How equitable is social franchising? Case studies of three maternal healthcare franchises in Uganda and India

Abstract

Substantial investments have been made in clinical social franchising to improve quality of care of private facilities in low- and middle-income countries but concerns have emerged that the benefits fail to reach poorer groups. We assessed the distribution of franchise utilization and content of care by socio-economic status (SES) in three maternal healthcare social franchises in Uganda and India (Uttar Pradesh and Rajasthan). We surveyed 2179 women who had received antenatal care (ANC) and/or delivery services at franchise clinics (in Uttar Pradesh only ANC services were offered). Women were allocated to national (Uganda) or state (India) SES quintiles. Franchise users were concentrated in the higher SES quintiles in all settings. The percent in the top two quintiles was highest in Uganda (over 98% for both ANC and delivery), followed by Rajasthan (62.8% for ANC, 72.1% for delivery) and Uttar Pradesh (48.5% for ANC). The percent of clients in the lowest two quintiles was zero in Uganda, 7.1 and 3.1% for ANC and delivery, respectively, in Rajasthan and 16.3% in Uttar Pradesh. Differences in SES distribution across the programmes may reflect variation in user fees, the average SES of the national/state populations and the range of services covered. We found little variation in content of care by SES. Key factors limiting the ability of such maternal health social franchises to reach poorer groups may include the lack of suitable facilities in the poorest areas, the inability of the poorest women to afford any private sector fees and competition with free or even incentivized public sector services. Moreover, there are tensions between targeting poorer groups, and franchise objectives of improving quality and business performance and enhancing financial sustainability, meaning that middle income and poorer groups are unlikely to be reached in large numbers in the absence of additional subsidies.

Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys

“…However, fewer than 20% of private health facilities are classified as level III health centres or higher, the minimum level at which maternal health services are to be provided, and the majority of these are not-for-profit facilities [ 28 , 29 ]. A number of interventions aimed at capitalising on the presence of the private sector have been implemented in Uganda over the years, some with an express aim to increase coverage among hard-to-reach groups and to alleviate the undue financial burden of reproductive health services (e.g., voucher schemes) [ 32 – 36 ]. Though these interventions were often evaluated separately, the contribution of the private sector to maternal and reproductive health in Uganda has not been assessed comprehensively over time.…”

Reaching rural communities through ‘Healthy Entrepreneurs’: a cross-sectional exploration of community health entrepreneurship’s role in sexual and reproductive health

“…This includes studying more tacit knowledge through observations. In addition, evidence indicates that communities are willing to pay for health products and services (Turinawe et al , 2016) but the measurable equitableness of payment schemes in community health worker approaches remains disputed (Shah et al , 2011; Haemmerli et al , 2018; Mumtaz, 2018). It would be worthwhile to explore this aspect further through both quantitative and qualitative inquiry.…”

Delivering reproductive health services through non-state providers in Pakistan: understanding the value for money of different approaches

“…Nevertheless, when considering the scale-up of such initiatives policy makers need to be careful not to overestimate their effectiveness or their reach among the most disadvantaged. A recent evaluation of maternal healthcare franchises in India and Uganda found a limited ability of social franchises to reach the poorest areas [ 42 ]. As such, a more complex and context-specific set of incentives (e.g.…”