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Entrepreneurship       Unleashed

The Indian Medical Association estimates that of the 450,000 private doctors in India, an estimated 5% provide family planning services. The chief reason for such low level of participation is that preventive care, to which category family planning belongs, has very little financial viability.

Unlike selling products, delivering clinical services is immensely complex. The providers need more sophisticated skills. Service marketing also makes transparent pricing difficult because the fee of the provider often varies with the location, skills and qualifications.

In such a context, prices to clients can be reduced only by creating a strong franchise that can generate large caseloads and achieve economies of scale. After about four years of programming, it is also evident that these caseloads cannot be limited to family planning.

There are an estimated 32,000 private doctors in Bihar and Jharkhand. Janani’s target was to train 800 doctors to form the franchisee network. The programme has so far trained over 800 private and government doctors, of which 620 became franchisees. Currently, only 174 are fully active. In this total franchisee 115 doctors have accepted franchisee network with a payment of Rs. 45,000/- as franchisee fee on yearly basis in 2^nd phase of Programme. In this 48 are currently following our norms and 18 clinics are being run by Janani directly.

Another deficiency of the network was the lack of exclusivity, thereby undermining profitability. Janani accepted any doctor wanting to become a franchisee, often resulting in many Surya Clinics within a town. (Some of the towns ended up having seven!) The caseload was divided and so was the franchisees’ interest.

Janani also did not collect a fee from the franchisees because a vertical family planning focus was not strong enough to induce enough caseloads and financial interest.

With four years of experience, Janani is now restructuring the Surya Clinic network which will ensure:

• Ensure exclusivity of clinic in each location
• Expand services to include reproductive health and general health
• Focus on surgical skills of doctors and undermedicalise routine procedures
• Integrate technologies more aggressively
• Establish infection control and waste disposal in each clinic
• Janani to have administrative control, fully or partially
• Janani’s own clinics to provide large enough caseloads to influence franchise norms
• Membership fee

Studies indicate that Surya Clinics serve a significant number of poor. The franchisee clinics in sub-district towns are doing this much better than the clinics located at cities and big towns (see table below.)
The network of 505 doctors is being rescaled to 360, at an average of six per district. Unlike the earlier plan where there was more than one Surya Clinic in a town, under the new plan there is only one per town. This gives economic viability to the value addition, and creates a conducive setting to enforce quality norms.

In order to strengthen the equity of the Surya Clinic franchise, and to establish benchmarks within the community, Janani has established 18 clinics either on its own or in partnership with a doctor or an entrepreneur. Janani hopes to achieve through its own clinics a “tipping point” of at least 15% of all services provided by the entire Surya Clinic network. This proportion of quality care, Janani hopes, will positively influence the quality of service at franchisee clinics. As of January 2008 the number of restructured clinic is 130 out of which 18  are Janani-owned and  112 are franchisees.

Based on a willingness to pay study in February 2003 in its clinics as well as among the community at large, Janani has made adjustments to the price structure.

As part of the franchise, Janani also arranges for infection control and waste disposal in each of the Surya Clinics. Swabs are taken regularly to independent agencies in order to detect infection levels, and the coordinators are trained to arrange for deep burial of hospital wastes or disposal through municipal facilities.

The basket of services under the franchise has also been expanded to include, besides comprehensive family planning, safe motherhood, child survival and general health. Doctors are expected to focus primarily on surgical skills. Janani helps by both undermedicalising and paramedicalising many services.

The Surya Clinics at the sub-district level use the Super Surya Clinics at the district level for referral. Where available, these Super Surya Clinics have specialists. Clients are sent back by the Super Surya Clinics to the Surya Clinic that referred them—this ensures local access to care, and the financial incentive to the referee.

A doctor performs a minilap tubal ligation without general anaesthesia. One of Janani’s objectives is to undermedicalise services.

A baby is born at a Surya Clinic. Surya services are being expanded from the earlier vertical family planning focus. Obstetric services, maternal & child health and menopausal care are part of the current package.

Larger range of services means larger client loads (below). This enables Janani to charge from each franchisee an annual membership fee (currently Rs 60,000 or US$ 1,300). All Surya Clinics now have (page 25) a standardized look.

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