The private sector is an important source of healthcare in low- and middle-income countries, with the majority of the care paid for out-of-pocket. Social franchises are one mechanism for improving the quality and access of care, through training, demand creation, and supervisory visits to private providers within a network. Population Services International (PSI) operates 22 social franchises in low- and middle-income countries worldwide. Knowing the wealth profile of social franchise clients is important for understanding the role franchises have in coordinated health systems.
Exit interviews were conducted in 2012 with PSI social franchise clients in Benin, Mali and the Democratic Republic of Congo (DRC). Population proportionate to size sampling was used to select facilities, based on client volume for the previous 1-3 months. In the DRC, the sample was first stratified by location – Kinshasa or a provincial capital (Mbuji-Mayi). An asset index and wealth quintiles, using principal components analysis, was created within the recent Demographic and Health Survey (DHS) for each country, for the national population, and restricted to the urban population only. Only assets found in both the DHS and exit interviews conducted at the PSI facilities were used. The first eigenvector of the assets in the DHS was multiplied by the standardized value of the asset in the exit interviews for each of the three samples. Cutoff points denoting the quintiles of the national and urban populations in the DHS were used to place franchise clients within a nationally representative wealth distribution.
Franchise clients in all three countries were markedly wealthier than the national population distribution, and were also wealthier than the distribution of urban residents, although the distribution was less skewed. In Benin, among the 535 clients interviewed, 76.8% were in the wealthiest quintile of the national distribution, while 39.8% were in the wealthiest quintile of the urban stratum only. Franchise clients in Benin came from all wealth quintiles, with 15.5% of clients in the poorest 40% of the urban population. In Mali, only 2.4% of the 293 clients interviewed were in the poorest 40% of the urban population, while 78.5% were in the wealthiest quintile of the urban stratum. In the DRC, 90.9% of the 242 clients were in the wealthiest national quintile; 41.7% were in the wealthiest urban quintile.
Results demonstrate that social franchises in these three West African countries serve a wealthier segment of the population, likely those who are able to afford out-of-pocket costs for private care. The relative wealth of social franchise clients must also be assessed within the context in which they are located, and all three of these West African franchise networks are concentrated in capital cities and other urban settings. Depending on the franchise goals, program managers can use this information to target middle-income clients, offer subsidies to the poorest, or continue to provide a high quality private sector alternative to those who can afford to pay, relieving a burden on stressed public systems.
Keywords: Private sector, equity, social franchise, West Africa