Physicians in private practice: reasons for being a social franchise member

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Description

Evidence is emerging on the cost-effectiveness, quality and health coverage of social franchises. But little is known about the motivations of providers to join or remain within a social franchise network, or the impact that franchise membership has on client volumes or revenue earnings. Methods (i) Uncontrolled facility based of a random sample of 230 franchise members to assess self-reported motivations; (ii) A 24 month prospective cohort study of 3 cohorts of physicians who had been in the franchise for 4 years, 2 years and new members to track monthly case load and revenue generated. Results The most common reasons for joining the franchise were access to high quality and cheap drugs (96.1%) and feelings of social responsibility, (95.2%). The effects of joining the franchise on the volume of family planning services is shown in the 2009 cohort where the average monthly service volume increased from 18.5 per physician to 70.6 per physician during their first 2 years in the franchise, (p<0.01). These gains are sustained during the 3 rd and 4 th year of franchise membership, as the 2007 cohort reported increases of monthly average family planning service volume from 71.2 per physician to 102.8 per physician (p<0.01). The net income of cohort 2009 increased significantly (p=0.024) during their first two years in the franchise. The results for cohorts 2007 and 2005 also show a generalized trend in increasing income. Conclusions The findings show how franchise membership impacts the volume of franchise and non-franchised services. The increases in client volumes translated directly into increases in earnings among the franchise members, an unanticipated effect for providers who joined in order to better serve the poor. This finding has implications for the social franchise business model that relies upon subsidized medical products to reduce financial barriers for the poor. The increases in out of pocket payments for health care services that were not price controlled by the franchise is a concern. As the field of social franchises continues to mature its business models towards more sustainable and cost recovery management practices, attention should be given towards avoiding commercialization of services.

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RESEARCH

OpenAccess

Physiciansinprivatepractice:reasonsforbeinga
socialfranchisemember
DaleHuntington
1*
,GaryMundy
2
,NangMoHom
3
,QingfengLi
4
andTinAung
3

Abstract
Background:
Evidenceisemergingonthecost-effectiveness,qualityandhealthcoverageofsocialfranchises.But
littleisknownaboutthemotivationsofproviderstojoinorremainwithinasocialfranchisenetwork,ortheimpact
thatfranchisemembershiphasonclientvolumesorrevenueearnings.
Methods:
(i)Uncontrolledfacilitybasedofarandomsampleof230franchisememberstoassessself-reported
motivations;(ii)A24monthprospectivecohortstudyof3cohortsofphysicianswhohadbeeninthefranchisefor
4years,2yearsandnewmemberstotrackmonthlycaseloadandrevenuegenerated.
Results:
Themostcommonreasonsforjoiningthefranchisewereaccesstohighqualityandcheapdrugs(96.1%)
andfeelingsofsocialresponsibility,(95.2%).Theeffectsofjoiningthefranchiseonthevolumeoffamilyplanning
servicesisshowninthe2009cohortwheretheaveragemonthlyservicevolumeincreasedfrom18.5perphysician
to70.6perphysicianduringtheirfirst2yearsinthefranchise,(p<0.01).Thesegainsaresustainedduringthe3
rd
and4
th
yearoffranchisemembership,asthe2007cohortreportedincreasesofmonthlyaveragefamilyplanning
servicevolumefrom71.2perphysicianto102.8perphysician(p<0.01).Thenetincomeofcohort2009increased
significantly(p=0.024)duringtheirfirsttwoyearsinthefranchise.Theresultsforcohorts2007and2005alsoshow
ageneralizedtrendinincreasingincome.
Conclusions:
Thefindingsshowhowfranchisemembershipimpactsthevolumeoffranchiseandnon-franchised
services.Theincreasesinclientvolumestranslateddirectlyintoincreasesinearningsamongthefranchise
members,anunanticipatedeffectforproviderswhojoinedinordertobetterservethepoor.Thisfindinghas
implicationsforthesocialfranchisebusinessmodelthatreliesuponsubsidizedmedicalproductstoreducefinancial
barriersforthepoor.Theincreasesinoutofpocketpaymentsforhealthcareservicesthatwerenotprice
controlledbythefranchiseisaconcern.Asthefieldofsocialfranchisescontinuestomatureitsbusinessmodels
towardsmoresustainableandcostrecoverymanagementpractices,attentionshouldbegiventowardsavoiding
commercializationofservices.
Keywords:
Socialfranchising,Reproductivehealth,Myanmar

Introduction
Therehasbeensomevariationinthetypesofproviders
Duringthepastdecadesocialfranchiseshavemovedwhoaremembersofasocialfranchise,butingeneral
fromanemergent,proofofconceptstageofdevelop-thefollowingcharacteristicsdefineasocialfranchise:
menttobeingestablishednetworksofprivatesectorclinicsareoperatorowned,paymentstotheproviderare
providersforreproductivehealthandotherprimarycarefeeforservice(andaremadebythepatient,athird
services.Atthecloseof2011therewere59franchisedparty,voucherorothersystem),servicesarequalitycon-
networksofover150,000privatepracticeproviderstrolled/standardizedandincludebothfranchiseand
spreadover35lowandmiddleincomecountries,serv-non-franchisesupportedservices,[2,3].
inganestimated31millionpoorpatientsannually[1].Thegoalsofasocialfranchisenetworkhaveremained
remarkablyconsistentoverthisperiodofgrowth:(i)Ac-
*
1
Correspondence:huntingtond@wpro.who.int
cess:increasecoveragethenumberofprovidersand
ReproductiveHealthandResearchDepartment,WorldHealthOrganization,
healthcareservicesoffered;(ii)Cost-effectiveness:
Geneva,Switzerland
Fulllistofauthorinformationisavailableattheendofthearticle
©2012Huntingtonetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

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provideaserviceatanequalorlowercosttootherser-
vicedeliveryoptionsinclusiveofsubsidyorsystemcosts;
(iii)Quality:provideservicesthatadheretoqualitystan-
dardsandimprovethepre-existinglevelofquality;and
(iv)Equity:serveallpopulationgroups,emphasizing
thoseinneed,[3,4].Thebasicbusinessmodelforthe
franchiserhasalsoremainedlargelyunchangedaswell:
thefranchiserisdependentuponexternalfundingto
supportthecostsofnetworkmanagement,commodity
subsidies,qualityassurance.Somefranchiseshavebeen
movingtowardsmorecommercialmodelsofoperating
thenetworks(e.g.,chargingmembershipfees),butnone
operateonacostrecoverybasis.
Thespeedatwhichtheprivatesectoringeneraland
socialfranchisesinparticularhaveexpandedoperations
hasoutpacedtheavailabilityofevidenceontheircost-
effectiveness,changesinservicequality,impacton
healthcoverage,outcomesandequity,[5,6]Someevi-
denceisemergingthatindicatessocialfranchisedhealth
serviceshavehadapositiveimpactonthenumberofre-
peatusersoffamilyplanning,[7,8],servicequalityas
perceivedbyclients[9],andthefranchise'sabilityto
servepoorandvulnerablepopulations[10].Butthere
hasbeeninsufficientattentioninthepublishedliterature
oneitherthemotivationsofproviderstojoinorremain
withinasocialfranchisenetwork,ortoevaluatetheim-
pactthatfranchisemembershiphasonclientvolumesor
revenueearnings,[11].Withpricecapitationsoftenset
belowtheproviders

customaryfeesandtheincreased
administrativeburdensoffranchisedmembership,the
motivationsofproviderstojoinandremainwithinaso-
cialfranchisearepoorlyunderstood.Thisinformationis
criticallyimportantgivenrecentevidenceonrelative
highcostsassociatedwithmanagingafranchise[12].
However,thereisingeneralverylittleevidenceinthe
publishedliteratureonthesustainabilityofsocialfran-
chisemodels,[13].
ThisstudyofprovidersintheSunQualityHealthnet-
workinMyanmaraddressesthisgapintheevidence
baseonsocialfranchisesthroughitsexplorationofpro-
vidermotivations

bothfinancialandnon-monetary

forjoiningandremaininginasocialfranchise.
Settingofthestudy
PopulationServicesInternational/Myanmarestablished
theSunQualityHealth(SQH)franchisein2001andby
theendof2011thenumberofactivemembersinthe
networkreached1,462.Inlate2008therewere748
physician-membersofSQHwhoprovidedReproduct-
iveHealth(RH)services(outofatotalof797SQHac-
tivemembers)spreadover140townshipsin12states.
Physiciansarecarefullyselectedtojointhefranchise
throughasubjectiveassessmentconductedbySQH
management,basedontheprovider'sreputation,length

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ofservice,interesttoservicesavailableinthenetwork,
theaccessibilityoftheclinictopoorandthecliniccon-
ditions.Assuch,SQHmembersmaybesomewhatdif-
ferentthanthegeneralpopulationofprivatepractice
physiciansinMyanmar.ProviderswhojointheSQH
franchisearefeeforservice,licensedGeneralPracti-
tionerslocatedinperi-urbanareasofcitiesandsmall
townswheremultipleothersourcesofcareareavailable,
includinggovernmentclinics.Theyworkfull-timein
theirclinics,manykeepingtheirclinicopenuntil7or
8pm.Physiciansareenrolledthroughaone-weeklong
inductiontraining,inbatchesofapproximately20.An-
nuallyaround100newmembershavebeenaddedtothe
franchisenetworksinceitslaunch
MembersoftheSQHfranchiseprovidebothfran-
chisedsupported(familyplanning,TB,pneumonia,mal-
ariaandHIVtesting)andnon-franchisedservices.For
thefranchisesupportedservices,theprovideragreestoa
pricecapitationonthemedicalproduct(whichishighly
subsidized)andconsultationfees.However,fornon-
franchisesupportedservicestherearenocapitations.
Franchisemembersalsoprovidemonthlyreportsonthe
volumeofconsultationsandcommoditiessoldforthe
franchisesupportedservicesandalsoagreetoadhereto
servicequalitystandardsincludingperiodicqualitycon-
trolvisits.Inreturnthefranchisemembersbenefitby
signage(thatindicatesqualitystandardstopatients),
receivedmedicalproductathighlysubsidizedprice,in-
servicetrainingandup-todateinformation.
Studydesign
Theresultsfromtwoseparatestudyelementsare
reportedonhere.Oneelementusedanuncontrolledob-
servationaldesign:230SunQualityHealthclinicswere
randomlyselectedwithprobabilityproportionatetosize
basedonaveragefamilyplanningcaseload(SQHstatis-
ticaldatasource).Fromthissampleoffacilities,228
memberphysiciansagreedtobeinterviewedfrom100
townshipsin10statesanddivisionsspreadacross
country.
Thesecondelementutilizedaprospectivecohort
studydesigntoexaminechangesintheproviders'case
loadvolumeandincomeoveratwoyearperiod.Based
onanecdotalexpertopinionfromtheSQHfranchise
management,thefulleffectsofjoiningthefranchise
wereestimatedtobecomeapparentonlyafteraperiod
oftimehadelapsedaftertheproviderjoinedthefran-
chise(inordertoallowforthecommunityservedto
recognizethebenefits).Thereforea2yearstudyperiod
wasusedinthecohortstudytoallowforthemoresus-
tainedeffectstobeevident,andtoassessifdifferent
cohortsoffranchisemembersareexperiencingsimilar
trajectoriesofrevenueandcaseloadgrowth.We
selected3cohortsofproviderstoexplorethissupposed

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2yeareffect:providerswhojoinedthefranchisein2005,
2007and2009(i.e.,thosewhohadbeeninthefranchise
4years,2yearsorwerenewmembersatthetimeofour
study).
Samplecharacteristics
Themajority(86.0%)oftheprovidersinthefacility-
basedsurveywerebetween44

59years,meanagewas
52.5years.Approximatelytwothirdsweremale(62.7%)
andhadbeenSQHmembersfor4yearsorlonger(69%).
Onaveragetheseprovidershavebeenworkingfor
16.6yearsattheclinicwheretheinterviewwascarried
out.TheoverallexperienceasGeneralPractitionerswas
24.1yearsonaverage
.
AnecdotalevidencefromSQH
franchisemanagementsuggeststhatthesecharacteristics
arecommonwithothermembersofthefranchise,asre-
cruitmenttargetsoldermoreestablishedphysiciansof
knownquality.
Allthephysicianswhojoinedthefranchisenetwork
duringeachofthe3selectedyears(2005,2007and
2009)wereaskedcompleteaspeciallydevelopedform
thatreportedmonthlycaseloadofallclienttypes(fran-
chisesupportedandnot),netandgrossincome.Of
those266providersweapproached,81.2%(n=216)
agreedtotakepartinthestudy.Theenrolledproviders
camefrom78townslocatedin13provincesofMyan-
mar.DatawascollectedbetweenMay2009andApril
2011(24months).
Theattritionratewasinitiallyhigh(6.9%)duringthe
first6monthsofdatacollection,(Table1)whichledus
tointroduceamonetaryincentiveof15US$perquar-
terforallproviderswhoreturnedacompletedsum-
maries.Inaddition,providerswhowerefullycompliant
for3consecutivemonthswereputintoalotterythat
awarded32providerswithdifferentmedicalproducts
(e.g.,pediatricsstethoscopes,Glucometer,minorsurgi-
calkits).Thecombinationofthemonthlycashincen-
tiveandlotteryprizesforsustainedcompliancehadthe
effectofloweringtheattritionrateto<2%forthe
remaining18monthsofthedatacollectionperiod.
Therewerenosignificantdifferencesbetweenthepro-
viderswhoagreedtotakepartintheprospectiveco-
hortstudyandothermembersofSunQualityHealth
Franchisewhowerenotinthestudyintermsoftheir
gender,ageandyearspracticingmedicine

withthe

Page3of8

exceptionofthe2009classwhichhadslightlymore
womenprovidersaccepttotakepartinthecohort
study,(p<.081).
Cohortstudydataanalysis
Thecohortstudymeasuredthemonthlycaseloadfor22
medicalservicesthatbelongto4categories:Family
Planning,MaternalHealth,ChildHealthandOther.The
datasetcontainedafewmissingvaluesassomeprovi-
dersfailedtoreportonall22servicesorincomevari-
ablesatsometimesduringthe24monthreporting
period.Thefinaldatasetusedinouranalysiscontained
96,448recordsofmedicalservices,withamissingrate
of10%(n=11,264missingvalues),aquitelowmissing
ratefora24-monthprospectivecohortstudy.Explora-
torydataanalysisindicatesthattherelationshipbetween
servicevolumeandtimeisgenerallylinear,solinear
interpolationmethodwasusedtoimputethemissing
values.
Grossandnetincomesarealsoreportedbytheparti-
cipantsinthisstudy.Thenumbersofrecordsofboth
incomesare4,384,whiletheyshouldbe4,896inaper-
fectlybalancedpaneldata.Themissingrateisthesame
asthatofmedicalservices,10%.Sincetherelationship
betweenincomeandtimealsoappearedtobelinear,we
imputedthemissingvaluesofgrossandnetincomewith
linearmethodsaswedidforthemedicalservicesdata.
Thelongitudinalmodelweusedintheanalysisofthe
cohortstudyisformallyexpressedinthefollowingway.
Y
it
¼
U
i
þ
β
0
þ
β
1
U
i

N
0
;
v
2
ε
it

N
0
;
τ
2
Thisisalinearmodelwithrandomeffectwhere
Y
it
is
theoutcomevariablereportedbyprovideriattimet.
U
t
isprovider-specificrandomeffect,usedtoadjustforthe
unobservedheterogeneityamongproviders;forexample,
it

sreasonabletoexpectthatsomepersonalitycharacter-
isticsmightaffectservicevolumesandincomeabove
andbeyondthefranchisesignageandproducts.The
studydidn

tmeasurepersonalitytraitssothisvariableis
usedinthemodeltoreflectthesetypesofunobserved
effectsthatcouldleadtoinconsistentmodelestimates
(whicharecommonincross-sectionalstudies).
X
it
isthe

XitþεitTable1CohortStudySamplingResults
YearofCohortTotalSQHmembershipin2009TotalenrolledinsampleTotalreporting/includedinanalysisAttritionAttritionRate
2005765852915.5%
200787767545.3%
200910382771315.9%
Total2662162042612.0%

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Page4of8

covariatesofprovideriattimet.Ourstudyonlycol-significantlymorelikelytocitesocialresponsibility
lectedtime-invariantprovidercharacteristics(e.g.,gen-(p=0.02)andhavingnoperceivedriskofdecreasedearn-
der,ageatjoiningthefranchiseanddateofjoiningtheings(p=0.03)asmotivatingfactorsforjoiningthefran-
franchise).Theinterpretationofcoefficientsissimilartochise.Otherimportantconsiderationswerebeingableto
across-sectionalmodel

thechangeintheoutcomeavailoftrainingcourses(87.7%)andopportunitiesfor
variablethatisbroughtaboutbyoneunitchangeincov-professionalnetworking(55.7%)thatcamewithfran-
ariates.Themodeldiagnosisresultsdidn

tfavorthein-chisemembership.Althoughinmanysocialfranchises
clusionofmorecovariatesbecausethesamplesizewasmemberscommonlyreportasenseofsocialresponsibil-
relativelysmallandinclusionofmorecovariatessignifi-ity,thestrengthofthesentimentinhelpingthepooras
cantlyreducedthemodel

sstatisticalpowerintestingbeingakeymotivationforbeingamemberofasocial
thesignificanceofcoefficients.franchiseissomewhatuniquetotheMyanmarnetwork,
Thereareseveralapproachesavailabletofitthismodelwhiletheinterestintrainingandaccesstodrugsiscom-
[14,15].Inthisstudy,thenumberofprovidersisrela-montomostsocialfranchises.Approximatelyonehalf
tivelysmallandthelengthoftimeisshort;wecouldnot(52.1%)oftheSQHmembersreportedthattheirearn-
findconclusiveevidencesupportinganyparticularcor-ingshaveincreasedasaresultofjoiningthefranchise,
relationstructureinthedata.ThereforeweusedGener-whichtheyattributedtoincreasedsalesoftheprice-
alizedEstimationEquation(GEE)methodbecauseitcancontrolledinjectablecontraceptive

aswellasgeneral
ensuretheconsistencyofestimatesevenwhenthespeci-increaseinpatientsforotherreasons.Thisself-reported
fiedcorrelationstructureisnotexactlythetruecorrel-increaseinrevenueandcaseloadisexaminedinmore
ationstructure,andbecausethenumberofprovidersisdetailthroughtheprospectivecohortstudy.
relativelysmallandthelengthoftimeintervalisshort,
[16].Afterweexaminedaseriesofrelevantplotsandesti-
Cohortstudyelement
matesofAutoCorrelationFunction(ACF),wedecidedtoInouranalysis,thetrajectoriesofthethreecohortsof
useanautoregressivemodeloforder1(AR1)correlationtheSQHfranchisearecomparedagainstthemonths
structureforgrossandnetincomesandallmedicalser-sinceeachjoinedthefranchise.Forexample,because
vicevariables,exceptonemonthinjectionwhichdisplayscohort2009joinedthefranchise24monthslaterthan
exchangeable(uniform)correlationstructure.cohort2007did,theperformanceofcohort2009inthe
24
th
monthshouldbecomparedtotheperformanceof
Results
2007inits1
st
monthofreporting,i.e.bothattheirre-
Thefindingsfromthefacilitybasedstudyelementspective24
th
monthinthefranchise.Similarlythe24
th
revealedthatthemostcommonreasonsgivenbyphysi-monthofreportingforcohort2007iscomparedtothe
stciansforjoiningtheSunQualityHealthfranchisewere1monthofreportingforcohort2005,i.e.,bothareat
accesstohighqualityandcheapdrugs(96.1%)andfeel-theirrespective24
th
monthinthefranchise.
ingsofsocialresponsibility,i.e.,helpingthepoorAsshowninFigure1,eachofthethreestudycohorts
(95.2%).Oldermembers(55

59yearsofage)wereexperiencedincreasesinthenumberoffamilyplanning

84420Months since Joining the Franchise
cohort2005cohort2007cohort2009
Figure1
NumberofFamilyPlanningConsultationsbyProviderCohort.

27

Table2LongitudinalModelResultsfor4categoriesofhealthservicemonthlycaseloadbycohort
Variable
BirthSpacingMethodsMaternalHealthServicesChildHealthServicesOtherHealthServices
Cohort2007v.s.Cohort2009v.s.Cohort2007v.s.Cohort2009v.s.Cohort2007v.s.Cohort2009v.s.Cohort2007v.s.Cohort2009v.s.
Cohort2005Cohort2007Cohort2005Cohort2007Cohort2005Cohort2007Cohort2005Cohort2007
Cohort

45.22**

33.00**

3916

49***

27**

33
(

87.09--3.36)(

61.62--4.38)(

112.22-34.32)(

19.77-51.71)(

81.98--15.18)(

51.24--2.30)(

8.45-2.56)(

5.02-10.58)
Gender(reference:Male)85.90***37.02**

19

2478***34***53
(40.30-131.51)(7.83-66.20)(

98.69-60.94)(

60.51-12.39)(41.51-114.29)(8.75-58.67)(

1.17-10.83)(

5.33-10.58)
AgeatJoining

3.77**

0.45

6**

1

4***

1

00
Franchise
(

6.86--0.68)(

1.81-0.90)(

10.95--0.15)(

3.05-0.35)(

6.28--1.36)(

1.82-0.50)(

0.61-0.21)
Constant314.39***112.44***442***189***317***120***27***
(159.26-469.53)(38.16-186.71)(170.99-713.99)(96.54-282.05)(193.72-441.27)(56.00-183.03)(6.97-47.78)
Observations3,0483,6483,0483,6483,0483,6483,048
Numberof127152127152127152127
Providers
Note:95%confidenceintervalsinbrackets,***p<0.01,**p<0.05,*p<0.1.

(

0.30-0.44)
11(

9.36-31.13)
3,648215

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consultationsduringthe24monthsofdatacollection.
Theeffectsofjoiningthefranchiseonfamilyplanning
servicesisclearlyshowninthe2009cohortwherethe
averagemonthlyservicevolumeincreasedfrom18.5per
physicianto70.6perphysicianoverthe24monthstudy
period,(p<0.01).Theincreaseduringthefirst24months
ofmembershipinthefranchiseappearstobesustained
duringthesecond24monthperiodaswell,asshownin
thefindingthatthe2007cohortreportedasignificant
increaseofmonthlyaverageservicevolumefrom71.2
perphysicianto102.8perphysician(p<0.01).These
effectsappeartobediminishedduringthethird
24monthperiodoffranchisemembership,asthe2005
cohortreportednosignificantchangeinfamilyplanning
servicevolume.Thispatternshowstheaccumulative
positiveimpactofjoiningthesocialfranchiseonthe
medicalservicevolumeandincomeofproviders.The
MinistryofHealthinMyanmarreportednoincreasein
theuseoffamilyplanningbetween2009

2011inthe
stateswherethecohortstudywasconducted,[17],al-
thoughthisdataisatahighlevelofaggregationandis
oflimitedvalueinmakingdirectcomparisonstothe
studysites.Priortothestudyperiodthenationalfertility
andreproductivehealthsurveyreportedanincreasein
contraceptiveprevalence.Ifthatwasthebeginningofa
trenditcouldsuggestthattheSQHprovidersinour
studywerebenefitingbyanoverallincreaseinfamily
planninguseinthecountry.
Ourlongitudinalresultsofchangesinmedicalser-
vices,summarizedinTable2,indicatethatthelonger
theproviderremainsinthefranchise,thegreaterlikeli-
hoodthattherewillbeincreasesinthecaseloadofchild
healthservices(significantdifferences),andmodest(al-
thoughnotstatisticallysignificant)increasesinmaternal
andothertypesofservicecaseloads.Duringthe24-

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monthperiodwhenthedatawerereported,theaverage
monthlyvolumeoffamilyplanningservicesofcohort
2005is45.22morethanthatofcohort2007,anddiffer-
enceisstatisticallysignificant(p<0.05).Cohort2007
alsohadalargermonthlyvolumeoffamilyplanningser-
vicesthancohort2009did.Thesamepatternis
observedforchildhealthservices.Cohortswhojoined
thefranchiseearlierclearlywereperformingbetterwith
familyplanningservicesthancohortsjoinedlater.How-
ever,formaternalhealthorothertypesofhealthser-
vices,theimpactofjoiningthefranchiseisunclear.
Thereisanimportantdifferenceinthegenderofthe
SQHproviders:Womendoctorsperformedbetterthan
theirmalecounterpartsintermsofbothbirthspacing
methodsandchildhealthservices.Weconductedsensi-
tivityanalysestoinvestigatethepotentialeffectsthata
singleorsmallgroupofprovidersmaybedrivingthe
cohort

soveralltrajectoryofchangeinfamilyplanning
servicevolume(notshowninTable2).Althoughthere
were2providerswhoexhibitedlargeincreasesinfamily
planningconsultations,removingthesecasesfromthe
analysisdidnotsignificantlychangetheregression
coefficients.
Changesinincome
TheresultsinFigure2showthatafter24monthsthe
netincomeofcohort2009increasedsignificantly
(p=0.024)andreachedapproximatelythesamelevelas
providerswhohadbeeninthefranchisefor2years(i.e.,
2007).Furthermore,sincethecoefficientoftimeinthe
regressionmodelispositiveandstatisticallysignificant,
weconcludethattheincomeforthe2009cohortisin
anincreasingtrenddespitethefluctuation(whichis
probablyduetotheeffectsofseasonalillnessesonclinic
visits).

80244Months since Joining the Franchise
cohort2005cohort2007cohort2009
Figure2
Trendsinnetincomebystudycohort.

72

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Theresultsforcohort2007showthatduringthesec-
ondandthirdyearoffranchisemembershipproviders
netincomedidnotincreasesignificantly;however,be-
causethecoefficientoftimeintheregressionmodelis
positiveandstatisticallysignificant,weconcludethat
themonthlynetincomeforthiscohortisinageneral-
izedincreasingtrenddespitethefluctuationsshownin
thefigure.Thecohort2005exhibitedthesamepattern:
nosignificantincreasebutageneralizedtrendtowards
largernetincomes.Overall,thethreecohortsareon
thedifferentstagesofthesametrajectoryintermsof
netincomegrowth,withshortspikesthatareprobably
associatedwithseasonalillnesses.Thetrendsforgross
incomebycohortwereessentiallythesame(not
shown).
Sensitivityanalyseswereconductedtoinvestigatethe
potentialeffectsthatasingleorsmallgroupofproviders
maybedrivingtheoveralltrajectoryofchangeinnet
andgrossincome.Althoughtherewas1providerwho
exhibitedaverylargepeakincomeinMay2010,there
wasnosignificanteffectontheoverallestimationofthe
modelsincedroppingthatprovideronlyleadtoanun-
noticeablechangetomodelresults.
Discussion
TheSQHmembersreportedastrongsenseofsocial
responsibilitytowardsthepoorandidentifiedwiththe
missionofPSI/Myanmarinensuringequitableaccess
toneededhealthservices.Althoughnotconclusive,the
findingsinthisstudyaresuggestiveofhowtheSun
QualityHealthfranchiseisexpandingcoverageofre-
productivehealthservices,notablyfamilyplanning,
throughagrowthinthenumberofclientsbeingserved
byitsmemberphysicians.Thetimingofthisstudyfol-
lowsuponmixedevidencefromearlyresearchthat
suggestscontraceptiveprevalencehadincreased,so
perhapstheincreaseinfamilyplanningclients
observedinthefranchisedclinicsispartofalarger
trendtowardsuptakeincontraceptiveuseinMyanmar.
Interestingly,therewasageneralizedincreaseinthe
caseloadofother,non-franchisedservicesaswell,par-
ticularlychildhealth(e.g.,seasonalillnesses).These
spill-overeffectsfromthe

fractionalfranchise

model
ontoothertypesofhealthcareservicesbeingprovided
bytheSQHphysiciansareanindicationofhowthe
franchise

squalityimprovementmeasuresareincreas-
ingpatientsatisfactionamongthisselectgroupof
healthcareproviders.
Theincreasesinclientvolumestranslateddirectlyinto
increasesinearningsamongtheSQHmembersinthis
study.Althoughthemotivationforincreasingincome
wasnotcitedbythemajorityofprovidersasanimport-
antconsiderationforjoiningthefranchise,olderphysi-
ciansweremorelikelytovaluethatSQHmembership

Page7of8

posednorisktotheirincome.Afterjoiningthefran-
chise,theincomeofthephysicianswasseentoin-
creaseinasteadytrendthroughthefirst6yearsof
membership

bothforthefranchisedfamilyplanning
servicesaswellasnon-franchisedservices.Thisfinding
hasimplicationsforfranchisebusinessmodel,suggest-
ingthatothertacticsforreducingfinancialbarriersfor
thepoorshouldbedeveloped.Forexample,theSQH
franchisemanagementcouldturnattentiontodevelop-
ingtheirmembership'sbusinesscompetencies,in
additionprovidingsubsidizedmedicalproductsasa
meansforensuringequitableaccesstoreproductive
healthservices.Crosssubsidization,slidingscalesand
feewaiversmightreasonablybeintroducedasclinic
revenuescontinuetoincrease.Alternatively,theSQH
franchisemanagementmayconsiderpassingsomeof
thefranchisecostsontothemembers,throughchar-
gingmembershipfees.
Theincreasesinservicevolumeandrevenueare
supportedbyoutofpocketpaymentsforhealthcare
servicesthatwerenotpricecontrolledbythefranchise
isaconcern.Asthefieldofsocialfranchisescontinues
toexpandandmatureitsbusinessmodelstowards
moresustainableandcostrecoverymanagementprac-
tices,attentionshouldbegiventowardsavoiding
commercializationofservicesleastthegoalofserving
thepoorbecomesthwartedbyincreasedpaymentsfor
otherservices.Integrationintonationalsocialhealth
insuranceschemes,theuseofvouchersandother
typesofdemandsidefinancingcanbedevelopedin
Myanmarandothersettingstolessentheoutof
pocketexpensesforobtainingneededprimaryhealth
careservicesbythepoor.
Competinginterests
Theauthorsdeclarethattheyhavenocompetinginterest.
Authors

contributions
DHconceivedthestudy;DH,TAandNMHdesignedthestudy;NMHandLQ
conductedthedataanalysis;allauthorsparticipatedintheinterpretationof
thefindingsandpreparedtextforthepaper.Allauthorsreadandapproved
thefinalmanuscript.
Acknowledgements
ThestudywassupportedbyagrantfromtheUNDP/UNFPA/WHO/World
BankSpecialProgrammeofResearch,DevelopmentandResearchTrainingin
HumanReproduction(HRP),WorldHealthOrganization,Geneva,Switzerland
andwasconductedbyPopulationServicesInternational/Myanmar.The
resultsandinterpretationpresentedinthispaperdonotrepresentthe
officialpositionoftheWorldHealthOrganizationorPopulationServices
International,andaresolelyattributabletotheauthors.
Authordetails
1
ReproductiveHealthandResearchDepartment,WorldHealthOrganization,
Geneva,Switzerland.
2
PopulationServicesinternational,273KimMaStreet,
BaDinhDistrict,HaNoi,Vietnam.
3
PSI/Myanmar,16WestShweGoneDine
4thStreet,BahanTownship,Yangon,Myanmar.
4
3101HuntingdonAve.,
Baltimore,MD21211,USA.
Received:13April2012Accepted:3July2012
Published:1August2012

Huntington
etal.HealthResearchPolicyandSystems
2012,
10
:25
http://www.health-policy-systems.com/content/10/1/25

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