Social franchising in healthcare: a systematic review and narrative synthesis of implementation and outcomes
Discussion
Our findings revealed a diverse and multifaceted landscape, with significant variations in implementation, outcomes and effectiveness of social franchises across different regions and health areas. The high prevalence of social franchises in LMIC countries highlights a strategic targeting of regions with significant healthcare challenges. These franchises are aligned with pressing health needs and align with global health priorities, addressing unmet FP demands; enhancing sexual, reproductive and maternal health services; and tackling communicable diseases like TB and malaria and child nutrition. This strategic focus is in line with previous reviews that emphasise the pivotal role of social franchising in improving reproductive health services in LMICs.5 12 13 62 63 However, health areas such as chronic disease and primary healthcare were significantly underrepresented in the social franchises we analysed.
Social franchises employed various interventions, primarily focusing on training and capacity building, service provision and increasing access to care, as identified in other systematic reviews.10 64 By addressing supply and demand-side barriers, they enhanced both the availability of health services and individuals’ ability to access them. However, there was comparably limited emphasis on promotion, demand creation, quality assurance and monitoring within these franchises.
We found that social franchises predominantly focused on health areas such as sexual and reproductive health and FP services, consistent with findings from other review studies.5 10 12 64 In contrast, another systematic review revealed that the majority of studies concentrated on HIV.63 Nevertheless, social franchises’ predominant focus on sexual and reproductive health services and FP could be due to the high demand and limited access in LMICs, as we found in our analysis. However, other important health issues, such as infectious diseases, non-communicable diseases and mental health, might receive less attention and funding in social franchise implementation. This can lead to an imbalance in healthcare delivery, where only certain aspects of health are improved, potentially creating inequities in care. Therefore, attention to other critical health areas is essential for a comprehensive and equitable healthcare approach.
In examining the landscape of social franchising, MSI and Private Sector Franchised and Affiliated Clinics stand out for their substantial role in the global delivery of FP services. This study’s method of analysing each franchise independently ensures that MSI’s and Private Sector Franchise’s wide reach does not skew the overall findings. Despite these franchises’ extensive impact, their broad-scale approach might not fully address the nuanced health needs specific to local communities. In contrast, smaller franchises such as the World Health Partners and the Sustainable Healthcare Foundation demonstrate a more localised focus, tailoring their services to meet urgent community-specific health challenges. These organisations have made significant contributions to local healthcare by improving access to essential drugs and healthcare services, showcasing the effectiveness of adaptive strategies that respond directly to local needs.
Most social franchises collaborated in some way with governments to integrate services into national health systems. Integrating franchise providers into local health infrastructure enhances programme sustainability, while public–private partnerships (PPPs) optimise resources and service continuity. However, for long-term impact, there is a growing argument to either integrate social franchises more deeply into government health systems or eventually transition operational control to the government itself. This strategic shift could ensure sustained support and scalability of healthcare services beyond the initial franchise interventions, promoting enduring health improvements across communities.
Healthcare franchising has shown mixed results in terms of impact and healthcare utilisation, with some franchises reporting increased client volumes, satisfaction and improved FP knowledge, while others struggled to reach target populations and maintain high utilisation rates among lower socioeconomic groups. Similarly, two reviews reported that while social franchising was positively associated with increased client volume and client satisfaction, it faced limitations in achieving health equity.5 12 62 This variability underscores the complexity and contextual sensitivity of healthcare interventions, highlighting that success hinges not just on the franchise model itself but also on the specific socio-economic, cultural and infrastructural environment in which it is implemented. Such findings align with other systematic reviews that emphasise the critical role of local implementation and support mechanisms.10 11
Positive health service outcomes, including improved access to healthcare and enhanced quality of care, highlight the potential of social franchising to significantly enhance healthcare delivery. Similar improvements in access to care through social franchising have been reported in other systematic reviews.5 10 However, contrasting evidence from another review indicates that being located in economically disadvantaged areas does not necessarily lead to equitable access across different wealth groups.12 While one review suggests that social franchising positively impacts the quality of care,10 others reported that franchising did not improve the overall quality of healthcare, cost-effectiveness or equity.5 12 14 However, our findings, along with those of other studies, indicate a lack of conclusive evidence to determine whether social franchising effectively improves the quality of healthcare.5 10 12 62 Nevertheless, the quality of healthcare in these initiatives can be further enhanced by advancing monitoring through the strategic use of digital technology and systematically integrating client feedback and evaluation mechanisms into continuous service improvement.38 65
The sustainability of social franchises is a critical concern, primarily due to their high dependence on donor funding and the provision of services that are often subsidised or free. This reliance raises questions about the long-term viability of these models once external funding diminishes. Many empirical studies have reported predominantly short-term outcomes within controlled contexts, leaving the long-term sustainability and impact of these interventions uncertain, as highlighted by other studies.10 62 This challenge underscores the need to develop innovative financing models and cost-sharing mechanisms that balance cost-effectiveness with accessibility. These models might include PPPs, tiered pricing systems based on income levels or integrating with national health systems to share costs and resources.
Digital technologies, particularly telemedicine, call centres and ICT, improved healthcare service delivery by enhancing quality monitoring, data collection and access to care in underserved areas. However, issues such as internet connectivity problems and high demand have impacted their efficiency and user experience. These findings are consistent with broader research that highlights the potential of telemedicine to transform healthcare delivery while also emphasising the need for effective management to address digital infrastructural challenges.66 Despite the promising benefits, previous systematic reviews have not thoroughly explored the integration of digital technologies within social franchises. Given the ongoing digital revolution, further research is needed to examine the role and impact of digital technology in health service delivery within social franchise models. This research should focus on identifying best practices for implementation, addressing technological and operational barriers and exploring how digital solutions can be optimised to enhance service quality and accessibility in social franchise.
Community mobilisation and marketing notably increased contraceptive use and healthcare awareness. However, challenges such as inadequate branding have limited their overall impact. Effective branding is crucial in social franchising, as it enhances brand recognition and consistency across health providers and facilities.11 13 To maximise impact, it is crucial to innovate branding strategies by employing dynamic media campaigns, harnessing digital platforms for targeted outreach and using real-time data to refine branding approaches.
Upon reviewing grey literature, we encountered numerous reports, which provide evidence but lack the rigor and detail necessary for comprehensive academic analysis. The lack of rigorous peer-reviewed evidence may be due to the focus of funders on service delivery rather than research. Major donors often avoid comprehensive data collection or independent evaluation to avoid negative implications,14 potentially indicating reporting bias. Future research on social franchising should focus on thoroughly documenting its effects and evaluating both its equity and cost-effectiveness, with an emphasis on understanding its role within the broader healthcare system and establishing a strong conceptual basis linking programme design to outcomes. To answer key questions about the feasibility and impact of social franchising, particularly regarding the equity in private sector interventions, more robust research designs are essential. Additionally, expanding research across diverse healthcare sectors and geographical regions, with attention to outcomes and trade-offs, will require global health investments aimed at filling evidence gaps and enhancing evaluation rigor.
The review faces several limitations. The reliance on diverse study designs introduces variability in methodological quality, which may affect the consistency of findings across studies. The exclusion of non-English literature and grey literature potentially limits the scope of evidence, particularly from low-resource settings where these sources might be more prevalent. Additionally, variability in outcomes across different contexts also complicates the synthesis of findings and the generalisation of recommendations.
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