6 lessons on social franchising for health

In 2002, Hannah Gachoka, a certified nurse, opened her own clinic in Thika, the largest town in the county of Kiambu, Kenya. With limited equipment and knowledge, Gachoka ended up referring more patients elsewhere than she diagnosed and treated at her own clinic. Today, Gachoka’s clinic is booming. She has her own laboratory and provides a range of health care services, such as screening and treatment for cervical cancer, ante-natal and postnatal services, family planning, HIV testing, care and counseling, immunizations for children and minor surgeries such as circumcision. Recently, she was also able to secure a loan for ultrasound equipment, for which she could earn 1,500-2,000 ($15-20) Kenyan shillings per patient. Gachoka attributes most of her current know-how and skills to the training she’s been receiving under the Tunza Family Health Network, a social franchise program launched in 2008 by PS Kenya, a locally registered and independent nongovernmental organization under the Population Services International brand. The social franchise — which operates much like commercial franchising but whose goal is twofold: earn profit while achieving social impact by creating more employment — provides business training and new and alternative methods of patient care to member clinics, particularly those related to maternal and child health and family planning, core programs of Tunza. Today, the franchise has more than 300 clinics in its network, and inquiries on how to be part of Tunza continue to come in from interested clinics, according to Dr. Job Makoyo, senior manager of quality assurance at PS Kenya. The organization’s ability to review and assess its activities, and apply any lessons or insights gained to improve or adjust its work has contributed to the program’s current successes. Makoyo identified some of these learnings below, and even today, he said the franchise continues to explore different ways and means to make the program more efficient, both for the franchisor as well as the franchisees. 1. Community mobilization is good business. Getting the right information to populations is crucial in fighting a health issue, condition or disease. This was evident at the height of the Ebola outbreak in 2014, and is true in the case of women in the rural areas of Kenya who perceive contraceptives as dangerous or leading to infertility. But educating citizens about their health makes business sense, too. With myths and misconceptions broken, individuals are more likely to have a change in their health-seeking behavior, and with this they are likely to seek care and treatment in the same health facility that carried the message forward. That said, it’s important to put in place a community mobilizer who can focus on the task, as providers might not have the capacity to market their facilities given their other duties at the clinic, Makoyo said. 2. Quality assurance officers need help, too. Quality assurance is a key component of any initiative or program. The Tunza social franchise hired individuals in charge of ensuring the quality of services provided by its member clinics. But as the network expanded and the range of health services covered grew, quality assurance officers grappled with scheduling, priorities and in ensuring messaging consistency among health care providers. So PSI and PS Kenya began discussing ways it could improve its QA system, and in mid-September this year, they launched the Health Network Quality Improvement System, a tablet-based app aimed at helping quality assurance officers plan their visits across their assigned clinics and better assess how health providers handle patient cases — for example, are they asking all the necessary questions when assessing or examining patients? It essentially answers common questions quality assurance officers deal with on a regular basis: Which clinic am I visiting today? What am I looking out for? How do I make use of all this data? How can I help the health provider improve? PSI’s technical team developed the app, but Makoyo said PS Kenya, particularly those involved in quality assurance of the Tunza health clinics, provided input on what they hoped it would include. One of the goals is reducing subjectivity in a QA officer’s decision making process. “We want it to have a checklist, give automatic feedback and [help us] plan for the next visit as opposed to a quality assurance officer coming up with his or her own schedule,” Makoyo said. All the information entered on the app links back to a central data health information system that helps give decision-makers at the organization a snapshot of what’s going on in a particular area to inform programming. 3. Understanding is key in breaking provider bad habits. The Tunza program provides health care providers with training and technical skills so they can provide a wide range of health care services, but some health providers end up offering medication or treatment options based on their personal biases, preferences or understanding. For example, despite having a range of options on family planning, some prescribe only pills over intrauterine devices. Other health providers also tend to prescribe antibiotics for children suffering from diarrhea when this can be remedied with oral rehydration solutions and zinc. Understanding where the health providers are coming from will help organizations arrive at the best-suited solution. If it’s limited understanding of what causes diarrhea, for example, the organization can come up with evidence showing that diarrhea is caused by rotavirus and so antibiotics are not necessarily needed 4. Build your brand by building relationships. One of the things Makoyo learned from dealing with health care providers in Kenya is that word of mouth from existing franchisees is crucial in winning over a new health provider to join the network. But the challenge doesn’t stop there. To keep health providers in the network, the organization had to find a way to reduce noncompliance. Some health providers find the monthly check-ins for quality assurance unreasonable, or the licensing and reporting requirements too cumbersome. This is particularly true for facilities unaccustomed reporting to the government, Makoyo said. The organization hopes to address the reporting burden through automation, although implementing that is a challenge in itself, as not all clinics have enough staff members with the patience and capacity to learn and take on the task. It also places important emphasis on showing health providers evidence of the value of the processes in place,as well as maintaining relationships with key decision makers at the facilities. “One of the things we always tell our field guys is ‘these are not your facilities.’ You cannot go in and dictate terms. Supportive supervision is a facilitative process, where you are working with providers through an assessment and understand where they are, why are they at that point, these are the gaps, and work with them to provide their own solutions at their most appropriate timelines dependent on the resources involved,” Makoyo said. 5. Technology isn’t a panacea. A lot of innovations center on the use of technology, like mobile phones. But that doesn’t mean they get traction. PS Kenya tried introducing SMS-based reporting among the clinics under Tunza. The idea was meant to reduce the burden of paperwork among health providers, and it came with an incentive — additional airtime for those who submitted their report through text. But the initiative failed, mainly because health providers found it “was a lot of work,” Makoyo said. The end result: Health providers went back to filling out their big black books at the end of each month. The organization has yet to unlock the key in reducing the paper burden, but Cristina Lussiana, malaria and child survival monitoring adviser at PSI, thinks that getting health providers to see the value of the reports — that it actually helps them see how many clients they are getting in a month, and understanding if they are actually earning or just breaking even — could be the game changer. 6. Donor funding can only work for so long. At present, all support health providers receive under the Tunza social franchise is 100 percent donor funded, according to Makoyo. The only cost health providers shoulder is the annual fee, which is as little as $10. While that is currently working, it’s not exactly sustainable. This is why the organization, with guidance from PSI, is working on a new business model aimed at making the franchise less dependent on donor funding. “If the donors pull out right now, the Tunza brand will remain, and we can continue providing support, but maybe not at the intensity that we’re providing … so that’s one of the key things that we’re discussing right now,” he said. Under the new model they’ve been trying and testing for the past six months, the program is set to become an enterprise and health providers are expected to shoulder part of the fees — in a tiered form, depending on their capacity — necessary to continue growing, learning and maintaining the quality of their services. “We got a lot of insights from the providers themselves. Providers are actually ready to pay for some of these trainings. Providers are ready to buy equipment. So it’s just trying to work with the providers and understand what are they able to afford [and] what can they not afford,” Makoyo said. Devex recently visited a Tunza family health clinic in Kiambu county, Kenya, as part of our Making Markets Work campaign with The Abraaj Group, Philips and PSI. Making Markets Work is an online conversation to explore what’s being done to make global health care markets accessible to people at the base of the pyramid. Over 10 weeks, we will amplify the discussion around effective health financing, analyze key challenges blocking universal market access in the health care supply chain, and explore the key strategies to make markets more effective. Join us as we look at this important issue, and share your thoughts by tagging #MakingMarketsWork and @Devex.