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The Global Health Group University of California, San Francisco May 2010 CLINICAL SOCIAL FRANCHISING COMPENDIUM An Annual Survey of Programs, 2010

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Page 1: CliniCal SoCial FranChiSing Compendium · CliniCal SoCial FranChiSing Compendium an annual Survey of programs, 2010. 2 Clinical Social Franchising, 2010 ... ProFam 16 democratic republic

The Global Health GroupUniversity of California, San FranciscoMay 2010

CliniCal SoCial FranChiSing Compendium an annual Survey of programs, 2010

Page 2: CliniCal SoCial FranChiSing Compendium · CliniCal SoCial FranChiSing Compendium an annual Survey of programs, 2010. 2 Clinical Social Franchising, 2010 ... ProFam 16 democratic republic

Clinical Social Franchising, 20102

Copyright © 2010 The Global Health Group

The global health groupGlobal Health Sciences University of California, San Francisco 50 Beale Street, Suite 1200 San Francisco, CA 94105, USA Email: [email protected] Website: globalhealthsciences.ucsf.edu/ghg

ordering informationElectronic download: This publication is available for electronic download at globalhealthsciences.ucsf.edu/ghg.

Print copies: Limited print copies are available from the Global Health Group. To request a copy, please send an email to [email protected]. Information will be updated over time and published online at globalhealthsciences.ucsf.edu/ghg.

recommended citationSchlein, K., Kinlaw, H. and Montagu, D. (2010). Clinical Social Franchising Compendium: An Annual Survey of Programs, 2010. San Francisco: The Global Health Group, Global Health Sciences, University of California, San Francisco.

Produced in the United States of America

First Edition, May 2010

This is an open-access document distributed under the terms of the Creative Commons Attribu-tion-Noncommercial License, which permits any noncommercial use, distribution and reproduc-tion in any medium, provided the original author and source are credited.

This document is a product of the Global Health Group at the University of California, San Fran-cisco. The information contained herein was provided by individual franchise programs and was not independently verified. This document is intended to serve as a guide, and the interpreta-tion and use of the information is the responsibility of the reader. Country designations do not express any judgment by the Global Health Group concerning the legal status of any country or territory. References to companies or products do not reflect endorsement or preference by the Global Health Group.

Cover imagePhoto © Rodrique Wanjala, Courtesy of Population Services International, Kenya

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Clinical Social Franchising, 20103

Table of Contents

introduction 5

program services table 7

Social franchise profiles by country 8

Bangladesh ..................................................................................................... 8

Blue Star 8

Smiling Sun 10

Benin ............................................................................................................. 12

ProFam 12

Cambodia ..................................................................................................... 14

Sun Quality Health 14

Cameroon ..................................................................................................... 16

ProFam 16

democratic republic of Congo ..................................................................... 18

Reseau Confiance 18

el Salvador .................................................................................................... 20

Vision Spring 20

ethiopia ........................................................................................................ 22

BlueStar 22

ghana ........................................................................................................... 24

BlueStar 24

MicroClinic International 26

india .............................................................................................................. 28

Drishtee Health Franchise 28

MerryGold 30

Saadhan 32

SkyHealth Rural Clinics 34

Surya 36

Kenya ............................................................................................................ 38

AMUA 38

Gold Star Network 40

Tunza Family Health Network 42

madagascar ................................................................................................. 44

BlueStar 44

ProFemina 46

Top Réseau 48

malawi .......................................................................................................... 50

BlueStar 50

mali ............................................................................................................... 52

ProFam 52

myanmar ....................................................................................................... 54

Sun Quality Health 54

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Clinical Social Franchising, 20104

nepal ............................................................................................................ 56

Sangini Social Franchising 56

nigeria .......................................................................................................... 58

Society for Family Health 58

Hygeia 60

pakistan ........................................................................................................ 62

Greenstar 62

Sehat First 64

Suraj 66

peru .............................................................................................................. 68

RedPlan Salud 68

philippines .................................................................................................... 70

BlueStar 70

Sierra leone .................................................................................................. 72

BlueStar 72

South africa .................................................................................................. 74

BroadReach Healthcare 74

Togo .............................................................................................................. 76

POMEFA 76

uganda ......................................................................................................... 78

Living Goods 78

ProFam 80

Vietnam ........................................................................................................ 82

BlueStar 82

Tinh chi em 84

Zimbabwe ..................................................................................................... 86

New Start 86

appendices 88

appendix a: acronyms ................................................................................. 88

appendix B: map of social franchises ........................................................... 89

appendix C: program summary graphs ........................................................ 90

Timeline 91

Franchises by region 91

Services offered 91

Couple years of protection (CYP) 92

CYP conversion factors 93

Number of clients served 94

Program expenditure 95

Expenditure per client 95

appendix d: demand-side financing ............................................................ 96

appendix e: donors contributing to franchising programs in 2009 .............. 98

appendix F: umbrella organizations ............................................................. 99

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Clinical Social Franchising, 20105

introduction

This second annual compendium of clinical social franchise programs is a testament to

the rapidly growing and changing field of social franchising in developing countries.

Forty franchises are profiled herein, ten of which are new additions to the compen-

dium. The data included was provided by the franchises in the first quarter of 2010 and

subsequent edits were made by the Global Health Group.

The profiles that follow describe new innovations in financing, healthcare delivery,

technology and involvement of community health workers. Each profile contains in-

formation relevant to the social franchising community as a whole. The successes and

challenges of each franchise are highlighted, providing lessons and a basis for further

communication among implementers and stakeholders of social franchising programs

worldwide.

Some of the novel initiatives profiled this year include the following:

• Video consultation with qualified physicians to support the local staff at Sehat First

clinics in Pakistan

• AMUA’s establishment of a public-private partnership with the MOH in Kenya

• Use of field workers to distribute vouchers as part of the Suraj program in Pakistan

• A toll-free hotline that offers anonymous information on HIV and family planning as

well as referrals to ProFam clinics in Benin

• Planning for a program where hairdressers, dressmakers and female students work-

ing as community health workers will refer clients to BlueStar clinics in Ghana

• Cross subsidies among a diverse product mix for Living Goods’ entrepreneurs in

Uganda

• An SMS-based reporting system for family planning sales being used by Tunza in

Kenya

What is a social franchise?

A social franchise encompasses a network of private health practitioners linked

through contracts to provide socially beneficial services under a common brand. To be

considered a social franchise for inclusion in this compendium, a network of providers

had to have the following characteristics:

• Outlets are operator-owned

• Payments to outlets are based on services provided1

• Services are standardized2

• Clinical services are offered, with or without franchise-branded commodities3

1 The mechanism of payment may vary and may include client out-of-pocket, voucher, third party insurance or other systems. 2 Additional, non-franchised products and services may also be offered.3 Clinical services are defined as any healthcare practice that would, in an OECD country, require service by a nurse or other higher-level provider. Under this definition, for example, injections are considered clinical, even if franchise-supported community health workers or pharmacists provide them.

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Clinical Social Franchising, 20106

goals

A social franchise has four primary goals:

• Access — Increase the number of service delivery points (providers) and healthcare

services offered

• Cost-effectiveness — Provide a service at an equal or lower cost to other service

delivery options, inclusive of all subsidy or system costs

• Quality — Provide services that adhere to quality standards and improve the pre-

existing level of quality

• Equity — Serve all population groups, emphasizing those most in need

Franchises by the numbers

The table below provides a snapshot of social franchising in 2009 and the subsequent

section summarizes the services provided by each franchise. For additional summary

tables, graphs and a map of franchises around the world, please see the appendices.

Total number of social franchises in the compendium 40

Social franchises that are new to the 2010 compendium 10

Franchises that do not have brick-and-mortar outlets 2

Franchises that post job aids / training materials on the internet 3

Computer-based inventory management systems in use by franchises 10

Median annual franchise membership fee (in USD) 21

Franchises using or planning to use SMS for client reporting/follow up 9

Programs that accept payment by vouchers or insurance 16

Franchises that target men as clients 15

Franchises offering access to loans as a benefit of membership 7

Programs that integrate community health workers in some way 30

Franchise programs with pharmacy affiliates 11

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Clinical Social Franchising, 20107

Family planning

other Sexual rh

hiV/aidS mCh malaria TB other

Number of Programs Providing Each Service

36 19 9 12 11 6 11

Blue Star, Bangladesh 6,387,172 25,023 2,964 241,109,310

Smiling Sun, Bangladesh 33,250,113 68,387 8,529,323 268 6,233 2,243,616

ProFam, Benin 11,769 3,136 2,100 43,371 87,130

Sun Quality Health, Cambodia 27,643 437 2,806 1,542 1,045

ProFam, Cameroon 22,707,163 ●

Reseau Confiance, DRC 546,541

VisionSpring, India/Ghana 211,000

BlueStar, Ethiopia 112,363 6,335

BlueStar, Ghana 129,632 2,052

MicroClinic, Ghana/Uganda 1,567 893 33,940 48,938 103 29,859

Drishtee, India 3,500 13,000

MerryGold, India 345,000 123,000

Saadhan, India 149,530 33,060

SkyHealth, India 809,635 3,130 2,700

Surya, India 28,993,884 115,142

AMUA, Kenya 1,004,932 43,648 10,803

Gold Star, Kenya 72,455 119,170

Tunza, Kenya 17,863

Top Réseau, Madagascar 59,059 23,244 143,248

BlueStar, Madagascar 1,823 41

ProFemina, Madagascar 15,200 ●

BlueStar, Malawi 16,895

ProFam, Mali 5,237 321

Sun Quality Health, Myanmar 1,527,953 65,265 100 682,598 15,242 441,259

Sangini, Nepal 16,914,071 105,077 ● 3,029,075

Hygeia, Nigeria 17,710 12,236 44,277 439

Society for Family Health, Nigeria

37,444

Suraj, Pakistan 158,464

Greenstar, Pakistan 99,010,825

Sehat First, Pakistan 30 156 1,540 194 4,808

RedPlan Salud, Peru 176,093

BlueStar, Philippines 112,432 3,158

BlueStar, Sierra Leone 10,509 1,125 87,130

BroadReach, South Africa 1,500**

POMEFA, Togo 44,165

Living Goods, Uganda ● ● ● ● ●

ProFam, Uganda 13,686

BlueStar, Vietnam 76,093 14,651

Tinh chi em, Vietnam 32,149 17,316

New Start, Zimbabwe ● 361,355 ●

* The numbers presented in this table represent either the number of commodities provided or the number of clients served. In cases where the numbers differ, the higher of the two is presented. The dots indicate that services are provided, but the quantity provided was not reported. ** Includes all patients initiated on treatment to date.

number of services provided by franchise and health area in 2009*

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Clinical Social Franchising, 20108

At a glance

Franchise details Services

Timeline Launched in 1998 Family planning

USAID calculation 435,441 CYP MSI/DKT calculation 451,442 CYP

Location 64 out of 64 districts Other sexual and reproductive health

Business model Fractional franchise HIV/AIDS

Target clientele Men, women, children Maternal and child health ●

Average staffing 1 doctor and 1 non-graduate medical practitio-ner per outlet

Malaria

Outlet types 3,600 clinics Tuberculosis ●

Number of clients served in 2009 Diarrheal disease treatment, vitamins

Average clients/outlet

Payment sources 100% out-of-pocket payment (OOP) (The contraceptive injectable “SOMA-JECT” is donated by USAID to SMC and sold at a subsi-dized price to Blue Star providers.)

2009 program expenditure (USD) $244,126

Donor support USAID

Contact information Dr. Salah Uddin Ahmed, Manager www.smc-bd.org

Bangladesh

Social marketing Company (SmC)Blue Star Bangladesh

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Clinical Social Franchising, 20109

Description

Bangladesh

BackgroundSocial Marketing Company (SMC) started Blue Star as a pilot project with a goal to increase informed demand for high priority public health services through partnerships with private health providers. A private health practitioner becomes a Blue Star provider after meeting the selec-tion criteria, signing a partnership agreement that states they will deliver a defined package of services, attending a training course, keeping records and sending reports to SMC. SMC provides training, quality assurance visits, on-site technical assistance, behavior change communication support, supplies commodities and promotes the social franchise brand through local and mass media.

Service detailsOral contraceptives, condoms, injectables, Copper T, emergency contraceptive pills, clean delivery kits, TB refer-rals, diarrheal disease treatment, vitamins

licensingDirectorate General of Family Planning of Government of Bangladesh

Job aids• FP counseling flip chart• Screening checklist• Voluntary family planning (FP) charts (also known as "Ti-

ahrt Charts") to ensure informed and voluntary decision making by clients

inventory managementBlue Star delivers products based on provider requests and requirements via pre-established service delivery points. Injectable contraceptives are distributed based on stock sheets maintained at the outlet level. From the central warehouse the products are distributed to 12 area offices, and from there the products go to wholesalers, retailers and Blue Star outlets.

TechnologySMS reporting

Successes• Strong brand image• Reputation for quality providers• Providers are available from morning until night

Future plansIntegrated management of childhood illness (IMCI), repro-ductive tract infection (RTI)/STI, maternal neonatal health

innovations• Documentation (record keeping and reporting)• Introduction of membership fees• Adding more public health priority services through Blue

Star

Health practitioners outside of Blue Star Bangladesh clinic

Social marketing Company (SmC)Blue Star Bangladesh

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Clinical Social Franchising, 201010

At a glance

Bangladesh

Chemonics internationalSmiling Sun

Franchise details Services

Timeline Launched in 2008 Family planning

USAID calculation 1,424,344 CYP MSI/DKT calculation 1,534,971 CYP

Location 61 out of 64 districts Other sexual and reproductive health ●

Business model Full franchise HIV

Target clientele Low income, migrants/refugees, women, youth Maternal and child health ●

Average staffing "Vital" clinics have an average of 12 staff "Ultra" clinics have an average of 30 staff

Malaria ●

Outlet types 320 clinics, 8,500 satellite sites Tuberculosis ●

Number of clients served in 2009 23,000,000 Diarrheal disease treatment, lab services, vitamins, pneumonia test-ing/treatment

Average clients/outlet 2,608

Payment sources 60% OOP, 1% vouchers, 29% free, 5% third party payers

2009 Program expenditure (USD) Around $10 million

Donor support USAID funds around 65% of the network's operational expenses

Contact information Juan Carlos Negrette, Chief of Partywww.smilingsunhealth.com

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Clinical Social Franchising, 201011

Description

Bangladesh

Chemonics internationalSmiling Sun

BackgroundSmiling Sun is a USAID-supported network of 28 NGOs that own 320 clinics, 8,500 satellite sites and an “army” of 6,000 community service providers (volunteer women who provide health products, basic services and referrals to clinics in their communities) that operates in 61 (out of 64) districts of Bangladesh. This full-franchise serves more than 20 million customers every year, and is the largest private healthcare network in the country.

Service detailsOral contraceptives, condoms, injectables, Copper T, implants, emergency contraceptive pills, STI treatment, cervical screening, post-abortion care, antenatal care (ANC), labor and delivery, emergency obstetric care, post-natal care, vaccinations, pediatric consultations, malaria treatment, tuberculosis (TB) case management, diarrheal disease treatment, lab services, vitamins, pneumonia test-ing/treatment

Community health workersCommunity Service Providers are volunteer women who provide contraceptives, acute respiratory infection prevention and diarrhea prevention to members of the community.

Job aidsA range of job aids and other resources can be found at the Smiling Sun website, www.smilingsunhealth.com (ac-cess restricted to members).

inventory management• Stock reports by outlet• Stock register book• Inventory management training• Physical stock counts• Refrigerators• Locked/secured storage rooms

Technology• Web-based reporting• Piloting SMS-based reporting for satellite clinics• Working with a general practitioner (GP) to develop a

hotline/SMS dialog with youth

Smiling Sun patients

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Clinical Social Franchising, 201012

At a glance

Franchise details Services

Timeline Launched in 2004 Family planning

USAID calculation 10,779 CYP MSI/DKT calculation 11,730 CYP

Location 5 out of 12 departments Other sexual and reproductive health ●

Business model Full franchise; annual franchise fee of $42 USD HIV/AIDS ●

Target clientele Low income, youth, men, women Maternal and child health ●

Average staffing 4 staff per clinic Malaria ●

Outlet types 50 clinics Tuberculosis

Number of clients served in 2009 2,153

Average clients/outlet 43

Payment sources OOP, vouchers

2009 program expenditure (USD)

Donor support USAIDThe Dutch Government

Contact information Lisa Moorhouse, HIV/FP Technical Advisorwww.psi.org

Benin

population Services internationalprotection de la Famille (proFam)

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Clinical Social Franchising, 201013

Description

Benin

population Services internationalprotection de la Famille (proFam)

BackgroundProtection de la Famille (ProFam) clinics aim to improve the quality and accessibility of FP services in the private sector and increase the demand for FP services.

Service detailsOral contraceptives, condoms, injectables, Copper T, implants, natural FP, STI testing and treatment, prevention of mother-to-child transmission (PMTCT), HIV counseling and testing (HCT), ANC, labor and delivery, emergency ob-stetric care, post-natal care, malaria testing and treatment, insecticide-treated nets

licensingAccreditation of midwives by the government through the Division of Family Health

Community health workersCHWs provide home visits and conduct education ses-sions. They are not paid a fee for each referral.

Job aidsChecklists designed by Family Health International

inventory managementStock reports by outlet

TechnologyTelephone hotline/counseling

SuccessesBenin’s Ligne Verte (toll-free hotline) was created to offer an anonymous way for callers to receive information on HIV, FP and referrals to ProFam clinics. In 2009, the Ligne Verte received 78,773 calls.

Challenges• Implementing and enforcing quality assurance• Desire of providers to be paid more

ProFam education session

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Clinical Social Franchising, 201014

At a glance

Cambodia

population Services internationalSun Quality health network

Franchise details Services

Timeline 2002: condom, pill, and injectables 2005: intrauterine device (IUD) 2008: implants

Family planning

USAID calculation 42,616 CYP MSI/DKT calculation 64,906 CYP

Location 13 out of 24 provinces Other sexual and reproductive health ●

Business model Fractional franchise HIV

Target clientele Low income Maternal and child health ●

Average staffing 1–2 doctors and 1–2 midwives per clinic Malaria ●

Outlet types 83 clinics, 6 mobile clinics Tuberculosis

Number of clients served in 2009 31,312 Diarrheal disease treatment ●

Average clients/outlet 352

Payment sources OOP

2009 program expenditure (USD)

Donor support KfW (German development bank)USAIDAnonymous donor

Contact information Leng Vanna, Franchise Manager www.psi.org

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Clinical Social Franchising, 201015

Description

Cambodia

population Services internationalSun Quality health network

BackgroundPopulation Services International (PSI) Cambodia man-ages a fractional franchise of 83 private health providers in support of reproductive health services. Sun Quality Health (SQH) providers are provided with a wide range of monitor-ing, support and training tools to improve their clinics.

Service detailsOral contraceptives, condoms, injectables, Copper T, im-plants, STI treatment, ANC, labor and delivery, emergency obstetric care, post-natal care, vaccinations, malaria test-ing/treatment, diarrheal disease treatment

licensingCertificate of medical doctor, medical doctor assistant or secondary midwife

Community health workersPSI Cambodia sub-contracts to a network of local NGOs which are given the skills and tools to support local volun-teers to conduct mobilization and outreach in the commu-nities surrounding the SQH clinics. Local NGOs implement interactive group sessions, individual outreach and special events to encourage women of reproductive age to access services at Sun Quality clinics. These volunteers are paid a nominal monthly stipend for their work.

Job aids• Standard Operating Procedures• Long-term methods services checklists• Counseling checklists• Counseling flipcharts

• A quarterly health magazine• Client record forms• Product display boxes and other point-of-sale materials

inventory managementStock reports by outlet

TechnologyTelephone hotline/counseling

Successes In an effort to expand access and choice to long-term methods, PSI hosts ‘Special Training Event Days’ to give providers the opportunity to refine their practical and counseling skills in IUD and implant insertions and counsel-ing. Additionally, by linking mobile event days to an SQH provider and to public health centers, PSI Cambodia can ensure that complications and method removal, if neces-sary, are addressed by a trained and qualified provider.

Challenges• Providers need consistent practice to maintain confi-

dence and competence in providing long-term methods.• Cost barriers remain an issue.

Future plans• Linkage of select services to health insurance, vouchers,

and equity funds to increase access to and choice of reproductive health services

• TB diagnosis, pneumonia and high blood pressure treatment are also being considered as health areas to integrate into the franchise.

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Clinical Social Franchising, 201016

At a glance

Franchise details Services

Timeline Launched in 2003 Family planning

USAID calculation 197,721 CYP MSI/DKT calculation 251,533 CYP

Location Yaoundé City Other sexual and reproductive health

Business model Fractional franchise HIV/AIDS

Target clientele Low income, sex workers and clients, men, youth, women, children under 5

Maternal and child health

Average staffing 4 staff (nurses, medical assistants, chemical sell-ers, midwives, doctors, surgeons) per clinic

Malaria

Outlet types 24 clinics, 1 mobile clinic Tuberculosis

Number of clients served in 2009 12,347 Pediatric care ●

Average clients/outlet 494

Payment sources OOP, vouchers

2009 program expenditure (USD) $497,671

Donor support (USD) PSI with Core Funds through Dutch government Strategic Alliance with International NGOs (SALIN): $1,259,870

Contact information Monda Léa, ProFam Coordinatorwww.psi.org

Cameroon

population Services internationalproFam Cameroon

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Clinical Social Franchising, 201017

Description

Cameroon

population Services internationalproFam Cameroon

BackgroundProFam started in 2003 with 25 private health centers in Yaoundé City. The objectives are to provide FP and pedi-atric care by offering IMCI according to the Health Ministry standards.

Service detailsContraceptives, condoms, female condoms, injectables, Copper T, implants, natural FP, lactational amenorrhea method, pediatric care

licensingThe Ministry of Health

Community health workersCommunity mobilizers are identified and are trained by the reproductive health staff.

inventory management• Stock reports by outlet• Computer-based inventory management system

Successes• Health talks organized with women's associations sur-

rounding health centers• Subsidized voucher system• Referral system for adverse events and emergencies

Challenges• Convincing clients to use IUDs• Increasing demand for FP services among youth

Future plans• Organizing "ProFam days" in the suburbs where fran-

chise clinics do not exist • Recruiting new clinics

ProFam Cameroon community mobilizer training session

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Clinical Social Franchising, 201018

At a glance

Franchise details Services

Timeline Launched in 2003 Family planning

USAID calculation 78,347 CYP MSI/DKT calculation 73,613 CYP

Location 10 out of 11 provinces Other sexual and reproductive health

Business model Fractional franchise HIV/AIDS

Target clientele Low income, women Maternal and child health

Average staffing 1 doctor, 4–6 nurses and 1 lab technician per health center

Malaria

Outlet types 93 health centers, 329 pharmacies Tuberculosis

Number of clients served in 2009

Average clients/outlet

Payment sources OOP

2009 program expenditure (USD)

Donor support (USD) USAID: $1.1 millionDutch government (SALIN): $400,000 (used to pay for ASF/PSI’s FP program, of which the network is the main activity)

Contact information Jamaica Corker, FP Technical Advisorwww.psi.org

Democratic Republic of Congo

association de Santé Familiale (aSF) (affiliate of pSi in drC)reseau Confiance (Confiance network)

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Clinical Social Franchising, 201019

Description

Democratic Republic of Congo

association de Santé Familiale (aSF) (affiliate of pSi in drC)reseau Confiance (Confiance network)

Service detailsOral contraceptives, injectables, Copper T, natural FP

licensingMedical staff (doctors, nurses) are accredited through the government.

Community health workers CHWs carry out interpersonal and mass media communica-tions, as well as referrals to network clinics and pharmacies. The network currently has 103 CHWs. They do not receive any fee for referrals but are paid monthly stipends.

Job aids• Client registration books• Consultation sheets, stock sheets• Follow-up reminder cards• Monthly reporting sheets• Eligibility criteria folders• Flipcharts • Family Planning: A global handbook for providers (in

French)—available at http://info.k4health.org/global-handbook/

inventory management• Stock reports by outlet• Arrangement of stock by First In/First Out (FIFO)/First

Expiry/First Out (FEFO)• Physical stock counts

TechnologyTelephone hotline/counseling

Successes• Signing of a collaboration agreement to ensure that

roles and responsibilities are being fulfilled; this can also be referred to if under-performing partners are asked to leave the network

• Meetings at the provincial level with all network mem-bers provide a forum to share information

• Teams of mobile educators in each province diffuse in-formation on FP and refer potential clients to Confiance network clinics/pharmacies.

Challenges• Insufficient product quantities (particularly as demand

continues to grow)• Mobility of clinicians and pharmacists—many leave their

posts within one or two years• Difficulties collaborating with local government to ensure

supervision of clinics and pharmacies

Future plans• Introducing the implant Jadelle into the network in 2010• Expansion of the network (within current sites and into

more cities in DRC) pending additional funds

Reseau Confiance pharmacy

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Clinical Social Franchising, 201020

At a glance

Franchise details Services

Timeline Launched in 2003 Family planning

Location 2 out of 14 departments in El Salvador, 6 out of 28 states in India

Other sexual and reproductive health

Business model 15% full franchise/85% fractional franchise HIV/AIDS

Target clientele Age 35+ who have difficulties with up-close vision

Maternal and child health

Average staffing 5,000 entrepreneurs Malaria

Outlet types Physical outlets not utilized Tuberculosis

Number of clients served in 2009 201,000 through partners; 25,000 through direct channels

Eye screening and glasses provision ●

Average clients/outlet

Payment sources OOP

2009 program expenditure (USD) $171,000

Donor support (USD)

BlackRock: $25,000Allergan Foundation.: $2,500Johnson & Johnson: $50,000The International Foundation.: $15,000

Contact information Sean Mayberry, Chief Operating Officer www.visionspring.org

El Salvador and India

VisionSpring

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Clinical Social Franchising, 201021

Description

El Salvador and India

VisionSpring

BackgroundVisionSpring trains local entrepreneurs in developing mar-kets to screen individuals and distribute reading glasses and sunglasses through their Business in a Bag. Vision-Spring addresses the market failure that leaves 500 million people in the world without access to affordable glasses.

Service detailsEye screening and glasses provision

Community health workersVisionSpring employs Vision Entrepreneurs, and they re-ceive approximately $1 on a $5 pair of eyeglasses.

inventory management• Stock reports• Stock cards• Computer-based inventory management system

TechnologyWeb-based reporting

Successes• With the Business in a Bag model, the entrepreneur has

everything s/he needs to run a successful business.• Since presbyopia is something that affects a high

percentage of those over 35 throughout the world, this franchise model can be easily replicated and brought to different developing markets.

Challenges• Providing a sustainable business opportunity for Vision

Entrepreneurs with few products in their basket to sell. • With a primary focus on a low-turnover product like

eyeglasses, the model runs the risk of market saturation for the entrepreneur.

• Awareness of the need for the product remains low in most developing countries, requiring greater investment in field marketing to raise both supply and demand.

Future plans• Creation of a more efficient partner engagement model

which should facilitate faster and more profitable scaling • New Products: photochromics (lenses that change shade

depending on amount of sunlight) and eye drops• Expansion to Indonesia and Brazil

innovationsTesting the viability of having an optometrist available on a bi-monthly basis at a central location to treat patients who have vision problems beyond presbyopia.

VisionSpring entrepreneur testing glasses on patient

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Clinical Social Franchising, 201022

At a glance

Franchise details Services

Timeline Pilot in 2007 with FP services. Medical and sur-gical abortion services started in January 2009. Will launch HCT/STI management services in some clinics in April 2010.

Family planning

USAID calculation 29,443 CYP MSI/DKT calculation 45,915 CYP

Location Amhara, Oromia and SNNP regional states (3 of 8 states)

Other sexual and reproductive health ●

Business model Fractional franchise; annual franchise fee of $3.70–11.10 USD (based on clinic size)

HIV/AIDS

Target clientele Low-income women, sex workers and clients, long distance truck drivers, military

Maternal and child health

Average staffing The minimum number of professionals in lower clinics is 2, while it is 3 and 6 for medium and higher clinics respectively.

Malaria

Outlet types 205 clinics, 2 hospitals Tuberculosis

Number of clients served in 2009 118,919

Average clients/outlet 574

Payment sources OOP, voucher

2009 program expenditure (USD) $490,038

Donor support Anonymous donor

Contact information Girma Mintesnot, Social Franchise Manager www.mariestopes.org

Ethiopia

marie Stopes international ethiopiaBlueStar healthcare network

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Clinical Social Franchising, 201023

Description

Ethiopia

marie Stopes international ethiopiaBlueStar healthcare network

BackgroundBlueStar Ethiopia provides franchised services including the provision of long-term FP methods, permanent FP methods and medical and safe surgical abortion services. Some of the clinics will soon provide HIV testing and STI diagnosis services.

Service detailsOral contraceptives, condoms, injectables, Copper T, im-plants, emergency contraceptive pills, sterilization, abortion (medical and surgical)

licensingThe Drug Administration and Control Authority

Community health workersInvolvement of CHWs is in a pilot phase

Job aids• BlueStar pictorial teaching aid• Global Hand Book for Providers (FP)• Internal audit checklists

inventory managementPhysical stock counts

TechnologyTelephone reporting

Successes• BlueStar Ethiopia is considered the first to offer long-

term and permanent FP methods in the private sector.• The provision of training on medical abortion and safe

surgical abortion services in private clinics.

Challenges• Because franchisees were not previously offering long-

term FP methods, training has taken a long period of time.

• The misconceptions about FP, and lack of awareness about the availability of services in the private sector

• Because long-term FP services are provided for free in government health facilities, BlueStar reduces the cost of delivering FP supplies to the franchisees to enable fran-chisees to provide services at a reduced price to attract business and make a profit.

Future plans• The program is planning to integrate HCT/STI testing

and diagnosis services in some of the BlueStar clinics and in some other private facilities.

• Geographic expansion is planned to the Afar regional state, Addis Ababa and Dire Dawa.

Family planning client in consultation with BlueStar provider

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Clinical Social Franchising, 201024

At a glance

Franchise details Services

Timeline Launched in March 2008 Family planning

MSI/DKT calculation 16,293 CYP

Location 1 out of 10 regions Other sexual and reproductive health ●

Business model Fractional franchise; annual franchise fees from $28–69 USD based on outlet type

HIV/AIDS

Target clientele Low income Maternal and child health

Average staffing 1–10 staff per clinic Malaria

Outlet types 25 clinics, 16 pharmacies, 19 chemical sellers Tuberculosis

Number of clients served in 2009 36,451

Average clients/outlet 608

Payment sources OOP

2009 program expenditure (USD) $278,395

Donor support (USD) Anonymous donor: $222,966

Contact information Senanu Arkutu, Social Franchising Managerwww.mariestopes.org

Ghana

marie Stopes internationalBlueStar ghana

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Clinical Social Franchising, 201025

Description

Ghana

marie Stopes internationalBlueStar ghana

BackgroundBlueStar is a private provider network made up of materni-ty homes, pharmacies and chemical shops. The outlets are trained to deliver FP and sexual and reproductive health services to their communities.

Service detailsOral contraceptives, condoms, vaginal foaming tablets, injectables, implants, abortion (medical and surgical)

licensingMidwives: by Midwives Association (Ghana Health Service) Pharmacies: by Pharmacy Council

Community health workersCHW program is currently being developed. Each clinic outlet aims to have ten CHWs. CHWs will include hairdress-ers, dressmakers, students, etc. who talk to clients and refer to designated outlets. CHWs will be paid for each effective referral.

Job aids• FP flipcharts• Labels for waste and emergency drugs

Successes• Demand creation events• Reaching low-income population through pharma-

cies and chemical shops (as these are the first point of contact)

Challenges• Providers changing their minds about providing abortion

services• Outlet staff turnover• Staff leaving after being trained by Marie Stopes

Pharmacist Akua Afi Ampofo greets clients outside BlueStar Ghana pharmacy

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Clinical Social Franchising, 201026

At a glance

Franchise details Services

Timeline Launched in 2009 Family planning

USAID calculation 104 CYP MSI/DKT calculation 112 CYP

Location Ghana and Uganda Other sexual and reproductive health ●

Business model 25% full franchise, 75% fractional franchise; an-nual franchise fee of $1000 USD

HIV

Target clientele No target groups Maternal and child health ●

Average staffing 3 nurses, 1 medical assistant,1 pharmacist, 1 midwife and 7 other staff per clinic

Malaria ●

Outlet types 4 clinics, 200 hospitals, 10 pharmacies Tuberculosis ●

Number of clients served in 2009 3,900 per clinic location

Average clients/outlet 3,900 Diarrheal disease treatment, vitamins, lab services, pneumonia testing/treatment

Payment sources 30% OOP, 10% insurance, 60% government reimbursement

2009 program expenditure (USD)

Donor support

Contact information Kojo Benjamin Taylor, President www.microclinics.com

Ghana and Uganda

microClinic international

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Clinical Social Franchising, 201027

Description

Ghana and Uganda

microClinic international

BackgroundFollowing a franchise business model that combines own-ership with proven operating, marketing and distribution standards, MicroClinic empowers community health nurses to own and grow their own MicroClinic.

Service detailsOral contraceptives, STI testing, ANC, labor and deliv-ery, post-natal care, vaccinations, pediatric consultations, malaria testing/treatment, insecticide-treated nets, TB case management, diarrheal disease management, lab services, vitamins, pneumonia testing/treatment

licensingThe government health education system

Job aidsStandard of care disease protocol resource manual

inventory management• Stock reports by outlet• Computer-based inventory management system• Inventory management training

• Physical stock counts• Refrigerators• Locked/secured storage rooms

TechnologyTelephone hotline/counseling

Successes• Enforcement of system standards• Establishment of a third-party payment system

Challenges• Traditional franchise business model is new to sub-Saha-

ran Africa, so educating policy makers is a crucial part of the enterprise.

• Entrepreneurship training and customer service are not emphasized in the healthcare education system, so MicroClinic has had to develop more elaborate training programs than anticipated.

Future plansBlood chemistry analysis

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At a glance

Franchise details Services

Timeline Launched in 2007 Family planning

Location 2 out of 28 states Other sexual and reproductive health

Business model Full franchise; one-time licensing fee HIV/AIDS

Target clientele Rural community Maternal and child health ●

Average staffing 1 doctor, 1 midwife, 1 nurse and 1 clinical officer per kiosk

Malaria

Outlet types 43 kiosks Tuberculosis

Number of clients served in 2009 8,000+ General medicine, lab services, vitamins

Average clients/outlet 186

Payment sources OOP

2009 program expenditure (USD) $1.8 million on all franchise activities, of which 10% was spent on health franchising

Donor support

Contact information Dr. Minal Singh, Area Controller-Health www.drishtee.com

India

drishtee development & Communication ltd.drishtee health Franchise

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Clinical Social Franchising, 201029

Description

India

drishtee development & Communication ltd.drishtee health Franchise

BackgroundFemale health franchisees are trained to work as Drishtee Health Franchisees (DHFs) at each cluster of villages on defined routes. The DHFs are trained in basic emergency care, non-invasive diagnostic and path tests and in busi-ness skills. DHFs are linked with qualified Bachelor of Medi-cine and Bachelor of Surgery (MBBS) doctors.

Service detailsPediatric consultations, gynecologist consultations, general medicine, lab services, vitamins

inventory managementComputer-based inventory management system

TechnologyTelephone/hotline counseling

Successes• The success of the model is directly related to the own-

ership of the DHF towards the outlet, quality of health services provided and the promotion of the services.

• If the location of the health outlet is remote, the utiliza-tion of the services is higher.

ChallengesEducating villagers about common diseases and their proper treatment since villagers trust the quacks/traditional healers who have been practicing in the villages for years.

Future plansThe Maternal Health Care program has generated demand for proper and timely maternal care. In the future, this program will be combined with the provision of maternal care in the form of check-ups within the villages at Drishtee Health Kiosks.

Drishtee Health Franchisees at a training

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Clinical Social Franchising, 201030

At a glance

Franchise details Services

Timeline Launched in 2007 Family planning

USAID calculation 24,975 CYP MSI/DKT calculation 34,114 CYP

Location 35 out of 70 districts in Uttar Pradesh Other sexual and reproductive health

Business model 30% full franchise, 70% fractional franchise; royalty after first year

HIV

Target clientele Low income, migrants/refugees, women, children

Maternal and child health ●

Average staffing 10–15 per clinic (doctors, nurses, medical as-sistants, chemical sellers, midwives)

Malaria

Outlet types 220 clinics, 35 hospitals, 6,000 Merry Tarang Tuberculosis

Number of clients served in 2009 417,000

Average clients/outlet 67

Payment sources OOP, insurance, government reimbursement, vouchers (services are subsidized for voucher holders)

2009 Program expenditure (USD) $630,000

Donor support $1.05 million in USAID through SIFPSA (State for Innovations for Family Planning Services Agency)

Contact information Mr. Sharad Agarwal, State Director UP; Mr. Birender Kumar, Team Leader www.hlfppt.org

India

hindustan latex Family planning promotion Trust (hlFppT)merrygold

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Clinical Social Franchising, 201031

Description

India

hindustan latex Family planning promotion Trust (hlFppT)merrygold

BackgroundHindustan Latex Family Planning Promotion Trust (HLFPPT) works with partners pioneering innovations for improving the health of the poor. The social franchising project in Ut-tar Pradesh (UP) aims to create a sustainable public-private partnership in healthcare for the low income, working class and poor by developing a sustainable network of franchised hospitals (MerryGold Hospitals) offering quality reproductive child health services at pre-fixed prices.

Service detailsOral contraceptives, condoms, Copper T, sterilization, ANC, clean delivery kits, labor and delivery, post-natal care

licensingThe staff members are not accredited individually, but hospitals and clinics are accredited by the Chief Medical Officer of the District. The units are accredited by various government schemes like Rogiswasthya Beema Yojana and Sobhagyawati Yojana.

Community health workersCHWs are used and are involved in a referral gift scheme for motivation

Job aids• Manuals: obstetric, FP, infection prevention, basic new-

born care, emergency newborn care • Posters on infection control and waste management (in

Hindi)

inventory management• Stock reports by outlet• Physical stock counts

• Refrigerators • Locked/secured storage rooms

TechnologyTelephone hotline/counseling

Successes• Strong brand image associated with quality• Attitude change in service providers towards safe deliv-

ery promotion and preventive health• Integrated platform for promoting MCH through various

modes, and options like direct paying clients

Challenges• Identification and selection of franchisees with desired

qualifications• Maintaining attendance during training sessions, as doc-

tors are reluctant to leave their practice • Conversion of knowledge into practice, as the staff attri-

tion rate at private hospitals/nursing homes is high• 80% of beneficiaries are from a rural background—trans-

port in itself is a challenge

Future plans• Integrating the safe motherhood initiatives with PMTCT• Upgrading the services to other gynecological treat-

ments like infertility• Expanding infant care to pediatric care

innovationsCall center for clients, franchisees and other stakeholders available 24 hours a day

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At a glance

Franchise details Services

Timeline Launched in July 2008 Family planning

USAID calculation 437,945 CYP MSI/DKT calculation 749,888 CYP

Location 3 out of 28 states Other sexual and reproductive health ●

Business model Fractional franchise HIV/AIDS

Target clientele Low income, men, women Maternal and child health

Average staffing At least 1 doctor, some clinics also have a nurse Malaria

Outlet types 1,000 clinics Tuberculosis

Number of clients served in 2009

Average clients/outlet

Payment sources OOP, free

2009 program expenditure (USD)

Donor support

Contact information Sanjeev Dham, Director of Programs www.psi.org

India

population Services internationalSaadhan

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Clinical Social Franchising, 201033

Description

India

population Services internationalSaadhan

BackgroundTo improve maternal health, PSI India harnesses private qualified gynecologists and doctors with gynecology prac-tices through its Saadhan network. The members of the network are private practitioners providing health services to urban and peri-urban women.

Service detailsCondoms, Copper T, injectables, medical abortion

licensingEducational degrees and registration numbers (with Medi-cal Council of India) are verified by program staff before including them in the network. Most of the doctors are also members of the Federation of Obstetric and Gynecological Societies of India (FOGSI).

Community health workersCHWs serve as interpersonal communicators, who make house-to-house visits in the target area to provide IUD counseling and referrals to network doctors.

Job aids• Manuals and handbook containing minimum quality

standards• Checklist for IUD counseling and insertion/removal• Checklist for instrument processing• Posters on IUD insertion steps • Poster on instrument processing• Manual on medical abortion• Poster on medical abortion• Pictorial client information booklet in prepackaged

medicines kit, called Safe Abort, for medical abortion

inventory managementStock cards

TechnologyTelephone hotline/counseling

Successes• Working with already existing private providers—the

outlets are perceived as providers of quality services and the providers are already well trained in IUD and medical abortion skills.

• The partnership with FOGSI enhances the visibility of the program, encourages doctors to join the network and helps to increase standards for quality related to IUD and medical abortion services.

Challenges• Changing historically negative perceptions about IUDs• Lack of spousal support is a barrier to adoption of IUDs• Discontinuation by IUD users • Working with private providers who are motivated by

profits• Educating chemists on medical abortion drugs

Future plansExpansion of injectables in the network clinics of Delhi and Uttar Pradesh

innovationsOn-site demonstration of infection prevention measures by program staff. These visits help the network doctors in supervised practice sessions of IUD insertion on a pelvic model, using the infection prevention measures.

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At a glance

Franchise details Services

Timeline Launched in 2008 Family planning

USAID calculation 84,757 CYP MSI/DKT calculation 113,559 CYP

Location 3 districts in Western Uttar Pradesh and 1 dis-trict in Madhya Pradesh

Other sexual and reproductive health ●

Business model Fractional franchise HIV/AIDS

Target clientele Low income, women Maternal and child health

Average staffing 1–3 doctors, 1–5 nurses per clinic and 1 visiting midwife, 3 technicians at diagnostic centers

Malaria ●

Outlet types 16 clinics, 1,400 chemical sellers, 127 telemedi-cine centers, 1,339 rural referral centers

Tuberculosis

Number of clients served in 2009 Telemedicine Provision Centers: 12,756 (consul-tation through Central Medical Facility); fran-chised clinics: 7,490 ( family planning services)

Average clients/outlet

Payment sources OOP, free sterilization services during camps (Profits from some services to people above poverty line are used to offset cost of services to people below poverty line.)

2009 program expenditure (USD) $2,200,000

Donor support (USD) Anonymous donor: $3 million

Contact information Gopi Gopalakrishnan, Project Director www.worldhealthpartners.org

India

World health partnersSkyhealth rural Clinics

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Clinical Social Franchising, 201035

Description

India

World health partnersSkyhealth rural Clinics

BackgroundWorld Health Partners runs four mutually beneficial franchisee networks, which are also linked to shops and medical specialists. Providers earn profits by providing care or facilitating care at a higher level. The franchisees earn profits by delivering curative care but also have to deliver a mandated quantum of preventive services which are not commercially viable.

Service detailsOral contraceptives, condoms, injectables, Copper T, emergency contraceptive pills, sterilization, abortion (medi-cal and surgical), malaria testing

licensingThree of the medical clinics are government-accredited.

Community health workersA public sector nurse-midwife visits the village centers to provide paramedical care in person or in tele-consultation with a town-based doctor

Job aids• Medical algorithms• Instrument sterilization procedures• Post-abortion care guides

inventory management• Stock reports by outlet• Computer-based inventory management system• Physical stock counts

Technology• Telemedicine• SMS client follow up• SMS reporting

• Web-based reporting• Telephone hotline/counseling

Successes• By identifying private providers on the basis of skill levels

and location, and breaking down service provision into various components, the project delivers some compo-nents locally and others through a physical and virtual referral or consultation process.

• Using disparate elements of the public sector ensures a continuum of care and generates an immediate client response.

• Informal providers are easier to franchise because they are more open to following standards than doctors are.

ChallengesLack of facilities makes training difficult.

SkyHealth Rural Clinics clinic

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Clinical Social Franchising, 201036

At a glance

India

dKT international/JananiSurya

Franchise details Services

Timeline Launched in 1995 Family planning

USAID calculation 905,820 CYP MSI/DKT calculation 1,371,734 CYP

Location 2 out of 28 states—Bihar & Jharkhand Other sexual and reproductive health ●

Business model Fractional franchise HIV

Target clientele Low income, youth, sex workers and clients, truck drivers, migrants/refugees, military, men, women

Maternal and child health

Average staffing 10 per clinic (doctors, nurses, medical assis-tants, lab techs, counselors, etc)

Malaria

Outlet types Chemists/pharmacists: 50,000 in Bihar and 8,000 in Jharkhand Clinics: 36 own clinics and 60 franchisee clinics

Tuberculosis

Number of clients served in 2009

Average clients/outlet

Payment sources OOP, government reimbursement, free

2009 Program expenditure (USD) $456,990

Donor support

Contact information S.P. Bose, Program Directorwww.janani.org

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Clinical Social Franchising, 201037

Description

India

dKT international/JananiSurya

BackgroundJanani’s operational framework includes 1) its own clinics which provide clinical FP services, and 2) franchisee clinics, chemists/pharmacists and rural providers who create access to products and services for village communities.

Service detailsOral contraceptives, condoms, injectables, Copper T, emer-gency contraceptive pills, sterilization, abortion (medical and surgical)

licensingAccredited under the District Health Society under the Public Private Partnership of the National Rural Health Mission (NRHM)

Community health workersThe Surya Health Promoters work as the first point of con-tact for the community. They advise and counsel the clients on the range and usefulness of available contraceptives.

Job aids • Contraception Technology • Handbook on Family Planning• Call Admission Control (CAC) Protocol• Government Guideline for Male and Female Sterilization• NSV (no-scalpel vasectomy) for Male Sterilization• Minilaprotomy for Female Sterilization Guideline• Medical Termination of Pregnancy Act—2009

inventory management• Stock reports by outlet• Stock cards at franchisee outlets• Computer-based inventory management system• Inventory management training• Physical stock counts• Refrigerators• Locked/secured storage rooms

Successes• Providing high-quality FP services • Providing services free of cost, making them more widely

accessible• Stationing the Surya Health Promoters at the village

level, making it convenient for the clients to access infor-mation about the services being provided

Challenges• Identification of requisite number of health providers • Accreditation under the NRHM for the franchisee clinics• Behavioral change of the community towards contraception

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Clinical Social Franchising, 201038

At a glance

Kenya

marie Stopes internationalamua

Franchise details Services

Timeline Launched in 2004 Family planning

USAID calculation 116,597 CYP MSI/DKT calculation 155,308 CYP

Location 3 out of 7 provinces (Nyanza, Rift valley, Western) Other sexual and reproductive health

Business model Full franchise; annual franchise fee of $35 USD HIV ●

Target clientele Low income, men, women, youth Maternal and child health ●

Average staffing 2 medical assistants and 1 clinical officer per clinic

Malaria

Outlet types 186 clinics Tuberculosis

Number of clients served in 2009 157,103

Average clients/outlet 845

Payment sources 100% OOP

2009 Program expenditure (USD)

Donor support KfWVenture StrategiesUNFPA

Contact information Walter Odhiambo, Deputy Country Directorwww.mariestopes.org

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Clinical Social Franchising, 201039

Description

BackgroundAMUA is a fractional social franchise currently made up of 186 privately owned and operated clinics. AMUA is imple-mented on behalf of the Government of Kenya by Marie Stopes Kenya with funds from the German Development Corporation (KfW). AMUA franchisees operate in peri-urban and rural areas of five strategically selected zones where Kenya DHS data indicate higher fertility and unmet need for FP. The majority of franchisees comprise small, stand-alone medical clinics that are owned and operated by a licensed nurse and staffed by a few other health workers.

Service detailsOral contraceptives, condoms, injectables, Copper T, implants, sterilization, HCT, labor and delivery, emergency obstetric care

Community health workersAMUA currently works with 350 CHWs. The CHW model is:

• 2 individuals assigned per franchisee• CHWs receive branded materials, pictorial aids, bicycles • For other FP services, incentives are negotiated and paid

individually by franchisees.

inventory managementStock reports by outlet

TechnologySMS reporting (planned)

Successes• Improving private-public partnership with the Ministry

of Health. AMUA franchisees are now recognized by the government and are able to source FP commodities from the Ministry stores.

• Use of already recognized CHWs• Demand generation activities

Challenges• The inability to recruit medical doctors due to low inter-

est in FP• AMUA staff reported having to provide significant sup-

port in order to bring franchisees up to quality stan-dards.

• Client inability to pay private sector fees • Government facilities offer a comparable range of ser-

vices at no cost to the user. • Healthcare market saturated with private sector provid-

ers, including providers at other social franchises• High staff turnover at larger facilities such as hospitals

and maternity homes• Regulating service fees actually charged by the providers

Kenya

marie Stopes internationalamua

AMUA clinic

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At a glance

Kenya

Family health internationalgold Star network

Franchise details Services

Timeline Launched in 2006 Family planning

USAID calculation 8,850 CYP MSI/DKT calculation 11,167 CYP

Location 4 out of 8 provinces Other sexual and reproductive health

Business model Fractional franchise; annual fee of $47 HIV ●

Target clientele Employed persons and business people who can pay for part of their healthcare costs

Maternal and child health

Average staffing 5 staff per outlet (doctors, nurses, medical as-sistants, pharmacists, clinical officers)

Malaria

Outlet types 393 clinics, 57 hospitals, 13 pharmacies, 17 labs, 9 nursing homes

Tuberculosis

Number of clients served in 2009 109,567

Average clients/outlet 232

Payment sources 50% OOP, 20% insurance, 30% free antiretroviral therapy (ART)

2009 Program expenditure (USD) $180,118 (program activities only)

Donor support USAID: $513,520

Contact information Dr. Margaret Kaseje, Director, Program Supportwww.goldstar-network.org

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Clinical Social Franchising, 201041

Description

Kenya

Family health internationalgold Star network

BackgroundThe Gold Star Network (GSN) is a private-sector HIV care and treatment program executed in collaboration with the Ministry of Health, Kenya Medical Association, Kenya Clini-cal Officers Association and Pharm Access Africa Limited. This project is a private healthcare and financing model that involves training accredited doctors in private clinics, nursing homes, mission and for-profit hospitals and work-place health centers to provide safe and affordable ART. While the network was originally established to provide HIV care and treatment, family planning services have been added.

Service detailsOral contraceptives, condoms (male and female), inject-ables, Copper T, implants, natural family planning, steriliza-tion, PMTCT, HCT, ART, opportunistic infection manage-ment

licensingThe providers are accredited and given a certificate with NASCOP (National AIDS and STI Control Programme) serialization.

Job aids• Guidelines to ARV Therapy in Kenya• National Home-Based Care Programme and Service

Guidelines (summary)• National Condom Policy and Strategy• National Guidelines for Voluntary Counseling and Testing• National Guidelines for PMTCT• Guidelines for HIV Testing in Clinical Settings• Handbook on Pediatric AIDS in Africa• Kenyan National Clinical Manual for ARV providers, a

concise and practical guide to ARV provision

inventory management• Stock reports by outlet• Physical stock counts

Technology• Telemedicine• Telephone hotline/counseling• SMS client follow up• SMS reporting• Web-based reporting• Emails

Successes• Strong brand presence and unique brand positioning—its

positioning has allowed GSN to tap into a niche (private sector patients who can pay some or part of the cost)

• Workplace program—GSN carries out numerous work-place sensitization and HCT activities. From these activi-ties, clients are referred to GSN sites or alternatively, GSN trains workplace and clinic healthcare providers

Challenges• Marketing/brand promotion has never been a forte for

NGOs such as GSN. At the funding level it is difficult to justify this cost center.

• Geographical challenges—GSN facilities are scattered. To collect lab samples and deliver them in good time/condition to labs is often a challenge. By partnering with strategic partners e.g. the AIDS, Population and Health Integrated Assistance II, GSN has been able to access motorcycle courier facilities to ease the problem. How-ever, the coverage is still low and occasionally samples/drugs are delivered late.

Future plansExpansion of services to cover: TB, FP/RH, MCH and malaria treatment

innovationsPartnerships with insurance companies—GSN is working on strategies to partner with insurance companies in the provision of HIV treatment services. Being a registered non-profit organization, GSN is unable to accept monies from companies and individuals. To remedy that issue, GSN will become an incorporated company.

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Clinical Social Franchising, 201042

At a glance

Franchise details Services

Timeline Launched in December 2008 Family planning

USAID calculation 62,521CYP MSI/DKT calculation 94,880 CYP

Location 7 out of 8 provinces Other sexual and reproductive health

Business model Fractional franchise; annual franchise fee of $13 USD

HIV

Target clientele Low income, men, women Maternal and child health

Average staffing 2 staff per clinic (majority of clinics in network are owned by nurses and operated by one nurse or nurse-midwife)

Malaria

Outlet types 184 clinics Tuberculosis

Number of clients served in 2009 16,227 IUDs and 1,636 implants

Average clients/outlet 97

Payment sources OOP, vouchers

2009 program expenditure (USD) $1,400,000

Donor support (USD) Anonymous donor (approximately $340,000)

Contact information Joyce Wanderi, Deputy Director, RH Marketingwww.psi.org

Kenya

population Services internationalTunza Family health network

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Clinical Social Franchising, 201043

Description

Kenya

population Services internationalTunza Family health network

BackgroundThe Tunza Family Health Network is a fractional franchise that is made up largely of nurses and a few clinical officers. PSI Kenya provides standards, service delivery protocols, provider training and supportive supervision for long-term FP methods. Tunza is a Kiswahili word meaning "to nurture or care for."

Service detailsCopper T, implants

licensingNurses are accredited by the Nursing Council of Kenya. Clinical officers are certified by the Clinical Officers Council. For both cadres, the license to operate a private clinic is from the Medical Practitioners and Dentists Board.

Community health workers• Each clinic has one–two community mobilizers who mo-

bilize women in their communities to attend FP educa-tional sessions conducted by PSI/Kenya.

• CHWs refer women to franchise clinics using a referral card and hold educational sessions.

• CHWs are paid for organizing and conducting the ses-sions and for any successful referrals for IUDs.

Job aidsA variety of job aids including the Quick FP Methods Refer-ence Guide (a small booklet used by mobilizers in case they forget a point while mobilizing)

inventory managementStock reports by outlet

TechnologySMS reporting

Successes• Strong private sector in Kenya makes recruitment of

qualified providers relatively easy

• Support from the MOH• Community mobilization and education through small

groups of women

Challenges• The deeply entrenched myths and misconceptions about

long-term FP methods• The adjustment to a newly introduced SMS-based

reporting system that is expected to replace paper reporting

Future plansIntegration of other services into the network: PMTCT of HIV, HCT, voluntary medical male circumcision, diarrhea prevention, early diagnosis and treatment of pneumonia

innovationsSMS-based reporting system that ensures real-time report-ing on service uptake of IUDs, complications/adverse events related to IUDs and implants, implant removals and reasons for removal

Registration of patients at a Tunza clinic

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Clinical Social Franchising, 201044

At a glance

Franchise details Services

Timeline Network was fully operational in December 2009; official launch in February 2010

Family planning

USAID calculation 899 CYP MSI/DKT calculation 1,303 CYP

Location 6 out of 22 regions Other sexual and reproductive health ●

Business model Fractional franchise; annual franchise fee of $20 USD

HIV/AIDS

Target clientele Low income, women Maternal and child health

Average staffing 1 doctor per clinic Malaria

Outlet types 71 clinics Tuberculosis

Number of clients served in 2009 1,765

Average clients/outlet 25

Payment sources 90% OOP, 10% token free week

2009 program expenditure (USD) $300,000

Donor support MSI

Contact information Ranja Chrys Rakotomahanina, Social Franchis-ing Director www.mariestopes.org

Madagascar

marie Stopes internationalBlueStar madagascar

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Clinical Social Franchising, 201045

Description

Madagascar

marie Stopes internationalBlueStar madagascar

BackgroundBlueStar is a fractional franchise comprised of doctors who are already practicing. Marie Stopes Madagascar builds their capacity to deliver high-quality sexual and reproduc-tive health services, focused on long-term FP methods. Fanchisees are located in peri-urban and rural areas.

Service detailsOral contraceptives, condoms, injectables, Copper T, im-plants, post-abortion care

Community health workersCHWs develop informed demand within the community by doing interpersonal communication through household visits and small-group sensitization. They are incentivized by client referrals and service uptake.

Job aids• Operation manual• Training manual

inventory management• Stock reports by outlet• Arrangement of stock by FIFO/FEFO• Inventory management training

TechnologyIn mid-2010 an SMS client follow-up and reporting system, coupled with a hotline and web-based reporting will be implemented.

Successes• Co-branding with local MSI chapter• Focus on long-term contraceptive methods• Strong public and private partnership (Ministry of Health,

National Board of Doctors)

Challenges• Finding private doctors in rural and peri-urban zones, as

there are fewer than 700 accredited doctors nationwide • To achieve national impact, a wide geographic area is

covered, which is difficult for the monitoring and evalua-tion team.

• The 2009 political crisis made the implementation phase longer than expected due to administrative red tape and changes in key government decision makers.

Future plansExpansion to 14 regions and to 200 members by the end of 2010. By 2011, the majority of members will offer the full range of sexual and reproductive health services.

BlueStar Madagascar launch

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Clinical Social Franchising, 201046

At a glance

Franchise details Services

Timeline Launched in 2009 Family planning

USAID calculation 53,200 CYP* MSI/DKT calculation 81,718 CYP*

Location 26 out of 116 districts Other sexual and reproductive health ●

Business model Fractional franchise HIV/AIDS

Target clientele Low income, women Maternal and child health

Average staffing 1.3 staff per clinic (doctors, nurses, midwives) Malaria

Outlet types 68 clinics Tuberculosis

Number of clients served in 2009 15,206 clients served with long-term methods (LTMs)

Average clients/outlet 224

Payment sources 40% OOP, 60% vouchers, free services at public sector franchised clinics

2009 program expenditure (USD)

Donor support Anonymous donor, in cost share with USAID

Contact information Brian McKenna, Country Representativewww.psi.org

Madagascar

population Services internationalproFemina

* Excludes services not tracked at the franchise level

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Clinical Social Franchising, 201047

Description

Madagascar

population Services internationalproFemina

BackgroundProFemina serves all women of reproductive age, in urban and rural areas. The network consists of public, liberal sec-tor centers (independent doctors) and NGO partners. The main mission of this program is to create demand for FP while also serving the RH needs of target populations.

Service detailsOral contraceptives, condoms (male and female), inject-ables, Copper T, implants, natural FP, STI treatment

licensingAll outlets are authorized to practice under local law, and are certified through PSI and its partner organization Jhpiego.

Community health workers• CHWs educate community members, hold community

events, offer referrals to the franchised clinics and sup-port follow-up care in collaboration with the provider.

• They receive a fixed salary in urban areas, and fixed in- kind compensation in rural areas. Up to 11% of their pay can include performance-based compensation, based on both qualitative and quantitative criteria.

Job aids• Infection prevention, counseling, LTM insertions• Service provision reference guides• Complication management job aids developed for the

franchise network• Client screening checklist• WHO eligibility wheel• Anatomical models• Information Education and Communication (IEC) materials

inventory management• Stock reports by outlet• Stock cards at franchises• Computer-based inventory management system• Physical stock counts• Arrangement of stock by FIFO/FEFO

Successes• The “canalization”strategy provides a safe, sustainable

and cost efficient approach (with a first-tier franchised fixed site provider offering RH services on a regular ro-tating basis at second-tier remote non-franchised sites).

• Using private sector providers (mostly in urban areas) and public sector providers where the private sector is not developed enough, allows for a more sustainable intervention strategy while maximizing reach.

Challenges• Conforming to quality assurance standards by private

sector providers • Maintaining providers’ motivation over time requires that

their expectations be regularly monitored and adjust-ments be made to fulfill them. PSI is currently conduct-ing a provider survey on the determinants of productivity for LTM service provision specifically.

Future plans• Expansion of the franchise to other sites• Expansion of the “canalization” strategy• MCH services • Other RH services being considered: cervical cancer

detection and prevention, emergency contraception

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Clinical Social Franchising, 201048

At a glance

Franchise details Services

Timeline Launched in 2001 Family planning

USAID calculation 15,156 CYP MSI/DKT calculation 15,970 CYP

Location 12 out of 116 districts Other sexual and reproductive health ●

Business model Fractional franchise; annual franchise fee of $3 USD

HIV/AIDS ●

Target clientele Low income, sex workers and clients, youth, truck drivers, military personnel, men who have sex with men

Maternal and child health

Average staffing 1 doctor per clinic Malaria

Outlet types 135 clinics Tuberculosis

Number of clients served in 2009 140,140

Average clients/outlet 1,038

Payment sources 75% OOP, 25% vouchers

2009 program expenditure (USD)

Donor support (USD) $625,000

Contact information Brian McKenna, Country Representativewww.psi.org

Madagascar

population Services internationalTop réseau

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Clinical Social Franchising, 201049

Description

Madagascar

population Services internationalTop réseau

BackgroundTop Réseau aims to improve access to reproductive health services among vulnerable groups, particularly youth. Locations are selected based on 1) epidemiological and behavioral data on reproductive health, 2) the number and interest of private sector providers who could become po-tential franchise members and 3) a strategic location with large at-risk populations.

Service detailsOral contraceptives, condoms, injectable, STI treatment, HCT

licensingAccredited through the government

Community health workersPeer educators sensitize target groups and make referrals to franchised clinics.

Job aids• Flipchart to guide syndromic management of STIs and

FP counseling• Algorithm on HIV test• STI prevention kits• Partner referral cards

inventory management• Stock reports by outlet• Stock cards at franchises• Computer-based inventory management system• Physical stock counts• Arrangement of stock by FIFO/FEFO

TechnologyWeb-based reporting for VCT services

Successes• Top Réseau network was integrated into existing health

facilities which offer the normal range of primary care• Integration of HIV and FP services• Integrated communication campaign (mass media, mo-

bile video unit and interpersonal communication)

ChallengesImplementation of quality assurance plan in the private/liberal sector

Future plansExpansion of HCT services to other sites

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Clinical Social Franchising, 201050

At a glance

Franchise details Services

Timeline Launched in 2008 Family planning

USAID calculation 7,873 CYP MSI/DKT calculation 10,285 CYP

Location 12 out of 28 districts Other sexual and reproductive health

Business model Fractional franchise; annual franchise fee of $70 USD

HIV/AIDS

Target clientele Low income, women Maternal and child health

Average staffing 1 nurse, 1 clinical officer and 2 other staff per clinic

Malaria

Outlet types 60 clinics Tuberculosis

Number of clients served in 2009 17,748

Average clients/outlet 296

Payment sources OOP

2009 program expenditure (USD)

Donor support MSI

Contact information Linda Edwards, Country Directorwww.banja.org.mw

Malawi

Banja la mtsogolo/marie Stopes internationalBlueStar malawi

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Clinical Social Franchising, 201051

Description

• Diversification of service provision at general medicine practices by including family planning methods

• Referral system established to refer tubal ligation clients to Banja La Mtsogolo centres

Challenges• Very few providers with skills to provide tubal ligations in

the current network• Persisting misconceptions surrounding IUDs in most

communities

Future plans• Scaling up in the central and northern regions of Malawi • Training more BlueStar community mobilizers

Malawi

Banja la mtsogolo/marie Stopes internationalBlueStar malawi

BackgroundFractional franchise of FP services in private clinics

Service detailsOral contraceptives, injectables, Copper T, sterilization

Community health workersCHWs are utilized and paid a fee per client referred.

inventory managementStock cards

Successes• Introduction and improvement of quality standards in

most clinics

BlueStar Malawi clinic

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Clinical Social Franchising, 201052

At a glance

Franchise details Services

Timeline Launched in 2005 Family planning

USAID calculation 2,776 CYP MSI/DKT calculation 3,132 CYP

Location Bamako only Other sexual and reproductive health

Business model 90% full franchise, 10% fractional franchise HIV/AIDS ●

Target clientele Women Maternal and child health

Average staffing 1 doctor, 2 nurses and 3 medical assistants per clinic

Malaria

Outlet types 53 clinics Tuberculosis

Number of clients served in 2009 5,598

Average clients/outlet 106

Payment sources OOP

2009 program expenditure (USD)

Donor support USAID

Contact information Boureima Maiga, Presponsable PF/Diarrhéewww.psi.org

Mali

population Services internationalproFam

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Clinical Social Franchising, 201053

Description

Mali

population Services internationalproFam

BackgroundProFam is a social franchise network with 53 private clinics which offer FP services in the district of Bamako.

Service detailsOral contraceptives, condoms, vaginal foaming tablets, injectables, Copper T, implants, natural FP, HCT

licensingMOH, Order Des Medecins

inventory managementStock reports by outlet

SuccessesPromotion of ProFam during vaccination meetings in private clinics

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Clinical Social Franchising, 201054

At a glance

Franchise details Services

Timeline Launched in 2001, RH: 2001, Malaria: 2003, STI: 2003; TB: 2004, Pneumonia: 2007, Diarrhea: 2009

Family planning

USAID calculation 255,754 CYP MSI/DKT calculation 313,473 CYP

Location 15 out of 17 states Other sexual and reproductive health ●

Business model Fractional franchise HIV/AIDS ●

Target clientele Low income, sex workers and clients Maternal and child health

Average staffing 1 doctor and 2 medical assistants per clinic Malaria ●

Outlet types 1,186 clinics Tuberculosis ●

Number of clients served in 2009 1,389,212 Diarrheal disease treatment, pneu-monia testing treatment

Average clients/outlet 1,171

Payment sources 88% OOP, 10% free (TB and VCT), 2% vouch-ers (vouchers mainly used for long-term FP methods)

2009 program expenditure (USD) $6,700,000

Donor support (USD) UNFPABill and Melinda Gates Foundation William and Flora Hewlett FoundationPackard FoundationUSAID Anonymous donorTotal contributed: $5,200,000

Contact information Dr. Nyo Nyo Minn, Franchising Director www.psi.org

Myanmar

population Services internationalSun Quality health

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Clinical Social Franchising, 201055

Description

Myanmar

population Services internationalSun Quality health

Background PSI Myanmar provides reproductive health products and services to low-income communities through the Sun net-work. The network consists of a first tier of private licensed general practitioners called Sun Quality Health (SQH). SQH clinics offer services in the following areas: reproductive health; TB; pneumonia; diarrhea; malaria and HIV including STIs. In July 2008, a Sun Primary Health (SPH) channel was launched to reach poor and vulnerable rural communities within a three-hour radius of an SQH clinic. SPH workers are a second tier of the Sun network and are trained on a range of health areas for which they sell subsidized products.

Service detailsOral contraceptives, condoms, female condoms, inject-ables, Copper T, implants, emergency contraceptive pills, STI treatment, ART, opportunistic infection management, malaria testing/treatment, insecticide-treated nets, KO tabs, TB case management, diarrheal disease treatment, pneumonia testing/treatment

licensingLicense to practice issued by the Government of Myanmar

Community health workersSPH workers refer clients to the SQH clinic for TB and IUD services. SPH workers keep the sales margin on the prod-ucts and are also paid up to $25 USD per month if they reach set criteria within the health areas.

Jobs aids/training• Counseling flipcharts• Infection prevention step by step poster• IUD insertion and removal posters

inventory management• Stock reports by outlet• Physical stock counts

Successes• Effective strategies for how to remove non-performers

from the network (dissociation)• Strong links with the government that is generally sup-

portive of engagement with the private sector and plays an instrumental role in addressing policy issues around de-medicalizing procedures

Challenges• Lack of documentation of the FP policy of Myanmar

results in different and confusing instructions at the local level.

Future plans• Postpartum hemhorrage prevention through use of

Misoprostol distributed through SPH workers• Screening for cervical cancer

Patient consultation at Sun Quality Health clinic

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Clinical Social Franchising, 201056

At a glance

Nepal

nepal CrS CompanySangini Social Franchising

Franchise details Services

Timeline Launched in 1994 Family planning

USAID calculation 372,642 CYP MSI/DKT calculation 419,712 CYP

Location 69 out of 75 districts Other sexual and reproductive health

Business model Fractional franchise HIV ●

Target clientele Truck drivers, military, women, low income, men Maternal and child health ●

Average staffing 2-3 staff per outlet Malaria

Outlet types 4,679 pharmacies, 2,684 tier-one outlets, 100 tier-two outlets

Tuberculosis

Number of clients served in 2009 121,838 Diarrheal disease treatment, water purification

Average clients/outlet 44

Payment sources

2009 Program expenditure (USD)

Donor support USAIDKfW

Contact information Mr. Krishna Bahadur Rayamajhi, Managing Directorwww.crs.org.np/sangini

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Clinical Social Franchising, 201057

Description

Nepal

nepal CrS CompanySangini Social Franchising

BackgroundIn 1994, with USAID support, Nepal CRS Company intro-duced social franchising of injectable contraceptives in Kathmandu Valley, through a network of pharmacies, under a local brand name called “Sangini-Tin Mahine Sui.” In the first year, Sangini was introduced through 50 trained and certified service providers (paramedics) in selected medi-cal shops of Kathmandu Valley. The social franchising of Sangini has now been expanded to 69 of 75 districts, and the total number of franchising outlets has reached 2,684, while sales went beyond 460,000 vials in the year 2009.

Service detailsOral contraceptives, condoms, injectables, Copper T, implants, emergency contraceptive pills, clean delivery kits, labor and delivery, emergency obstetric care, diarrheal disease treatment, water purification

licensingIn the private sector, paramedics are accredited by a local NGO called Nepal Fertility Care Centre.

Job aids• Informed choice poster• Clients' rights poster• Puncture-proof container• Screening checklist• Participants manual• Log book (clients’ record book)• ID cards

inventory management• Physical stock counts• Arrangement of stock by FIFO/FEFO

SuccessesStrong expansion geographically and also strong expan-sion of the number of outlets

Challenges• Expanding Sangini services to the remaining six districts

which encompass hard-to-reach areas• Conducting monitoring of hilly, hard-to-reach outlets

Future plansExpand Misoprostol distribution to five additional districts in hilly, hard-to-reach regions in the coming fiscal year

Nepal CRS medical shop

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Clinical Social Franchising, 201058

At a glance

Nigeria

Society for Family health (affiliate of pSi in nigeria)(Franchise name TBd)

Franchise details Services

Timeline Launching in second quarter of 2010 Family planning

USAID calculation 131,054 CYP MSI/DKT calculation 197,395 CYP

Location 20 out of 36 states Other sexual and reproductive health

Business model Fractional franchise; franchisees will pay annual fee

HIV

Target clientele Low income, men, women, youth Maternal and child health

Average staffing 5–6 per outlet (doctors, nurses, midwives, medi-cal assistants)

Malaria

Outlet types 60 clinics Tuberculosis

Number of clients served in 2009 37,444

Average clients/outlet 624

Payment sources 100% OOP

2009 Program expenditure (USD)

Donor support Anonymous donor

Contact information www.sfhnigeria.org

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Clinical Social Franchising, 201059

Description

BackgroundThe proposed franchise will include only private sector facilities which means that there will be a brand name (TBD). Providers will be certified and facilities will have standardized quality indicators. FP services will be offered. Sites will be evaluated based on the infrastructure in place, provider's attitude toward RH/FP services and willingness to ensure services are provided according to the recom-mended practices.

Service detailsCopper T, implants

licensingThe government accredits doctors, nurses and community health officers.

Community health workersTraditional birth attendants and CHWs will be used.

Job aids• PSI quality service delivery protocols• Jhpiego, Family Health International and Federal Minis-

try of Health protocols• Self designed protocols

inventory management• Stock reports by outlet• Physical stock counts• Arrangement of stock by FIFO/FEFO• Refrigerators• Locked/secured storage rooms

Successes• Having referrals in place for specialized care• FP is not an integral part of services in the private sector,

so adding this to the core service areas contributed to the providers' motivation

Challenges• Getting private sector providers to provide affordable

services and spend time on counseling • Managing services which do not pay much compared

to the more lucrative ones like ANC, immunization and malaria treatment

Future plans• Advertising of branded facilities and developing more

effective referral linkages for networking

Nigeria

Society for Family health (affiliate of pSi in nigeria)(Franchise name TBd)

Society for Family Health provider

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Clinical Social Franchising, 201060

At a glance

Nigeria

hygeia nigeria limitedhygeia

Franchise details Services

Timeline Hygeia launched in 1986, franchise launched in 2006

Family planning

Location 36 out of 36 states Other sexual and reproductive health

Business model Fractional franchise HIV/AIDS ●

Target clientele Low income, general population Maternal and child health ●

Average staffing Outlets are staffed with a small number of employees.

Malaria ●

Outlet types Pharmacies within 79 clinics and 1,676 hospitals Tuberculosis ●

Number of clients served in 2009 229,577

Average clients/outlet 131

Payment sources Insurance, free

2009 program expenditure (USD)

Donor support Dutch Health Insurance Fund World Bank

Contact information Mrs. Fola Laoye, Group Managing Director www.hygeiagroup.com

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61

Description

Nigeria

hygeia nigeria limitedhygeia

BackgroundHygeia is a healthcare services group which offers fully integrated healthcare services. It incorporates both private and public sector initiatives through various subsidiaries that work with operator-owned and contracted hospitals. Low-income communities access care through a subsidized health insurance scheme. Hygeia is also involved in the implementation of a free ART program.

Service detailsHCT, ART, opportunistic infection management, ANC, clean delivery kits, vaccination, malaria case management, TB case management

licensing• Doctors: Medical and Dental Council of Nigeria• Nurses: National Nurse and Midwife Council• Pharmacists: Pharmacists Council of Nigeria• Laboratory technicians: Medical Laboratory Science

Council of Nigeria• Facilities: National Health Insurance Scheme

Community health workersHygeia utilizes community members under the auspices of community health associations to mobilize enrollment into the scheme and motivate the utilization of providers. People living with HIV and AIDS (PLWHA) are also utilized to mobilize their peers to visit the clinics/hospitals to re-ceive ART care.

Job aidsGuidelines on management of malaria, hypertension, diabetes mellitus, ANC, labor and post-natal care, enrollee identification and benefit administration, ART, PMTCT and Cotrim administration, laboratory activities, pharmacy stock activities

inventory management• Stock reports by outlet• Inventory management training• Locked/secure storage rooms

TechnologyTelemedicine

Successes• Focus on healthcare quality management• Effective partnership with providers• Demand-driven funding of franchises

ChallengesHuman resource challenges, particularly in sites outside of the major cities. Hygeia is working to improve this through a continuing medical education framework.

Future plansExpansion of franchisees and training activities

innovations• Data management system that allows monitoring of

provider utilization activities• Provider continuing healthcare worker educational

system • Provider quality management framework to evaluate

provider performance against identified clinical and non- clinical metrics

Women waiting to see a physician at a franchised clinic

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Clinical Social Franchising, 201062

At a glance

Pakistan

population Services internationalgreenstar

Franchise details Services

Timeline Launched in 1995 Family planning

USAID calculation 2,104,333 CYP MSI/DKT calculation 2,794,327 CYP

Location 4 out of 4 provinces Other sexual and reproductive health

Business model Fractional franchise HIV

Target clientele Low income, women Maternal and child health

Average staffing 2 staff per outlet Malaria

Outlet types 6,500 clinics, 1,000 hospitals, 20,000 pharma-cies, 80,000 retail outlets

Tuberculosis

Number of clients served in 2009 2,100,000

Average clients/outlet 20

Payment sources 90% OOP, 5% government reimbursement, 5% vouchers

2009 Program expenditure (USD) $9.83 million

Donor support USAIDKfWAnonymous donor

Contact information Dr. Aminah Khan, DM - Centralwww.greenstar.org.pk

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Clinical Social Franchising, 201063

Description

Pakistan

population Services internationalgreenstar

BackgroundThe Greenstar franchise accepts private sector healthcare providers that have the facilities to insert an IUD, have a good reputation in the community and have taken Green-star’s classroom and clinical skills training in FP and RH service provision. Providers include doctors (MBBS), Lady Health Visitors, Family Welfare Workers and midwives (in rural areas).

Service detailsOral contraceptives, condoms, IUD, injectables, sterilization

licensingMBBS doctors are registered with the Pakistan Medical and Dental Councils and Lady Health Visitors with their con-cerned institute.

Community health workersGreenstar has an Interpersonal Communications (IPC) department which supports newly trained providers by working in the catchment area of the provider for two weeks. During this time an IPC team sensitizes clients, motivates them, gives them tokens and invites them to the trained provider's outlet on two assigned event days known as “Clinic Sahoolat.” Products and services are sold to the clients at subsidized prices on these days.

Job aids• IEC Material• IUD insertion guide and checklists• Infection prevention checklists and brochures

inventory managementStock reports by outlet

Successes• Introduction of innovative private sector approaches

for reducing maternal and newborn mortality, including public-private partnerships

• Large-scale provision of services: Greenstar is Pakistan's second largest FP provider, after the government.

Challenges• Maintain quality standards• High volume of clients results in reduced counseling

time per client• Initiating FP perinatal period• Record keeping

Future plansPlanning to reach underserved areas (rural focus) using 13 mobile service units equipped with resources required to insert IUDs

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Clinical Social Franchising, 201064

At a glance

Pakistan

Sehat First

Franchise details Services

Timeline Launched in 2008 Family planning ●

Location 1 out of 4 provinces Other sexual and reproductive health ●

Business model Full franchise HIV ●

Target clientele Low income, women, men, children Maternal and child health ●

Average staffing 5 staff per clinic (Lady Health Visitors, Dispens-ers, Store Keepers)

Malaria ●

Outlet types 3 clinics that each have a pharmacy, as well as a general store and a multi-purpose telecenter

Tuberculosis

Number of clients served in 2009 5,944 Diarrheal disease treatment, lab services, vitamins, general medicine

Average clients/outlet 1,981

Payment sources 100% OOP (health services subsidized through the revenues generated at the general store)

2009 Program expenditure (USD) $100,000 (approximately)

Donor support None

Contact information Shahida Saleem, Chairpersonwww.sehatfirst.com

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Clinical Social Franchising, 201065

Description

Pakistan

Sehat First

BackgroundSehat First is a social enterprise that provides access to ba-sic healthcare and pharmaceutical services across Pakistan through self-sustainable franchised telehealth centers. A central component of the Sehat First model is the tele-health consulting service, which supports the local clinic staff with Intranet-protocol-based video phone consulta-tions with a qualified physician.

Service detailsOral contraceptives, condoms, injectables, STI treatment, ANC, post-natal care, vaccinations, pediatric consultations, malaria treatment, diarrheal disease treatment, general medicine, lab services, vitamins

licensing• Lady Health Visitors certified by the Public Health School• Dispensers certified by provincial pharmacy councils

Community health workersThe health staff at the centers create linkages with the ex-isting CHWs who are working in their respective catchment areas. The CHWs are employed by the government.

Job aidsSome job aids were developed internally and some were provided by other local and international institutions.• Pakistan Pharma Guide• Family Guide for Paramedics (by Greenstar)• Reference Manual for Antenatal and Post-natal Care (by

Greenstar)• Reference Manual for Neonatal Health• The Essentials of Contraceptive Technology• Integrated Management of Neonatal and Childhood

Illnesses—Identify Treatment• Illustrated manual for maternal, newborn and child

health and RH/FP Services (by Women Empowerment Group)

inventory management• Stock reports by outlet• Inventory management training

• Physical stock counts• Use of a discrepancy report form• Locked/secured storage rooms

Technology• Telemedicine• Telephone hotline/counseling• Mobile and RFID (radio frequency identification)-based

patient tracking system for Pneumonia patients, with the aim to replicate the same for tracking the patients

• Implementing an e-Referral Network supported by a Clinical Decision Support System and Electronic Medical Records System

• Implementing low-cost remote medical diagnostics

Successes• Using a proven business model (franchise model)

which takes advantage of expertise from a variety of knowledge areas (i.e. health, business and information technology)

• Video consultation service maximizes the use of avail-able scarce human, financial and technical resources

• The telehealth service and other non-traditional revenue streams enable subsidization of services

Challenges• Availability of trained and qualified human resources• Developing practical processes to be implemented by

the available human resources• Unavailability of required infrastructure (e.g. electricity

and internet connectivity)• The design of the ideal telehealth solution • Identifying technical assistance to develop comprehen-

sive franchise marketing plan

Future plans • Remote medical diagnostic services and e-Referral Net-

work services• Distance learning programs using the same technology

infrastructure

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Clinical Social Franchising, 201066

At a glance

Franchise details Services

Timeline Launched in 2008 Family planning

USAID calculation 156,545 CYP MSI/DKT calculation 243,436 CYP

Location 2 out of 4 provinces Other sexual and reproductive health

Business model Fractional franchise; annual franchise fee of $1.75 USD

HIV/AIDS

Target clientele Low income, women, rural population Maternal and child health

Average staffing 1 staff per outlet (doctor, nurse, midwife or Lady Health Visitor

Malaria

Outlet types 100 clinics Tuberculosis

Number of clients served in 2009 77,736

Average clients/outlet 777

Payment sources 61% OOP, 39% vouchers

2009 program expenditure (USD) $560,611

Donor support Anonymous donor

Contact information Dr. Mohsina Bilgrami, Managing Directorwww.mariestopespk.org

Pakistan

marie Stopes SocietySuraj

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Clinical Social Franchising, 201067

Description

Pakistan

marie Stopes SocietySuraj

Background“Suraj” (sun) is a branded network of private providers in rural areas in the Punjab and Sindh provinces. The provid-ers provide FP methods and make referrals to Marie Stopes Society health centers for permanent FP methods.

Service detailsOral contraceptives, condoms, injectables, IUDs, emer-gency contraceptive pills

Community health workers A full-time Field Worker of Marketing at each clinic is responsible for marketing, generating referrals, distributing vouchers and following up with clients.

Job aidsHandouts on infection prevention, FP and counseling

inventory management• Stock reports by outlet• Stock cards• Inventory management training• Physical stock counts• Arrangement of stock by FIFO/FEFO

TechnologyTelephone/hotline counseling

Successes• Output-based aid (OBA) voucher scheme• Training of private providers on basic business manage-

ment• The Field Worker of Marketing is one of the most im-

portant factors contributing to the success of the model through generating client load and distributing the OBA vouchers.

ChallengesEnsuring quality of services, especially infection prevention standards

Future plans• Post-abortion services in 2010• Scale-up of Suraj network in all four provinces of Pakistan

by 2012

Field Worker of Marketing making door-to-door visits to market products and services available at Suraj clinics

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Clinical Social Franchising, 201068

At a glance

Franchise details Services

Timeline Launched in 2003 Family planning

USAID calculation 24,659 CYP MSI/DKT calculation 28,371 CYP

Location 9 out of 25 regions Other sexual and reproductive health

Business model 20% fractional franchise, 80% full franchise HIV/AIDS

Target clientele Low income, women, youth Maternal and child health

Average staffing 1 doctor, 2 medical assistants, 1 midwife and 1 clinical officer per clinic (most clinics managed by a midwife)

Malaria

Outlet types 1,784 clinics Tuberculosis

Number of clients served in 2009 574,542

Average clients/outlet 322

Payment sources OOP

2009 program expenditure (USD) $561,400

Donor support

Contact information Daniel Aspilcueta, Executive Directorwww.inppares.org

Peru

instituto peruano de paternidad responsible (inppareS) redplan Salud

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Clinical Social Franchising, 201069

Description

Peru

instituto peruano de paternidad responsible (inppareS) redplan Salud

BackgroundRedPlan Salud is a network of affiliated health profession-als who provide reproductive healthcare in private offices under the support of INPPARES.

Service detailsOral contraceptives, condoms, injectables, Copper T, im-plants, emergency contraceptive pills

licensingPeru Midwives Association or Peru Medical Association

inventory management• Stock reports by outlet• Computer-based inventory management system• Physical stock counts• Arrangement of stock by FIFO/FEFO

Successes• Receiving visitors and offering a wide range of products• Access to credit• Access to free training• Suppliers of products participate in promotional activities

Challenges• Collecting information and statistics • Increasing product distribution capability in remote and

poor areas

• The product portfolio is broad and demand has grown more than planned

• Developing and implementing more effective strate-gies for social marketing, as there are other competitors where none existed before

Future plans• Continue to expand the network to other regions of the

country• Develop branded pharmaceutical products

RedPlan Salud training

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At a glance

population Services pilipinas, incorporated (pSpi)BlueStar pilipinas

Franchise details Services

Timeline Launched in 2008 Family planning

USAID calculation 75,008 CYP MSI/DKT calculation 114,412 CYP

Location 34 out of 80 provinces (including 10 cities in Metro Manila)

Other sexual and reproductive health ●

Business model Fractional franchise; annual franchise fee of $21 USD

HIV/AIDS

Target clientele Low income, women Maternal and child health

Average staffing per outlet 1 midwife per clinic Malaria

Outlet types 200 clinics Tuberculosis

Number of clients served in 2009 75,622

Average clients/outlet 378

Payment sources OOP

2009 program expenditure (USD) $1,238,460

Donor support MSI

Contact information Franklin John T. Francisco, Portfolio Projects Officer www.mariestopes.org

Philippines

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Clinical Social Franchising, 201071

Description

Philippines

population Services pilipinas, incorporated (pSpi)BlueStar pilipinas

BackgroundBlueStar Pilipinas is an FP franchise run by licensed mid-wives. PSPI started BlueStar Pilipinas in 2008 to increase availability of accessible and affordable quality FP services.

Services detailsOral contraceptives, condoms, injectables, Copper T, cervi-cal screening, RTI management

licensingPhilippine Regulatory Commission for private practice

Job aids• Provision of FP services manual• Facility management manual• Flipchart and models as counseling guides

inventory management• Stock reports by outlet• Stock cards at franchises• Inventory management training• Physical stock counts• Arrangement of stock by FIFO/FEFO

Technology• SMS client follow up• SMS reporting

Successes• Use of SMS messages collected by computer software

makes the Field Training Managers more effective at providing supportive supervision

• Reducing the cost of the franchised services has increased the volume of clients.

Challenges• Franchise cannot support the current level of activity and

expenditure on demand generation

A BlueStar midwife-franchisee explains the benefits of the IUD dur-ing a marketing and promotional event.

• Franchisor has thus far been skewed towards lengthen-ing the membership roster which has resulted in some clinics with little business

• Due to the low member-acceptance rate, the franchisor has been compelled to explore nearly all geographic regions of the country. Expanded geographical reach creates difficulties related to monitoring and support.

• Provision of supplies ‘at cost’ and on credit will not be possible in the future. Cost mark-ups and cash-orders-only shall have to be imposed to finance franchisor operations.

Future plans• PSPI is considering raising the qualifications of the

franchisees so they are eligible to accept PhilHealth, the national health insurance that serves the poor.

• PSPI will implement a demand-side financing initiative, financed through the Global Partnership on Output-Based Aid.

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Clinical Social Franchising, 201072

At a glance

Franchise details Services

Timeline Launched in 2008 Family planning

USAID calculation 15,060 CYP MSI/DKT calculation 17,680 CYP

Location 4 out of 4 regions Other sexual and reproductive health ●

Business model Fractional franchise; annual franchise fee of $13 USD for clinic and $8 USD for pharmacy

HIV/AIDS

Target clientele Low income, sex workers and clients, youth, military, women

Maternal and child health

Average staffing 3 per clinic, 2 per pharmacy Malaria ●

Outlet types 61 clinics, 48 pharmacies Tuberculosis

Number of clients served in 2009 13,000+

Average clients/outlet 119

Payment sources 30% OOP, 70% free

2009 program expenditure (USD) $271,960

Donor support (USD) CARE from KfW: $81,960 MSI: $190,000

Contact information Manty Tarawalli, Private Sector Partnerships Directorwww.mariestopes.org

Sierra Leone

marie Stopes internationalBlueStar healthcare network Sierra leone

Ê Ê

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Clinical Social Franchising, 201073

Description

Sierra Leone

marie Stopes internationalBlueStar healthcare network Sierra leone

BackgroundBlueStar Healthcare Network Sierra Leone delivers sexual and reproductive health services though a single-tier model. BlueStar aims to engage women new to long-term FP methods, and in a restricted environment, make safe surgical abortion services available to the underserved.

Service detailsImplants, sterilization, surgical abortion, malaria testing and treatment, Insecticide treated nets

licensingAll clinicians must be accredited by the Sierra Leone Medi-cal & Dental Council.

Community health workersCHWs are involved and non-financial incentives are pro-vided.

Job aidsBespoke job aid on FP counseling

inventory management system• Computer-based inventory management system• Physical stock counts• Locked/secured storage rooms

Successes• The quality of the private sector at an affordable price• Building on the reputation of the private sector by im-

proving on quality while also expanding knowledge and striving to address gaps in the supply chain

Challenges• External factors due to the structure of the country’s

health system• Managing the supply chain• Balancing the base cost of products• Sierra Leoneans’ ability to pay for services

Future plansIntroduce a more robust referral system in which drug stores would be franchised as referral agents and would receive a small payment for referrals for long-term FP ser-vices to any of the clinical franchisees

BlueStar Sierra Leone clinician

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Clinical Social Franchising, 201074

At a glance

South Africa

Broadreach healthcare

Franchise details Services

Timeline Launched in 2005 Family planning

Location North West Province (1 out of 9 provinces) Other sexual and reproductive health

Business model Public-private partnership — treatment model HIV ●

Target clientele PLWHA Maternal and child health

Average staffing Varies by clinic Malaria

Outlet types 60 contracted GPs supporting the clinics Tuberculosis

Number of clients served in 2009 1,500 (includes all patients initiated on treat-ment to date)

Average clients/outlet 25

Payment sources The President’s Emergency Plan for AIDS Relief (PEPFAR)

2009 Program expenditure (USD)

Donor support PEPFAR

Contact information Niles Friedman, Director www.broadreachhealthcare.com

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Description

South Africa

Broadreach healthcare

BackgroundThe program is a network of private sector GPs trained in HIV treatment. The program creates a parallel system of care that is closely tied to the public sector program, and operates in compliance with the South African Department of Health guidelines. The goal of the program is to allevi-ate some of the burden on the public sector by leveraging existing capacity within the private sector.

Service detailsART

licensingRegional continuing medical education program with ac-credited training program for healthcare providers

inventory managementProvincial hospital complex pharmacy procures and dis-tributes all patient medications to GP offices for patient collection

TechnologyDisease management and monitoring system

Successes • Demonstrated an ability to increase capacity of the pub-

lic sector health system in order to meet the demand for HIV care and treatment

• Over 1,500 patients on ARV treatment across the pilot program

• Viral load supression rates exceed 90% after 36 months.• Patient retention rates exceed 80% after 24 months.• 100+ physicians trained

Zanele Mphikwa delivers training on ARV adherence

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Clinical Social Franchising, 201076

At a glance

Franchise details Services

Timeline Launched in 2009 Family planning

USAID calculation 34,774 CYP MSI/DKT calculation 39,425 CYP

Location 33 out of 35 districts Other sexual and reproductive health

Business model Fractional franchise HIV/AIDS

Target clientele Low income, women, men, youth Maternal and child health

Average staffing Each clinic is staffed differently, and staff move depending on the need.

Malaria

Outlet types 57 clinics, 24 hospitals Tuberculosis

Number of clients served in 2009 16,777

Average clients/outlet 207

Payment sources OOP (free LTMs on special event days)

2009 program expenditure (USD) $905,403

Donor support (USD) About $1.8 million from the Dutch government (SALIN) USAID (commodity support)

Contact information Awa Tchedre, Project Coordinatorwww.psi.org

Togo

population Services internationalpomeFa (“pour une meilleure Famille”)

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Clinical Social Franchising, 201077

Description

Togo

population Services internationalpomeFa (“pour une meilleure Famille”)

BackgroundPOMEFA is a network that consists of 81 public and private sector clinics that offer quality FP services.

Service detailsOral contraceptives, injectables, Copper T, implants

licensingStaff members accredited through the government

Community health workersCHWs educate people on FP and refer them to network centers for further counseling and services.

Job aids• Flip chart to help with informing and counseling clients• A general reproductive health pamphlet

inventory management• Stock cards• Physical stock counts• Locked/secured storage rooms• Each center responsible for buying/maintaining stock• Stock management monitored by PSI employees during

bi-monthly visits

SuccessesThe linkage between IEC social mobilization, clinical ser-vices and the mobile outreach strategy

Challenges• Gathering accurate monthly reports from all 81 centers • The mobility of service providers within the medical

system—many providers move on quickly • Service providers who have not been trained by PSI are

reluctant to participate in network reporting activities.

Future plans• Train pharmacists and counter agents who are often the

first contact for FP information, especially in cities • Add an IEC focus that specifically targets men and ad-

dresses their role in reproductive decision making • Integrate HCT into existing FP services• Train service providers in the screening and treatment of

pre-cancerous cervical lesions

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Clinical Social Franchising, 201078

At a glance

Uganda

living goods

Franchise details Services

Timeline Launched in 2007 Family planning ●

Location 15 out of 81 districts Other sexual and reproductive health ●

Business model Full franchise HIV

Target clientele Low income, women, children under 5 Maternal and child health ●

Average staffing All Living Goods Community Health Promoters (CHPs) are independent agents. One branch office supports approximately 25–35 CHPs.

Malaria ●

Outlet types 540 Community Health Promoters who are sup-ported by 28 branch offices

Tuberculosis

Number of clients served in 2009 460,000 estimated Fortified foods, water treatment, ORS, de-worming

Average clients/outlet 900

Payment sources 100% OOP

2009 program expenditure (USD) $1.6 million

Donor support (USD) $1.6 million

Contact information Charles Slaughter, President and Founderwww.livinggoods.org

LivingGoods

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Clinical Social Franchising, 201079

Description

Uganda

living goods

BackgroundLiving Goods (LG) operates networks of ‘Avon-like’ women health entrepreneurs, called “Community Health Promot-ers.” (CHPs). The model synthesizes the best practices from microfinance, franchising, and public health in an effort to achieve a 100% sustainable system for defeating diseases of poverty. CHPs deliver health education and earn a mod-est income going door-to-door selling high-impact health products like ACT, ORS, mosquito nets, fortified foods, condoms and water treatment. LG also provides its agents a broad basket of items that help them increase sales and, thereby, bolster their financial sustainability. CHPs also track and support pregnancies, make prompt referrals for secondary care, and record all treatments. LG employs all the key characteristics of successful franchises: methodi-cally screened agents, strict quality monitoring and follow-up training, uniform branding and product mix, effective promotions, low cost of goods achieved through scale, and stiff penalties for violating the rules.

Service detailsKey Products: ACT, ORS, bed nets, fortified foods, con-doms, water treatment, de-worming, solar lights, high efficiency stoves. Services: home delivery, family planning, pregnancy care, referrals

Community health workersLG franchisees are essentially sustainable CHWs

Job aids• Visual Health education flip book on 17 key health be-

haviors—Simple Habits for Healthy Living• Visual Dosage Guide, Visual Referral Guide, script forms• Backpack, uniform, locking storage, business record

keeping tools

inventory management• Dozens of micro warehouses sited within 7 km of every

agent

• Computer-based inventory management system• Monthly physical stock counts• Stock reports by branch

Successes• Strong sales of high impact health items: ACT, ORS,

fortified foods, de-worming• Steady increases in sales per agent• Achieving 95%+ in-stock rates

Challenges• Hiring experienced, capable East Africa-based manage-

ment• Driving behavior change on preventative health behaviors• Price fluctuations of consumer products, especially imports

Future plans• Expanding geographically in Uganda• Launching divisions in Kenya and/or Rwanda• Testing new products, promotions and incentives• Testing hub and spoke clinics

LG Community Health Promoter talking to client

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Clinical Social Franchising, 201080

At a glance

Uganda

paCe* (affiliate of pSi in uganda)proFam

Franchise details Services

Timeline Launched in 2008 Family planning

USAID calculation 47,901 CYP MSI/DKT calculation 61,525 CYP

Location 34 out of 87 districts Other sexual and reproductive health

Business model Fractional franchise; annual franchise fee of $10 USD

HIV

Target clientele Low income, women Maternal and child health

Average staffing 4 staff per clinic (nurses, midwives, clinical officers) Malaria

Outlet types 100 clinics Tuberculosis

Number of clients served in 2009 13,686

Average clients/outlet 137

Payment sources 100% OOP

2009 Program expenditure (USD)

Donor support Anonymous donor (approximately $244,853 USD)

Contact information Dr. Susan Mpanga-Mukasa, Executive Director www.pace.org.ug

*PACE: Program for Accessible Health, Communication and Education

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Clinical Social Franchising, 201081

Description

Uganda

paCe (affiliate of pSi in uganda)proFam

BackgroundThrough mapping and facility audit, PACE identified 100 fa-cilities meeting defined quality criteria and recruited them into the ProFam network. At least two providers from each facility were trained in FP methods, and the clinics were fully equipped for LTM service delivery.

ServicesCopper T, implants

licensingRegistration with respective bodies, such as Uganda Medi-cal and Dental Practitioners Council, Nurses and Midwifery Council and Uganda Allied Medical Practitioners Council

Community health workersEach ProFam facility has five CHWs referred to as village health teams (VHTs) who implement demand creation activ-ities and follow up with new accepters. The VHTs are given a monthly performance-related stipend that ranges from $7.5 to $10 USD. The stipend is not tied to the number of women referred, but to the level of effort of the VHT.

Job aids• WHO medical eligibility criteria• IUD and implant insertions check list• Ministry of Health FP counseling guide• Infection control protocol and complication manage-

ment plan• Referral directory

inventory management• Stock reports by outlet• Arrangement of stock by FIFO/FEFO• Physical stock counts• Locked/secured storage rooms

Successes• The facility/ProFam-led client mobilization strategy work-

ing with the VHTs• The VHT strategy: an effective way of not only mobilizing

clients but also following up to address any side effects • Satisfied user strategy: satisfied users go out to the

community and mobilize new users (a less expensive, but effective way of mobilizing communities)

Challenges• Data capture at facility level • Equipment and instruments required for adequate inser-

tion and infection control are not always not available.

Future plansIntroduction of diagnosis and management of childhood illness

ProFam training

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Clinical Social Franchising, 201082

At a glance

Vietnam

marie Stopes internationalBlueStar Vietnam

Franchise details Services

Timeline Launched in April 2008 Family planning

USAID calculation 6,257 CYP MSI/DKT calculation 38,733 CYP

Location 7 out of 58 provinces Other sexual and reproductive health ●

Business model Fractional franchise; annual franchise fee of $120–150 USD (poor/small clinics pay less)

HIV

Target clientele Low income, women, migrants/refugees, youth Maternal and child health

Average staffing 1 doctor, 1 nurse, 1 midwife and 1 clinical officer per clinic

Malaria

Outlet types 95 clinics Tuberculosis

Number of clients served in 2009 191,087

Average clients/outlet 2,011

Payment sources OOP, vouchers, free (With an IUD voucher, a free IUD insertion is combined with a paid cervical cancer screening as a form of cross-subsidization.)

2009 program expenditure (USD) $295,903

Donor support Marie Stopes International, UK

Contact information Le Thi Kim Yen, Social Franchise Managerwww.mariestopes.org

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Clinical Social Franchising, 201083

Description

Vietnam

marie Stopes internationalBlueStar Vietnam

BackgroundBlueStar Vietnam operates in seven provinces in all three geographical areas of Vietnam: Northern, Central and Southern. Duration of establishment and support of the network is four years, from 2007 to 2011 (2008 launch). Services include modern FP methods and safe surgical abortion services.

Service detailsOral contraceptives, condoms, Copper T, emergency con-traceptive pills, injectables, abortion (medical and surgical)

licensingAccredited by the government and by licensing bodies

Community health workers• CHWs disseminate information about the location and

services provided by clinics• They promote an IUD insertion plus cervical cancer

screening package• For distributing an IUD insertion/cervical screening

voucher, they are paid a small fee for pre-service coun-seling of women on a per-case basis

Job aidsBlueStar brand management guide for clinic staff for refer-ence and observation of the brand standards

inventory management• Monitoring checklists for quality control• Physical stock counts

Technology• SMS reporting• MSI Vietnam launched a One Call Center in April 2009

to support and encourage MSI Vietnam and franchise clients to access information and services, especially ap-pointment bookings and post-treatment support.

Successes• The first intervention targeting the private healthcare

sector to promote FP and safe surgical abortion services to date in Vietnam

• Building organizational capacity for MSI Vietnam and its local partners in new approaches to FP/RH care

• Building rapport and trust with BlueStar service providers• Building database to create evidence for decision mak-

ing and advocacy

Challenges• Lack of support for a social franchise, as this is a new

model in Vietnam • Difficulty obtaining government approvals for project

implementation • Low level of interest among private providers to provide

at-cost FP methods, without financial support• Cost-cutting measures (taken by some providers) that

compromise patient care

Future plans• Pilot of vouchers for IUDs and medical abortion services • Adding other long-term FP method such as new IUD

(GyneFix) and implant• Expansion of the network by 160 clinics• Consideration of pharmacies as referral sites to clinics

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Clinical Social Franchising, 201084

At a glance

Vietnam

marie Stopes internationalTinh chi em (“Sisterhood”)

Franchise details Services

Timeline Launched in July 2007 Family planning

USAID calculation 4,884 CYP MSI/DKT calculation 9,852 CYP

Location 5 out of 58 provinces Other sexual and reproductive health ●

Business model Fractional government franchise HIV/AIDS

Target clientele Low income, migrants/refugees, youth, men, women

Maternal and child health

Average staffing 6 staff per health station Malaria

Outlet types 56 commune health stations Tuberculosis

Number of clients served in 2009 63,337

Average clients/outlet 1,131

Payment sources 10% OOP, 50% insurance, 40% government reimbursement

2009 program expenditure (USD) $290,000

Donor support The Atlantic Philanthropies

Contact information Nguyen Thi Bich Hang, Country Representativewww.tinhchiem.vn

*Note that this program does not currently include all of the characteristics of a social franchise as defined for this compendium.

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Clinical Social Franchising, 201085

Description

Vietnam

marie Stopes internationalTinh chi em (“Sisterhood”)

Background“Tinh chi em” is the first government-run social franchise model in Vietnam. With technical assistance from MSI Vietnam, the provincial Department of Health (franchisor) forms and operates the model at commune health stations (franchisee).

Service detailsOral contraceptives, condoms, injectables, Copper T, emer-gency contraceptive pills, counseling on FP, STI treatment, surgical abortion, normal birth delivery, counseling on RH

licensingThrough the government

Community health workers• Brand ambassadors are selected from the community.

They receive training on basic RH/FP, brand manage-ment, communication skills, etc. in order to mobilize clients.

• They receive a monthly allowance to compensate for the time and transportation costs used for referrals (about $5 USD per month).

Job aids• Franchise manual• Operational guide in Vietnamese (www.tinhchiem.vn)

inventory management• Physical stock counts • Stock reports by outlet • Refrigerators • Locked/secured storage rooms

Successes• Strong partnership with local authorities• Training on service quality, infection prevention, demand

generation

ChallengesLack of fee collection from patients at the commune health stations

Future plansExpansion into three new provinces, with a target of estab-lishing over 70 franchise units

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Clinical Social Franchising, 201086

At a glance

Zimbabwe

population Services internationalnew Start

Franchise details Services

Timeline Launched in 1999 Family planning ●

Location 10 out of 10 provinces Other sexual and reproductive health

Business model 20% full franchise, 80% fractional franchise HIV ●

Target clientele Truck drivers, military, women, low income, men, sex workers and clients, youth, migrants/refugees

Maternal and child health

Average staffing 8 per site (nurses, pharmacists, clinical officers, social workers)

Malaria

Outlet types 17 statics sites, 23 outreach teams Tuberculosis ●

Number of clients served in 2009 361,355

Average clients/outlet 9,034

Payment sources 100% OOP

2009 Program expenditure (USD)

Donor support DFIDUSAID

Contact information Dr. Karin Hatzold, HIV Services Directorwww.psi.org

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Clinical Social Franchising, 201087

Description

Zimbabwe

population Services internationalnew Start

Background New Start is an HIV testing and counseling franchise started in Zimbabwe in 1999 in support of the Ministry of Health and Child Welfare Testing and Counseling Program. The franchise is managed by professional counselors who have another professional background such as nursing, teaching or social sciences. To improve access to care, treatment and support for people living with HIV, PSI has introduced TB screening using a standard questionnaire and FP counseling.

Service detailsART, HCT, TB screening, FP counseling

licensingAccredited through the professional bodies they belong to e.g., nursing, teaching, social sciences

Job aidsSite staff are provided with counseling guides and operat-ing procedure manuals designed by PSI Zimbabwe.

inventory management• Stock reports by outlet• Arrangement of stock by FIFO/FEFO• Locked/secured storage rooms• Physical stock counts

TechnologyWeb-based reporting

Successes• Guidance on operation of the sites• Instilling a sense of program ownership into partner• Ability to reach remote rural areas

Challenges• Unstable political and economic environment—few

clients visit sites during periods of political unrest• Aging vehicle fleet (requesting more vehicles in proposals)• Poor road networks and accessibility

Future plans• Reaching out to poor rural communities by intensifying

outreach activities• Incorporation of CD testing, TB screening and investiga-

tions• FP distribution through New Start centers to promote

dual protection and prevent unwanted pregnancies• ARV therapy supply through private partnership

innovations• Expansion of outreach activities to displaced popula-

tions and returned migrants• Setting up an HCT site for returned migrants at the

border• Capacity building for partners with weaknesses in man-

agement of testing and counseling programs• Incorporation of new innovations in the HCT program—

TB smear microscopy, FP counseling, CD4 cell count testing

• Setting up strong referral and referral tracking systems with all referral partners in each area of operation

New Start training session

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Clinical Social Franchising, 201088

appendix a: acronymsANC Antenatal careART Antiretroviral therapyARV Antiretroviral drugsCYP Couple years of protectionFIFO First in, first outFEFO First expiry, first outFP Family planningGP General PractitionerHCT HIV Counseling and TestingIEC Information, Education and CommunicationIMCI Integrated management of childhood illnessIUD Intrauterine deviceLTM Long-term methodMBBS Bachelor of Medicine and Bachelor of SurgeryMCH Maternal and child healthMSI Marie Stopes InternationalOBA Output-based aidOOP Out-of-pocket paymentORS Oral rehydration saltsPEPFAR The US President’s Emergency Plan for AIDS ReliefPLWHA People living with HIV and AIDSPMTCT Prevention of mother-to-child transmissionPSI Population Services International RH Reproductive healthSALIN Strategic Alliance with International NGOsRTI Reproductive tract infectionSMS Short messaging service STI Sexually transmitted infectionTB TuberculosisVCT Voluntary counseling and testing for HIV/AIDS

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89

ap

pen

dix

B: m

ap o

f so

cial

fra

nchi

ses

Clinical Social Franchising, 2010

Soci

al fr

anch

ises

in 2

009

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Clinical Social Franchising, 201090

appendix C: program summary graphs

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

num

ber

of

fran

chis

es

45

40

35

30

25

20

15

10

5

0

TimelineThe number of franchises has doubled every four years since 1994.

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Clinical Social Franchising, 201091

Franchises by region86% percent of social franchising clients are from South asia.*

86%

6%

5%2% 1%

South Asia

South East Asia

East & Southern Africa

Latin America

West Africa

*23 million clients are from Smiling Sun, Bangladesh

Services offeredSince 2008, more franchises are offering services in family planning, Srh, malaria, hiV/aidS, TB and other areas.

2 008

FP Other SRH MCH Malaria HIV/AIDS TB Other

Services

num

ber

of

fran

chis

es

0

5

10

15

20

25

30

35

40

2009

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Clinical Social Franchising, 201092

100

1,00

0

10,0

00

100,

000

1,00

0,00

0

10,0

00,0

00

BlueStar, M

adag

asca

r

ProFam

, Mali

Tinh chi e

m, V

ietnam

BlueStar, V

ietnam

BlueStar, M

alawi

Gold Sta

r, Kenya

ProFam

, Benin

BlueStar, S

ierra Le

one

Top R

éseau

, Mad

agas

car

RedPlan Salu

d, Peru

Merry

Gold, In

dia

BlueStar, E

thiopia

POMEFA

, Togo

Sun Quali

ty Healt

h, Cam

bodia

ProFam

, Ugan

da

Profe

mina,

Mad

agas

car

Tunza

, Kenya

BlueStar, P

hilippines

Reseau

Confia

nce, D

RC

SkyHealt

h, India

AMUA, K

enya

Society

for F

amily

Healt

h, Nig

eria

Suraj, P

akist

an

ProFam

, Cam

eroon

Sun Quali

ty Healt

h, Mya

nmar

Sangini, N

epal

Saadhan

, India

Blue Star, B

anglad

esh

Surya, In

dia

Smilin

g Sun, Ban

gladesh

Greensta

r, Pak

istan

Co

uple

yea

rs o

f p

rote

ctio

n (C

Yp

)C

Yp

cal

cula

tio

ns u

sed

by

uSa

id a

nd m

Si/d

KT

are

clo

sely

co

rrel

ated

.

USA

ID c

alcu

latio

n

MSI

/DK

T ca

lcul

atio

n

log scale

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Clinical Social Franchising, 201093

CYp conversion factors

uSaid (last updated: June 2009) mSi/dKT (last updated: February 2010)

method units needed to provide 1 CYp units needed to provide 1 CYp

Oral contraceptive pill (1 cycle, paid*) 15 14

Oral contraceptive pill (1 cycle, free) 15 70

Male condom (1 piece, paid) 120 100

Male condom (1 piece, free) N/A 500

Female condom (1 piece, paid) 120 20

Female condom (1 piece, free) N/A 100

1-month injectable 13 12

2-month injectable 6 6

3-month injectable 4 4

Foam tablet (paid) 120 150

Foam tablet (free) N/A 750

IUD 0.29 0.182

Sterilization (male or female)—Asia 0.1 0.08

Sterilization (male or female)—Latin America

0.1 0.08

Sterilization (male or female)—Africa 0.125 0.08

Implant (5 years) 0.29 0.286

Implant (3 years) 0.5 0.286

Emergency contraception 20 9

Surgical abortion N/A 0.5

Medical abortion N/A 0.5

*This report assumes that all reported services were paid for.

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Clinical Social Franchising, 201094

num

ber

of

clie

nts

serv

edTh

e m

edia

n nu

mb

er o

f cl

ient

s se

rved

by

fran

chis

es in

crea

sed

32%

bet

wee

n 20

08 a

nd 2

009.

*

*Rec

ently

laun

ched

fran

chis

es n

ot

incl

uded

Clinical Social Franchising, 2010

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

TOP Rése

au, M

adag

asca

r

Smilin

g Sun, Ban

gladesh

Greensta

r, Pak

istan

Sangini, N

epal

Sehat Firs

t, Pak

istan

BlueSta

r, Ghan

a

Sun Quali

ty Healt

h, Mya

nmar

BlueSta

r, Mala

wi Hyg

eia, N

igeria

POM

EFA, T

ogo

RedPlan Salu

d, Peru

New Start,

Zimbab

we ProFam

, Mali

ProFam

, Benin

Gold Sta

r, Kenya

M

erryGold

, India

BlueStar, V

ietnam

Sun Quali

ty Healt

h, Cam

bodia

Living G

oods, Ugan

da percent increase 2008–2009

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Clinical Social Franchising, 201095

program expenditureThe majority of franchises had < $1 million uSd in program expenditure in 2009.*

10 programs

7 programs

4 programs

3 programs

*24 of 40 programs reported on program expenditure.

< $400,000 USD

$4,000,000 – $1,000,000 USD

$1,000,000 – $5,000,000 USD

> $5,000,000 USD

$0.10

$1.00

$10.00

$100.00

$1,000.00

1

10

100

1,000

10,000

100,000

1,000,000

10,000,000

100,000,000

expenditure per clientas the number of clients treated increases, the expenditure per client decreases.

Clients served in 2009

Expenditure per client treated (USD)

log

sca

le

log

sca

le

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Clinical Social Franchising, 201096

appendix d: demand-side financing

Social franchising offers a way to improve the accessibility and quality of a wide range

of health services using existing private providers. Nearly two decades of evidence

exists to demonstrate the effectiveness of social franchising as a platform for service

delivery in developing countries. However, the social franchising model alone, as

financed through supply-side mechanisms such as donor funding of inputs (i.e.

physical infrastructure, salaries and commodities), does not ensure that services reach

all the patients who need them, particularly poor and vulnerable populations.

The limitations of supply-side financing impact both the receipt and delivery of ser-

vices by patients and providers, respectively. When subsidies target solely the supply

side, there is no mechanism in place to ensure that poor patients can afford the ser-

vices and there is no guarantee that patients have a choice of provider. For the provid-

ers, there is no incentive to spend the subsidy efficiently with a goal of providing the

best care for the most patients. Furthermore, there is no linkage between the payment

and performance once the subsidies are delivered, regardless of the services provided.

One way to overcome these constraints is through a demand-side financing mecha-

nism—a third-party-payer linked to patient use—which involves channeling the subsidy

for health services directly to patients and allowing them to purchase health services

themselves. This process incentivizes providers to deliver high quality services and to

reach a larger population because they are reimbursed based on performance. For

patients, they now have the ability to choose which provider to visit and can access

services that otherwise might have been unaffordable. Demand-side financing

mechanisms are also attractive to donors who often prefer to purchase outputs (i.e.

consultations provided) as opposed to the inputs.

In the context of social franchises, demand-side financing can take the form of a

voucher program, an insurance program or other systems of output-based service

reimbursement provided to franchisees. Of the 40 social franchising programs identi-

fied in this compendium, 16 have implemented demand-side financing initiatives. The

table below provides a brief summary of these franchises and their programs. A Work-

ing Group on Social Franchising and Demand-Side Financing is actively engaged in

documenting best practices and sharing experiences and tools in this area. For more

information, visit SF4Health.org.

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Clinical Social Franchising, 201097

umbrella organization

Franchise name, Country

demand-side Financing mechanism

description of mechanism

Family Health International Gold Star, Kenya Insurance Gold Star is working on strategies to partner with insurance companies in the provision of HIV treatment services.

Hindustan Latex Family Planning Promotion Trust

MerryGold, India Voucher, Insurance MerryGold facilities are accredited as part of a larger voucher program, meaning clients can redeem vouchers at MerryGold in addition to other facilities. In addition, MerryGold is linked to an insurance scheme.

Hygeia Nigeria Ltd. Hygeia, Nigeria Insurance Demand driven financing initiative that has enrolled 119,382 clients since inception in 2007. To enroll, the client pays $2 per annum in Kwara and $8 per annum in Lagos.

Marie Stopes International BlueStar, Sierra Leone Voucher 6,000 Healthy Life vouchers for LT family planning and 1000 Healthy Baby vouchers for maternal health will be distributed over 12 months. The client pays 50 cents for the Healthy Life voucher and 75 cents for the Healthy Baby Voucher.

Marie Stopes International BlueStar, Vietnam Voucher In October, 2009, a pilot voucher scheme was launched. 9000 vouchers for IUD and other medical abortion services have been disbursed. The voucher is free to the client.

Population Services International

Sun Quality Health, Myanmar

Voucher Vouchers are mainly used for long term FP methods and reach 30,000 patients per annum. PSI Myanmar first piloted the use of vouchers in 2005 and since then has launched 11 such OBA schemes for FP/RH services as well as TB screening and treat-ment.

Marie Stopes International Suraj, Pakistan Voucher Voucher scheme was launched in 2008 and to date, 21,112 vouchers have been redeemed. The voucher is free to the client.

MicroClinic International MicroClinic, Ghana/Uganda Insurance Clients can access services through the National Insurance Plan that is run by the private sector.

Population Services International

Greenstar, Pakistan Voucher Voucher booklets are sold to clients identified through the Paki-stan Poverty Scorecard (developed by World Bank) for delivery and ANC/PNC visits. Vouchers pay for 98% of total cost and available to poor women with no history of clinic based deliver-ies, implemented in three districts of Pakistan. The client pays $1.25 for voucher booklet.

Population Services International

ProFam, Benin Voucher The voucher scheme offers subsidized FP services and was introduced in April 2009. Vouchers are given out during event days. To date, 16,502 vouchers have been distributed and 4162 vouchers have been disbursed. The voucher is free to the client.

Population Services International

ProFam, Cameroon Voucher The vouchers are used to redeem FP services at 25 clinics.

Population Services International

ProFemina, Madagascar Voucher The voucher scheme targets low income women and subsidizes long term FP methods. The scheme was launched in 2008 and to date,13,136 vouchers have been disbursed. The voucher is free to the client.

Population Services International

Sun Quality Health, Cam-bodia

Voucher The voucher scheme offers subsidized IUD services at franchised private sector clinics. The program was introduced February 2010 and to date, 277 vouchers have been disbursed. The client pays $1.25 at the point of service.

Population Services International

Top Réseau, Madagascar Voucher The voucher scheme targets youth and high risk groups and subsidizes FP/RH counseling and STI treatment. The scheme was launched in 2005, and to date, 282,552 vouchers have been disbursed. The voucher is free to the client.

Population Services International

Tunza, Kenya Voucher Referral vouchers are distributed to women of reproductive age via community mobilizers and PSI communications staff following behavior change communication sessions on family planning. The referral vouchers are redeemed at 172 Tunza clinics and entitle women to FP counseling and subsidized FP services, with a focus on IUDs. To date, 7763 vouchers have been disbursed. The client pays $2.66 for the voucher.

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Clinical Social Franchising, 201098

appendix e: donors contributing to franchising programs in 2009

The Allergan Foundation

An anonymous foundation

The Atlantic Philanthropies

The Bill & Melinda Gates Foundation

BlackRock

The David & Lucile Packard Foundation

Dutch Health Insurance Fund

The International Foundation

Johnson & Johnson Corporate

KfW

PEPFAR

Strategic Alliances with International NGOs (SALIN) of the Dutch Government

UNFPA

USAID

Venture Strategies

The William and Flora Hewlett Foundation

World Bank

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Clinical Social Franchising, 201099

appendix F: umbrella organizations

The 40 programs profiled in this compendium are implemented by the following

agencies.

Banja La Mtsogolo banja.org.mw

BroadReach Healthcare broadreachhealthcare.com

Chemonics chemonics.com

DKT dktinternational.org

Drishtee drishtee.com

Family Health International (FHI) fhi.org

Greenstar Social Marketing greenstar.org.pk

Hygeia Nigeria Limited hygeiagroup.com

INPPARES inppares.org

Living Goods livinggoods.org

Marie Stopes International (MSI) mariestopes.org

Marie Stopes Society (MSS) mariestopespk.org

Hindustan Latex Family Planning Promotion Trust hlfppt.org

MicroClinic International microclinics.com

Nepal CRS Company crs.org.np

Program for Accessible health,

Communication and Education (PACE) pace.org.ug

Population Services International (PSI) psi.org

Sehat First sehatfirst.com

Social Marketing Company (SMC) smc-bd.org

Society for Family Health (SFH) sfhnigeria.org

VisionSpring visionspring.org

World Health Partners worldhealthpartners.org

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Visit the Global Health Group at globalhealthsciences.ucsf.edu/ghg.

Find this document and other franchising information at SF4Health.org.