On the path to end TB: How social franchising can effectively engage private practitioners

Tuberculosis specialists visit clinics to review cases and distribute medication in Papua New Guinea. Social franchising would help ensure that every TB patient has access to quality care. Photo by: Australian Department of Foreign Affairs and Trade / CC BY

End TB!”

Over the past 20 years, that rallying cry has gone from fantasy to imperative. Since the advent of the World Health Organization’s directly observed treatment strategy in 1995, more than 61 million people have been successfully treated for tuberculosis, and new TB cases and TB-related deaths are on the decline. Furthermore, countries have achieved the Millennium Development Goal of halting and reversing the TB epidemic by 2015. Thus, today, we have important successes to celebrate. Ending TB is within reach.

But it’s far from certain.

This year, 1.5 million people will die from TB and 9 million people will develop the disease.  These numbers are staggering. As the global community pursues a bold vision of universal health coverage, in which all people are able to access the health services they need without suffering financial hardship, we must be even smarter in our efforts to ensure every TB patient has access to high-quality affordable TB care without incurring catastrophic costs.

To achieve UHC, we need a comprehensive approach to health systems — one that incorporates engagement of all public, private, voluntary and corporate care providers to deliver quality health services, supported by bold systems and social policies. Often, discussions of UHC focus on the public sector. This makes sense — the sector remains the backbone of health systems worldwide. Yet private, voluntary and corporate care providers play a critical role in providing patients with access to care.  The TB community knows all too well that we ignore their role at our peril.

This year, an estimated 3 million people with TB will go untreated, or will be cared for in unregulated private sectors. It is likely that many of these people will receive treatment of uneven quality that both fails to cure the patient and potentially augments the problem of multidrug-resistant TB. Compounding this danger, out-of-pocket expenses in the private sector can lead to catastrophic patient costs and further impoverishment. Therefore, ensuring universal access to quality TB care requires that we engage all providers who care for people with TB.

The good news is that we have proven strategies to do just this. WHO has documented a host of successful approaches for engaging private hospitals, workplaces and private practitioners in the provision of high-quality TB care. One strategy particularly effective at engaging individual private practitioners is social franchising.

In this approach, based on commercial franchising techniques and employed by PSI since 2004, an intermediary agency engages existing private practitioners in a franchise network.  As members of this network, practitioners are trained to adhere to quality guidelines and are provided ongoing supportive supervision. To ensure the use of quality diagnostics and treatments, franchised providers are often linked to national laboratories and provided supplies of TB drugs through the national program. In exchange, they agree to prenegotiated prices for standardized and quality-assured services. Franchise clinics operate under a common brand, which is promoted among patients to drive demand for high-quality TB care in the private sector. Today, initiatives in eight countries use this approach.

Social franchising for TB care has worked in many settings. In Myanmar, for example, the decadeold Sun Quality Health franchise network treated more than 18,000 TB patients last year with quality, affordable care; 13 percent of all cases detected nationally were detected by a Sun Quality Health provider. This is a critical complement to the ongoing efforts of the Ministry of Health to expand and improve TB services in the public sector. Importantly, research from Myanmar shows that the social franchise model can enhance equity to care and reach the most vulnerable people, including the poor.

Global experience in TB care teaches us that realizing the UHC vision and ensuring access to quality, affordable TB care requires that we engage all care providers. This must include private practitioners who are often a patient’s first point of contact.

However, challenges remain. Models like social franchising still face difficulties ensuring long-term sustainability.

We must invest resources to develop, test and refine funding structures to ensure the impact of social franchising and other private sector engagement approaches lasts long into the future. For example, in a franchising approach, fees paid by practitioners may provide partial support for ongoing franchise operation.

Alternatively, third-party payers, including the public sector and health insurance organizations, might opt to support franchise activities to accomplish public health goals. We should work now to determine how private practitioner engagement models can be a part of the solution for universal access to TB care.  

Twenty years ago, ending TB seemed unattainable. Now it is within our grasp. This ancient killer can be vanquished by getting all affected people access to TB care without suffering financial hardship.

The UHC vision can accelerate the pace of the fight against TB and prove that it truly contributes to better health outcomes. In turn, the TB community, through its collaboration with all care providers, public and private, can advance the goals of UHC.

Let’s scale private sector engagement models that work and ensure the success of those models long into the future.

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About the authors

  • Karl Hofmann

    Karl Hofmann is president and CEO of Population Services International, a Washington, D.C.-based global health nonprofit focused on family planning and reproductive health, malaria, child survival, HIV, maternal and child health, and NCDs. Before joining the organization in 2007, he was a career U.S. diplomat for 23 years, serving as ambassador to Togo, executive secretary of the Department of State and deputy chief of mission at the U.S. embassy in Paris.
  • Mario Raviglione

    Dr. Mario Raviglione is the director of the World Health Organization's Global TB Program.He is responsible for setting norms, policies and standards on global TB control, coordinating technical support, monitoring the global situation and developing innovative interventions through translation of new evidence into policies & practice and through addressing system challenges such as community and private sector engagement. He also lead the development of the new WHO End TB strategy.