Correspondence
Setting the record
straight on social
franchising
Author’s reply
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,1 and McBride lists
some of them.
She does not, however, provide
rigorous evidence that these social
franchise programmes are success­
fully 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.2 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,
www.thelancet.com/lancetgh Vol 6 June 2018 e612
a social franchise in Bihar, India, 3 Mohanan M, Babiarz KS, Goldhaber-Fiebert JD,
Miller G, Vera-Hernández M. Effect of a
funded by the Bill & Melinda Gates
Foundation to deliver childhood
large-scale social franchising and telemedicine
program on childhood diarrhea and
diarrhoea and pneumonia services. pneumonia outcomes in India. Health Aff
2016; 35: 1800–09.
An embedded pre-post study 4 Mohanan M, Giardili S, Das V, et al.
found that the programme did not Evaluation of a social franchising and
telemedicine programme and the care
improve disease prevalences or provided for childhood diarrhoea and
appropriate treatment in a sample of pneumonia, Bihar, India.
67 950 children between 2011 and Bull World Health Organ 2017; 95: 343–52.
2014.3 Membership in the franchise
also did not significantly improve
health-care providers’ knowledge or
quality of care delivered.4
McBride’s letter has, perhaps
inadvertently, shed light on the
importance of differentiating pro­
cesses 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.
Copyright © The Author(s). Published by Elsevier
Ltd. This is an Open Access article under the
CC BY-NC-ND 4.0 license.
Zubia Mumtaz
zubia.mumtaz@ualberta.ca
School of Public Health, University of Alberta,
Edmonton, AB T6G1C9, Canada
1 Viswanathan R, Behl R, Seefeld CA.
Clinical social franchising compendium.
An annual survey of programs: findings from
2015. San Francisco, CA: The Global Health
Group, Global Health Sciences, University of
California, 2016.
2 Nyqvist 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.
London: Centre for Economic Policy Research, For World Health Partners see
2016. DP11515.
http://worldhealthpartners.org/