HIV antiretroviral therapy: can franchising expand coverage?

Between 6.5 and 11 million people are in need of antiretroviral therapy (ART) in developing countries.  Only 1.3 million are receiving it. With the public sector struggling to expand coverage, how can the private sector play a more significant role?  This paper reviews the experiences of franchising and its potential for HIV and AIDS services.

Public sectors suffer from serious and worsening shortages of staff, and from chronic organisational weaknesses including poor management, inflexible workforces, a lack of incentives and poor accountability. The result is that for many poor people in Africa, public health infrastructure is unavailable, difficult to access, or severely understaffed by qualified providers.

Meanwhile, the private sector is growing. Typically, there are more health care providers in private sectors than public – although many may not be qualified – and with lots of spare capacity.  Moreover, many health workers work in both sectors. Expenditures are now greater in private than public sectors in most poor countries, even for poor people. Those on the lowest incomes receive more of their health care from the private sector than do higher income groups. For many poor people, the choice of care is often not so much a choice between private and public, but between private and no care at all.

It is clear that the private sector offers huge potential to extend and maintain ART coverage. But the quality of care in private sectors is often low, and the challenge is to ensure that private providers achieve acceptable standards as well as coverage. Franchising may offer a way of achieving this in practice, thus maximising the prospects for universal access and associated prevention. 

Although developed for reproductive health services, more recently franchising has been adapted to offer general primary care. In Kenya, the Child and Family Wellness shops are selling high quality, price-controlled, essential drugs to semi-urban and rural populations, using a model that combines micro-credit and franchise principles and that is focused on financial sustainability. Private community health workers staff the rural shops, whilst private nurses provide clinic services in the more populated areas.

The benefits from franchising include:

• Franchising offers the potential to raise the quality of services by networking private providers and imposing common standards in return for enhanced income. 
• It can extend services rapidly and in places where public provision is weak. 
• It can provide competition for public services, thus creating incentives for inefficient government services to perform better to attract consumers and funding. 

It can also offer governments a vehicle for driving performance improvement: government bodies can themselves act as franchisor, thus creating an alternative to the human resource rigidities typical of the public sector and, for staff, an alternative to emigration to richer countries.  For governments that are seriously seeking change, franchising could be a major driver for sector reform – public and private.

ART and related HIV and AIDS services could reach many more of those in need if they were provided by the many health workers who work as private individuals or in private clinics or shops. Without subsidy, franchises can only provide services to those consumers able to pay the economic cost of producing them. But many poorer people are already paying unorganised private providers and a major objective of franchising is to improve the relevance and quality of the services they buy.  ART can be added to those services.

Source(s):
‘HIV antiretroviral therapy: can franchising expand coverage?’, DFID Health Resource Centre, by Roger England, June 2006 (PDF) Full document.

Funded by: UK Department for International Development (DFID)

id21 Research Highlight: 20 October 2006

Further Information:
Roger England
DFID Health Resource Centre
HLSP Institute
5-23 Old Street
London EC1V 9HL
UK

Tel: +44 (0) 20 7253 5064
Fax: +44 (0) 20 7251 9553
Contact the contributor: : roger.england@hlsp.org

UK Department for International Development's Health Resource Centre

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