Population Services International

Development's Changing Landscape

With 40 years of experience in social marketing – and use rates for contraceptives and condoms in particular reaching increasingly high levels – PSI’s bottom line is broadening from a primary focus on increasing use to an equal emphasis on fairness and efficiency when serving those in need. These objectives can conflict, but PSI is setting out to prove that they need not as it gains experience with its own version of the total market approach.

The total market approach (TMA) is social marketing’s response to the simple fact that access to contraceptives or any other product needs to diversify in countries with increasing numbers of people on both ends of the spectrum in terms of ability to pay for health products and services. But while some advocate for building better safety nets for the poor or larger commercial markets for those with sufficient incomes, PSI is working to do both to ensure that the entire market thrives.

“The real challenge is to increase use of the product whether it is through your own brand and distribution chain or not, and to do so among everyone who needs it at increasingly lower cost per product distributed,” said PSI President Karl Hofmann. “That should be the calling of all social marketers in health.”

And it is at PSI. In Cambodia, PSI has moved on all fronts to make this approach work, even as other countries, such as Kenya, embrace it as a tool for calibrated changes. Still others have complied with the spirit of the total market approach by activating the private sector in other ways that reduce the amount of subsidy inherent in PSI’s work while extending its reach.

“There is not going to be one recipe or approach that works everywhere,” said David Walker, PSI’s global director for social marketing. “It’s going to be an idiosyncratic process that depends on the local situation. Markets differ by country and health area, so we need to vary as well.”

By 2008, PSI's Number One condom brand captured 88 percent percent of the market while driving an increase in the total condom market over the past seven years of nearly 60 percent. That raised important questions, within PSI and among donors, about supporting the associated marketing campaigns amid ever-scarcer funds for health goals, while maintaining progress in use among lower income populations.

The new plan for Cambodia, launched in 2008, came straight out of the total market approach playbook. Number One got a makeover – the ubiquitous “1” on its package became sleek and shiny rather than squat and workaday – and its price increased for the first time since its introduction 15 years before to reflect an upmarket positioning. That created room for the emergence of private-sector brands, which benefited from an unbranded marketing campaign designed to educate consumers on the risks of unprotected sex.

“A big unexpected positive has been that we were forced to get much smarter as marketers after we set down this road,” said Chris Jones, the country representative for PSI/ Cambodia. “Promoting Number One was easier when we wanted everyone to use it; focusing its appeal meant tough choices in pricing and packaging and the need to monitor key marketing metrics regularly and react to them quickly.”

Increasing access to condoms in the middle and upper tiers of the Cambodian market came alongside a repositioning of its OK brand for poorer clients.

“There is an important notion of equity in the total market approach,” said Steven Chapman, PSI’s Chief Technical Officer. “We are shifting the ‘access frontier,’ as it is known, but we are also creating a safety net to provide supplies for people who cannot pay as much.”

Developed by Richard Pollard in a study for the U.K. Department for International Development, the total market approach grew out of the British agency’s desire for exit strategies that became credible by ensuring that in-country institutions could sustainably meet the need for health products and services.

That meant finding ways to buttress the entire market, not only the one created by international NGOs, and ensuring its long-term functioning. Out of this insight grew TMA, also known as the "making markets work for the poor" approach or the "comprehensive market" approach at the U.S. Agency for International Development.

Rather than being a generic, comprehensive strategy that is applied uniformly in each country, TMA is best understood as a framework through which the goal of greater access can be analyzed and achieved.

“It’s not a matter of ‘if you do it’ but ‘how you do it,’” said Daun Fest, the PSI country representative in Kenya. “There is plenty of data in every country, and this approach helps you make better decisions about how you are going to spend money and how you are going to design your marketing plans.”

By 2009, PSI/Kenya’s research concluded that 36 percent of the Kenyan government’s supplies of free condoms were not being used, but they were crowding out the private sector. Today, the National AIDS Commission uses PSI data in its own work and is ordering up fewer condoms to avoid both waste and to let the private sector do its work.

PSI also canvassed private-sector importers and distributors with the message that PSI’s generic behavior-change marketing would surely create demand for condoms. Slowly, they are increasing their own sales.

In Cameroon, TMA took the form of the ProFam network. ProFam has become a successful experiment in social franchising. Beginning in 2006, PSI struck deals to provide 25 private clinics with training and equipment.

The synergies were obvious. The clinics had a reach that PSI could not match but seldom offered the kind of reliable services that Cameroonians needed. PSI now provides a steady flow of necessities, in kind and in training, while even going so far as to boot clinics that do not measure up.

PSI now sees the network growing to include 50 clinics by the end of 2011, and Nestor Ankiba, PSI’s former country representative in Cameroon, leaves no doubt why.

“For me, the total market approach means focusing not only on what we do with our direct health interventions but also on the whole market as a ‘universe of opportunities,’” Ankiba said. “We need a holistic approach for the future that involves other agents, and I think we have found it.”

- Carter Dougherty and Steven Chapman, Ph.D.

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