By Rebecca Husband, FP/RH Technical Advisor, SIFPO2, PSI
The article below originally appeared on K4health.org.
There are now more than 300 million women and girls using modern contraception in the world’s 69 poorest countries, with more than 30 million of those users added since 2012. That’s the good news. The more challenging news is that despite this progress, health markets in low- and middle-income countries often operate inefficiently, failing millions of potential family planning (FP) consumers.
In an uncertain funding climate, donors, governments, and implementers need to target resources and create solutions that have the highest impact and return on investment. One approach that has gained increasing traction this past decade is the Total Market Approach, or TMA.
At its core, TMA for family planning is about making the most efficient use of existing resources and delivery points in the health system to generate demand for FP and ensure all consumers can access the products and services they want. But it’s not only about maximizing what’s going on in a market—it’s about shaping it as well. USAID defines market shaping as the ability of all actors in the market (producers, distributors, host governments, donors, providers) to use their purchasing power, competencies, influence, and technical know-how to address where the market is failing and make it work better to maximize public health impact.
To shape markets, PSI—and many other implementers in our field—now see governments, donors, commercial entities, NGOs, and faith-based organizations as market players operating at different levels, all playing a role in providing health services and products to the consumer. At PSI, we begin the journey of TMA by identifying who the market is failing, before identifying how it’s failing. Only then can we design interventions that address those failures. These interventions could touch on a range of areas in the market:
- Improving demand and supply across the value chain of consumers, providers, importers, and distributors
- Strengthening elements of the enabling environment (coordination, financing, quality assurance)
- Influencing the rules of the market (policy, regulation, taxes, social norms, etc.)
At the heart of this approach is the consumer perspective. PSI uses this as the starting point for analysis, and keeps it as a compass throughout the process. We ask: How will the interventions we design benefit the consumer both directly and indirectly? Are we considering how all the players in the market influence and affect the consumer’s experience? Are the incentives sufficiently aligned for all market actors to enable increased use of FP services and products? How can we apply our more than 40 years of experience in social and behavior change to influence both consumer and market behavior and achieve the health impact we seek? And, how do we leverage our unique position as an experienced actor in the market to help shape the interactions around us?
PSI is committed to shaping markets to bring quality care closer to consumers and create more effective and efficient market systems. Evidence of PSI putting this in practice is highlighted in the following select examples:
In Cambodia, PSI conducted an assessment of the total market that identified, in particular, gaps in knowledge and information on the reproductive health behaviors and needs of unmarried women—information that was not captured through previous DHS population surveys. PSI, in partnership with Pfizer and the government of Cambodia, is undertaking research to better understand the reproductive health needs of these women, and how to respond to them. The total market assessment also revealed that 95% of all oral contraceptives distributed in the market are second-generation models. These are known to have greater side effects than third-generation pills, with side effects being a common reason for method discontinuation. With USAID support, PSI and Population Services Khmer (PSK) conducted a market analysis and held consultations to confirm that a cost-recoverable, third-tier, third-generation oral contraceptive product had value in the FP market. As a result, this product will now be strategically introduced to the market.
With the support of USAID, PSI and our in-country network member ADEMAS conducted a TMA landscape exercise for FP products and services in Senegal at the request of the Department of Reproductive Health and Child Survival (DSRE). Our findings informed the DSRE’s 2016-2020 National Action Plan for Family Planning, which also included commitments to tangible policy and regulatory improvements to the market, such as facilitating the registration of providers and new products, and recommendations for allowing pharmacies to provide oral contraception without a prescription. DSRE has also committed to improved coordination with other market players as part of a multi-sectoral total market approach.
PSI has also applied this approach in India’s larger and more mature FP market. With support from the Bill & Melinda Gates Foundation, PSI is using TMA to analyze and shape the FP market in Uttar Pradesh (UP) and Bihar. The market is currently failing women across all wealth quintiles in urban and rural areas, particularly young women. The family planning market in India has traditionally been highly subsidized, hindered by an inefficient government procurement process and restrictive pricing caps on some products. Recent changes in these restrictions have opened the door for new market interventions. In response, PSI has established a family planning social enterprise, India Private Limited (LLC), that will drive the growth of the family planning market while building an efficient business model for sustained business operations. This business will offer a basket of FP methods for different consumer segments in the market. The LLC will operate as a commercial entity focused on driving operational efficiency to ensure that products remain accessible and affordable for our consumers.
- The UP government also turned to PSI-India (our nonprofit arm) for support in implementing the Hausala Sajheedari program, which incentivzes private-sector family doctors to offer contraceptive services, previously only available from public hospitals. Under this program, private-sector surgeons, hospitals, and nursing homes can apply for accreditation to offer family planning services under a standard reimbursement package from the government. PSI-India led a collaborative process between UP government agencies and other FP partners to streamline government guidelines, conceptualize, design, and develop the web portal, and train state and district health personnel. Since its launch, this initiative has resulted in more than 25,000 women receiving IUDs, 9,000 women using injectables, 13,000 women receiving oral contraceptives, and over 34,000 men receiving condoms.
For TMA champions and organizations like PSI that continually seek new and sustainable ways to bring quality care closer to consumers, this is an exciting time. We’re increasingly seeing donors, host governments, and non- and for-profit private-sector actors recognizing their combined power in coordinating effectively to harness their resources and shape markets. More efficient, more coordinated markets mean less burden on donor and public-sector resources, and more opportunity for the private sector to thrive. And with more optimal, varied, and visible service delivery channels and products, the millions of women that the market is currently failing have a better chance at accessing the sustainable, affordable, and high-quality family planning they need.
Photo: © Population Services International / Photo by: Jake Lyell