The sale of medical care episodes in competitive private markets allows one to observe prices paid by buyers. Competitive forces and the absence of insurance programs in Myanmar make it plausible that the equilibrium prices for private medical care observed in Myanmar reflect what patients are willing to pay to purchase medical care episodes and what suppliers can comfortably afford to sell them for. This market solution to medical care provision succeeds in balancing supply with demand. It is well known to fail to provide quality and to protect the poor .
Protecting the poor requires subsidies and improving quality requires resources. To improve and monitor the quality of professional services there must be some type of data collection exercise. Somehow or other information about services provided needs to be collected, inspected, and feedback must be given to the provider with advice and/or incentives for improvement. Low capacity, competing priorities, and political opposition hinders efforts to achieve adequate quality regulation of the private practice of medical care. The problem is global . The social franchising solution used by PSI/Myanmar is to use the commodity distribution network to also serve as way to monitor and improve the quality of service.
In a social franchise, a network of private providers is created. There are two separate networks in PSI Myanmar: Sun Quality Health (SQH) network is primarily physicians and advanced health professionals while Sun Primary Health (SPH) providers typically have a lower level of training and often operate as mobile providers in an effort to reach those most at risk and in rural areas. In the franchised delivery model “Sun Field Leaders” serve as the quality supervisors and the distributors of subsidized commodities. The subsidies sustain the continued voluntary membership and they encourage providers to devote time and space to services they might not otherwise provide. Sometimes the providers devote 100% of their activities to services associated with the franchise, sometimes, as in a fractional franchise, the providers offer other services or products besides those of the franchise. PSI/Myanmar is an example of a fractional franchise. Private providers in the franchise also agree to receive regular visits by the franchisor dedicated to monitoring and improving service quality in the use of these commodities [4, 5]. The structural design of a social franchise allows one to determine separately the costs of solving public policy problems of subsidizing access and enhancing quality. We compare these costs to the private costs that households expend to solve their private problem of acquiring medical services. This analysis can thus produce estimates of the ratio of costs expended to supply the publicly valued aspects of medical care episodes to the costs that patients routinely pay to purchase privately valued episodes.
In 2009, PSI’s franchising department supported a team of over 1,700 private providers currently enrolled in PSI’s Network. There were 1006 and 741 in the Sun Quality and Sun Primary Health Networks, respectively in 2009. Social franchising activities were supported in part by four other departments within PSI’s organizational structure. (1) Social Marketing (423 staff); (2) Strategic Information (36 staff); (3) Finance (136 staff); and (4) Program Support (125 staff). These departments were supported by international technical advisors, senior advisors, an executive office team, the finance monitoring unit, and a special advocacy team, all of which fall under the leadership of PSI-Myanmar’s country director. Most critically, the social marketing department works to provide support to product branding as well communications, whilst strategic information facilitates the collection of routine data on products sales, distribution, and incentives.
There is emerging evidence that the PSI network of providers in Myanmar is able to improve service quality. The SPH members can attend two initial 3-day trainings, one month apart and then receive regular visits by field leaders and stocks of rapid diagnostic test kits and artemisin containing treatment packs. In an evaluation of PSI/Myanmar’s effects on quality of care, a team of researchers validated  and applied the use of an observed simulated patient to assess the management of a child with malaria by providers before and after adopting the PSI-malaria line of service . They found that workers enrolled in PSI’s malaria program achieved and sustained better performance in managing malaria for over 12 months . There is also evidence that Myanmar’s PSI network is able to target the poor. In urban areas, TB patients at SQH clinics were more likely to be in the poorest quintile compared to the general TB positive urban population . These promising results motivate the present investigation into the cost of PSI/Myanmar’s service improvement and delivery model.