May, 2011 - 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. Effective overviews and quality standard enforcements of social franchising are often lacking.

Key messages

No evidence was found regarding the effects of social fran-chising on access to, and the quality of, health services in low- and middle-income countries
There is a need for well designed experimental studies that are informed by the theoretical and empirical literature

Who is this summary for?

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

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. DOI:10.1002/14651858.CD007136.pub2. See in Cochrane Library

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

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 access to 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. Effective overviews and quality standard enforcements, however, are often lacking. Concerns have beenvoiced that the introduction of further approaches to health care delivery could lead to increased competiton for already scarce resources. Additional concerns include, among others, the crowding out of health care providers and decreased levels of motivation.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

/	What the review authors searched for	What the review authors found
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.
Interventions	Social franchises delivering health ser-vices, driven by seeking social benefits Considered were: Randomized Controlled Trials (RCT), Non-Randomized Controlled Trials (CCT), Interrupted Time Series (ITS), Controlled Before-After Studies (CBA)	No studies meeting the inclusion criteria were identified.
Participants	All levels of health care delivery All types of patients and health care providers
Settings	Low-and middle-income countries
Outcomes	1. Health care access 2. Quality of care 3. Health outcomes 4. Adverse effects 5. Equitable access or utilization 6. Cost/service 7. Patient satisfaction
Date of most recent search: October 2007 – March 2008
Limitations: : This is a good quality systematic review with only minor limitations
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. DOI:10.1002/14651858.CD007136.pub2.

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

This is a good quality systematic review with only minor limitations. It failed to identify any study meeting the inclusion criteria.

No studies that met the inclusion criteria were identified
There is a need for well-designed experimental studies in-formed by theoretical and empirical literature

As new ways of expanding health services in LMICs 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 assessed in detail. The methodology for establishing the evidence required is available but, to date, no conclusions regarding the ef-fectiveness of social franchising on access to, and the quality of, health services in LMICs can be drawn.

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 population segments. However, there are no rigorous evaluations 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 health care delivery. Loss of motivation among existing providers is another downside of the introduction of new approaches.
ECONOMIC CONSIDERATIONS
Cost/service (from a societal perspective or the perspective of the franchiser, franchisee or patients) was a considered outcome.	The cost and cost-effectiveness of social franchising is unknown. The introduction of social franchising might result in competition for resources with existing or alternative approaches to health care delivery. This may result in reduced funding levels and overall quality erosion in instances where the existing or alternative approaches offer better cost-effectiveness or the effects of scale can not be realised any longer due to reduced demand.
MONITORING & EVALUATION
The review noted the absence of robust evidence from rigorously designed studies.	There is a need for well designed experimental studies informed by theoretical and empirical literature. All relevant interventions 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- and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

Additional information

Additional information

Related literature

Clinical Social Franchising Compendium – An Annual Survey of Programs, 2010. The Global Health Group; University of California. http://globalhealthsciences.ucsf.edu/GHG/docs/Social-Franchising-Compendium-2010.pdf

Lonnroth K, Aung T, Maung W, Kluge H, Uplekar M. Social franchising of TB through GBs in Myanmar: an assessment of treatment results, access, equity and financial protection. Heatlh 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 evi-dence and future directions. Guidance from a technical consultation meeting (unpublished) 2007.

This summary was prepared by

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

Conflict of interest

None. For details, see: Conflicts of interest

Acknowledgements

This summary has been peer reviewed by: Tracey Koehlmoos, Bangladesh; Catherine

Goodman, Kenya; Vivian Welch, Canada.

This 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. May 2011. www.support-collaboration.org/summaries.htm

Keywords

All Summaries: 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

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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