Empowering Women Health Providers through Social Franchising: Stories from Kenya and Uganda

"Capturing the life stories of women providers involved in social franchising illuminates how they empower themselves when they can access training, finance, insurance schemes, and supportive supervision."

Qualitative research has illustrated that the experiences of women in the health workforce are shaped by cultural norms and power dynamics. The private sector can be attractive to women providers because it offers flexibility and a path to leadership that may be denied to them in the public sector. In 2018, the Strengthening Health Outcomes through the Private Sector (SHOPS) Plus project visited women franchise owners in Kenya and Uganda to better understand how social franchising has affected their lives. This report analyses the findings from these interviews, and it offers recommendations on how social franchises and the private sector overall could take a more intentional approach to improving women's empowerment outcomes.

As SHOPS Plus explains, while social franchising interventions were designed to achieve positive health outcomes and were not intended to improve gender equality, franchisors in some countries primarily involve female cadres such as midwives. As a result, social franchising may unintentionally help women providers overcome gender-related barriers, such as the perception - enforced by gender norms and expectations discouraging women from risk-taking - that women should avoid loans.

SHOPS Plus adopted an ethnographic approach, conducting 14 life history interviews with female owners of facilities affiliated with 5 social franchises in Kenya and Uganda. The team analysed interviews using the Social Franchising Empowerment Framework, which looks at 4 dimensions of empowerment - power over; power to; power within; and power with - to identify how they might manifest in social franchising.

The research found that social franchising empowers women providers. Across the 2 countries and 5 franchises, women franchisees reported positive changes as a result of franchising that correspond to the 4 aspects of empowerment. They reported the ability to offer an increased array of services demanded by their communities, and the self-confidence in knowing that they were able to perform these services well. For one nurse, when her husband, who was a doctor in the clinic, passed away she felt that people weren't sure she could meet their needs. She said that joining Population Services International (PSI) Uganda's ProFam network and participating in their training gave her significant confidence in her skills.

Franchisees pointed to several factors as contributing to their empowerment: external support (e.g., from husbands), technical skills training, business training and support, quality assurance, and participation in peer networks. While social franchising helps women providers to problem solve with peers, networking does not harness their collective power to create structural or systemic change. (So, of the different aspects of empowerment, "power with" was the one that social franchising does not appear to contribute substantially to.)

The report shares various outcomes of franchising and empowerment. For example, franchised providers indicate that their success as business owners and providers has increased their status in their communities. Several providers said they shared their knowledge and leadership in different ways with their communities, including providing business advice to former staff, discussing the importance of family planning in their churches, or volunteering to provide health care in marginalised communities. Nearly all the women said they act as mentors to younger staff or their children who have entered the medical field.

Based on the findings, the brief outlines, in Table 4 of the brief, a series of gender-sensitive interventions to improve health and women's empowerment outcomes. To understand and learn from these interventions, it is recommended that social franchisors also consider the following:

• Collect data on the sex of providers to track applicants, franchisees, participation in trainings, access to credit, and attrition. Doing so can help franchise organisations better understand where their current practices might be creating gender-related disparities.
• Collect and analyse data on franchisees' perceived benefits of franchising and disaggregate by sex.
• Develop and track indicators of empowerment, potentially using the Social Franchising Empowerment Framework.

Lessons for the non-franchised private sector include: Offer skills and business training; address gender-related barriers to credit and technology (e.g., through women-specific trainings); and create spaces for collaboration and joint action - whether to advocate on a policy issue that affects their practice or to refer clients to each other when needed.

The women and programme staff interviewed agreed that family planning clients often seek women providers because they don't feel as comfortable discussing reproductive issues with male providers. For this reason, among others, "private health sector has much to gain from more deliberately addressing the gender-related obstacles to empowerment and business success that women providers commonly face."