Originally published on the Maternal Health Task Force, A part of the Women and Health Initiative at the Harvard School of Public Health.
In India, 212 out of every 100,00 women die in childbirth. In Uttar Pradesh (UP), India’s largest state where over 200 million people live, this number is almost double – 359 out of every 100,000. Although the government of India has incentive programs to encourage the rural poor to deliver in institutions, the majority of the population relies on a complex network of informal and formal private providers – the former serving as the first point of contact due to proximity, and the latter being utilized for more complicated services.
In fact, in India overall, approximately 2/3 of households seek health care in the private sector. However when thinking of “private sector providers” – one must employ an elastic definition of the “private sector.” We do not mean a high-tech private hospital, but rather a local resident from the village who provides basic care to his or her neighbors.
This sector is highly fragmented: there is not a standard, typical provider profile, but most will have received minimal training at best – perhaps they worked in a hospital in the near-by town and have now returned to provide care out of their house in their village. Or they might sell medicines out of a small stall, informally advising their customers on basic ailments.
These providers are also unregulated – meaning the quality of care is inconsistent. As these providers are operating in the private sector, their focus is on earning a profit, a fact that puts them very much at odds with the needs of the rural poor. Preventative services – such as antenatal care, family planning, and postnatal care – generally offer low profit margins. To consistently offer this care, informal providers need encouragement and financial incentives. These same providers are also trusted members of these communities; they have important social connections and business acumen.
How can those of us working in maternal health empower these ubiquitous informal private providers to deliver quality services at the village level? World Health Partners (WHP) and Pathfinder International are partnering, using a social franchising approach, to leverage these rural human resources in order to extend maternal health coverage in UP.
To understand franchising, think about how the popular franchise Subway operates. Each Subway outlet, or franchisee, is individually owned and managed, but serves the same foot-long BLT in the same paper wrapping, always prepared before the customer – ensuring that whether you bite into that BLT in DC or Delhi you are guaranteed that same Subway taste. Franchisees benefit from the globally recognized branding, supply chain, etc. Social franchising operates, in essence, just like a commercial franchise does, but with the aim of providing a social good. WHP (the franchisor) brings standardization and ensures that a certain level of quality is available at all members of its branded network (franchisees) in rural India.
The network, branded ‘Sky’, links disparate private providers – such as the village chemist shop owner – to various levels of high quality care. As Sky members, providers can facilitate consultations with formally trained doctors via telemedicine, and refer clients to network clinics in peri-urban areas for physical care, including emergency obstetric care. Increased caseloads and stature in the community are among some of the highly valued benefits to the franchisee.
In return, franchisees must adhere to WHP’s quality of care standards, supported by Pathfinder’s extensive knowledge in community-based maternal health interventions, and meet monthly targets in less profitable, preventative maternal health services. Franchisees can continue to offer profitable curative services they delivered pre-membership, but must now also deliver these critical maternal health services.