Setting the record straight on social franchising
Authors: Julie McBride
Journal: The Lancet Global Health (2018)

Zubia Mumtaz, in her Comment in The Lancet Global Health (February, 2018),1Mumtaz Z Social franchising: whatever happened to old-fashioned notions of evidence-based practice?.Lancet Glob Health. 2018; 6: e130-e131Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar 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. Newer, more promising social franchises use a business-format franchise model whereby the franchisor defines the business system and establishes the brand's standards. Several groups are using business-format franchising to achieve measurable results: Child and Family Wellness (CFW) reports that nearly 500 000 clients are served annually through franchised clinics that are located in low-income areas where people previously did not have access to care. CFW has also been able to show efficiency gains over time, with the cost per client cut almost in half in the past 4 years (unpublished data). The annual operating cost for the franchisor has also consistently declined, from US$300 674 in 2014, to $160 000 in 2018, to manage a network of 65 clinics in rural Kenya (unpublished data). A recently completed 3-year independent randomised control trial showed that Living Goods is reducing under-5 mortality in Uganda by more than 27%.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 The study also showed that drug prices fell by 17% at clinics and drug stores near where Living Goods operates, and that the prevalence of fake drugs fell by 50%, suggesting positive competitive pressure. Some examples of successful social franchises in other sectors include Jibu (water), Sanergy and Roots (sanitation), Right Light (energy), Farm Shop (agribusiness), and Petal (girls' hygiene). There is a range of up-and-coming health-care businesses that are in the early stages of designing or operating their franchise system. Each of these initiatives presents a tremendous opportunity to show how the franchise model can be effectively applied to the global health-care sector. Woman 360, a franchise created by PharmAccess in Ghana, recently launched a hub-and-spoke system for maternal child health services in Ghana. Unjani (South Africa) and Access Afya (Kenya) are successful health-care businesses that have proven that they are impactful, sustainable, and replicable, and they are considering expansion through a franchise model. More investment in these promising social franchises, as well as more research, is needed. 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 franchising – Author's replyJulie 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,1 and McBride lists some of them. Full-Text PDF Open Access