Perspectives on health product provision in developing countries have changed a great deal over the last 50 years. Stakeholders are examining the sustainability of public sector distribution (free products) and social marketing programs, and asking whether programs are as effective and efficient as they can be. Stakeholders are also asking if the poor and most vulnerable are benefiting from subsidies that support these programs. One outcome has been the development of a total market approach (TMA). TMA is a system in which all sectors – public, social marketing, and commercial – work together to deliver health choices for all population segments. The goal is to ensure that the poorest communities receive free products, those with slightly greater resources benefit from partially subsidized products, and those with a greater ability to pay purchase products from the commercial sector. The objective of this evaluation is to determine if actions taken by all three market sectors over the last five to seven years have increased condom use in an equitable and sustainable way in six African countries.
In 2013, we completed market evaluations in Botswana, Lesotho, Mali, South Africa, Swaziland, and Uganda. All have large, subsidized condom distribution programs, are affected by HIV, and have high maternal morbidity and mortality relative to their economic development. We conducted a literature review for each country, calculated seven key TMA metrics from national-level data, and completed interviews with stakeholders. This presentation focuses on findings relevant to equity and sustainability.
Across study years, condom use increased in Botswana, Lesotho, Swaziland, and Uganda, but declined in South Africa and remained extremely low in Mali. There were improvements in equity in Lesotho and Swaziland where the poor and wealthy use condoms at approximately the same rates. In Botswana, Mali, and Uganda, condom use is lower among the poor. All of the condom markets are heavily reliant on government or donor-funded products: Botswana (85%), Lesotho (70%), Mali (98%), South Africa (83%), Swaziland (85%), Uganda (98%).
The evaluations demonstrate that while there have been improvements in condom use, it is concentrated among the wealthy in half of the countries. Additionally, the markets are dominated by subsidized products from which the wealthy are benefiting. Country-level stakeholders, donors, and social marketing organizations are using the results of these evaluations to strengthen condom markets and inform their decisions about how to best increase use equitably and among those most in need. Stakeholders in all countries identified the need to make condom distribution more equitable, primarily through better coordination across the three market sectors and improved stewardship among local governments. Stakeholders also expressed the need for improved pricing strategies to ensure that cost recovery is possible and that the poor benefit from subsidized products. Wealthier populations should purchase condoms from the commercial sector, which will allow this sector of the market to grow. The result of these actions should be more sustainable markets that offer condoms at the right price points to different segments of the population.