. Neonatal health | |
Neonatal mortality (per 1000 live births) | Health outcome |
One-day mortality (per 1000 live births) | Health outcome |
Birth weight (kg) | Health outcome |
4. Breastfeeding | |
Immediate breastfeeding within 1 h of birth (%) | Healthy behaviour |
Colostrum given to baby (%) | Healthy behaviour |
Exclusive breastfeeding for 3 days (%) | Healthy behaviour |
5. Family planning | |
Modern contraceptive use at 3 months postpartum (%) | Use of healthcare |
Sample size calculations
Empirical analysis
Process evaluation
Indicator | Survey tool |
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1. Uptake of social franchising | |
Proportion of private health providers who join network (%) | Health provider census |
Proportion of providers who left network in past year (%) | Health provider survey |
Proportion of providers purchasing and selling SkyMeds (%) | Health provider survey |
2. Training | |
Proportion of social franchisees that have received clinical training (%) | Health provider survey |
Proportion of social franchisees that have received training in use of technology (%) | Health provider survey |
3. Information and marketing | |
Proportion of women who have ever heard of Sky social franchise network (%) | Household survey |
Proportion of social franchisees that have been branded (%) | Health provider survey |
4. Contacts with health workers | |
Proportion of women who had any contact with ASHAs during pregnancy (%) | Household survey |
Proportion of individuals who have used telemedicine in past 6 months (%) | Household survey |
5. Monitoring and feedback | |
Proportion of social franchisees that have received supervision visits past 6 months (%) | Health provider survey |
Proportion of social franchisees that have received feedback on quality past 6 months (%) | Health provider survey |