Addressing Health Care Inequality Through Social Franchising: The Role of Network Stewardship in Impact Intermediation

This study investigates how social franchises extend health care in rural areas, thus addressing vast and persistent disparities in health care access. We conducted an inductive study of Unjani, a South African organization that extended primary health services to disadvantaged rural communities through a network of 135 health clinics. Our analysis focused on the process of impact intermediation—the propagation of impact across multiple layers of the franchise network, including franchisees and downstream beneficiaries. To facilitate impact intermediation, the franchisor harmonized the mission of the franchisees with its own mission and integrated community impact among franchisees. Such coordination and monitoring activity exposed franchisees to intermediation problems in the form of mission conflict and impact divergence. Our analysis reveals how Unjani nurtured network stewardship that afforded the franchisee nurses with greater support, autonomy, and ownership, thus overcoming intermediation problems in their pursuit of shared communal responsibilities to extend health care to rural communities.