Social Franchising and Maternal Health Governance: Expanding Private Midwifery Access in Dar es Salaam's Informal Settlements

Maternal health outcomes in informal urban settlements remain a critical challenge across Africa. In Dar es Salaam, a reliance on fragmented, often unregulated private midwifery services has created significant governance and quality gaps in service provision. This commentary analyses the potential of social franchising models to structure and improve private midwifery networks. It aims to evaluate their role in enhancing service quality, accountability, and equitable access for low-income women. The analysis is based on a critical synthesis of existing programme documentation, grey literature, and policy reports on maternal health initiatives in the city. It employs a governance lens to assess the franchising mechanism. Preliminary evidence suggests franchising can improve clinical protocols and supply chains, yet a dominant theme is the tension between standardisation and the flexible, community-embedded practice required in informal settlements. Franchised clinics showed a marked improvement in the availability of essential drugs. Social franchising presents a viable, though complex, policy mechanism for coordinating private providers. Its success hinges on adaptive governance that balances quality assurance with contextual service delivery models. Policymakers should integrate franchising within broader health system strengthening, focusing on supportive supervision and sustainable financing. Future models must be co-designed with community health workers and clients. social franchising, maternal health, health governance, private sector, midwifery, informal settlements, Tanzania This commentary provides a novel analysis of social franchising as a health system governance tool, specifically for structuring the private midwifery sector in an African urban informal context.