Setting the record straight on social franchising – Author's reply
Authors: Zubia Mumtaz
Journal: The Lancet Global Health (2018)

Julie McBride's response, although aimed at providing an alternative perspective, essentially supports my argument that there is insufficient rigorous evidence to justify funding social franchises. There is no doubt that social franchising is an enticing idea. The business model, with its private profit motive, is assumed to be able to deliver high-quality services at scale and achieve sustainable effects on health care. It's a popular idea. More than 90 social franchises exist in 40 low-income and middle-income countries,1Viswanathan R Behl R Seefeld CA Clinical social franchising compendium. An annual survey of programs: findings from 2015. The Global Health Group, Global Health Sciences, University of California, San Francisco, CA2016Google Scholar and McBride lists some of them. She does not, however, provide rigorous evidence that these social franchise programmes are successfully delivering real, measurable population-level health or social outcomes. The randomised controlled trial that she cites is a preliminary report and not yet published in a peer-reviewed journal.2Nyqvist M Guariso A Svensson J Yanagizawa-Drott D Effect of a micro-entrepreneur-based community health delivery program on under-five mortality in Uganda: a cluster randomized controlled trial. Centre for Economic Policy Research, London2016Google Scholar A reading of the report suggests that the authors' focus was to assess whether introducing a new cadre of community health workers (CHW) through a micro-enterprise model improved child survival in rural Uganda. The trial does not tell us whether any improvements were due to the introduction of CHWs or the social franchise model. The only way this can be ascertained is by comparing sites where CHWs are organised under a social franchise model with sites where CHWs follow another model, such as voluntary work or salaried employment. As for generalising the failings of one application of the social franchising model to the whole field, let us look at the evidence of hub-and-spoke systems as an evolution of the social franchising model. The hub-and-spoke system was used by World Health Partners, a social franchise in Bihar, India, funded by the Bill & Melinda Gates Foundation to deliver childhood diarrhoea and pneumonia services. An embedded pre-post study found that the programme did not improve disease prevalences or appropriate treatment in a sample of 67 950 children between 2011 and 2014.3Mohanan M Babiarz KS Goldhaber-Fiebert JD Miller G Vera-Hernández M Effect of a large-scale social franchising and telemedicine program on childhood diarrhea and pneumonia outcomes in India.Health Aff. 2016; 35: 1800-1809Crossref PubMed Scopus (17) Google Scholar Membership in the franchise also did not significantly improve health-care providers' knowledge or quality of care delivered.4Mohanan M Giardili S Das V et al.Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India.Bull World Health Organ. 2017; 95: 343-352Crossref PubMed Scopus (19) Google Scholar McBride's letter has, perhaps inadvertently, shed light on the importance of differentiating processes from outcomes. By listing processes, such as Child and Family Wellness's serving of “500 000 clients” or that operating costs declined, McBride makes the common mistake of assuming that processes equate to outcomes. Although coverage is important, what evidence is there in these numbers to indicate that the Child and Family Wellness social franchise improved health outcomes in this population? I reiterate the need for rigorous evidence-generation before funding more social franchises, preferably with use of randomised controlled trial methods funded by independent research organisations with no conflict of interest in showing particular outcomes. I declare no competing interests. Social franchising: whatever happened to old-fashioned notions of evidence-based practice?Social franchising, which draws on principles of commercial franchising for achieving socially beneficial ends, is based on the premise that organising private sector health-care providers under a standardised, branded set of services will improve the quality and accessibility of services. The popularity of the idea can be gauged by its rapid growth worldwide: the number of social franchises have doubled every 4 years since 1994, and, by 2015, more than 90 such programmes existed in 40 low-income and middle-income countries. Full-Text PDF Open AccessSetting the record straight on social franchisingZubia Mumtaz, in her Comment in The Lancet Global Health (February, 2018),1 questions the effectiveness of social franchising as a method for expanding access to high-quality health care. As a long-time practitioner in the field of social franchising, I have seen how the social franchising model has evolved to become much more effective than the examples reviewed by Mumtaz. Unfortunately, Mumtaz generalises the failings of one narrow application of the model to the whole field of social franchising. Full-Text PDF Open Access