NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

Editor’s note: This article is part of the Market Dynamics initiative on NextBillion Health Care. The ongoing series is designed to encourage discussion and understanding around how markets impact health outcomes. Click here to read our recently published e-book on the topic. This blog is the second of three that PATH is contributing to the series; click here for the first article, wiritten by Amie Batson.

This article was written by Jane Hutchings, Seema Kapoor and Christopher Brady of PATH.

For decades, governments in low- and lower middle–income countries have been, often with significant development assistance, the primary provider of health care services, including family planning (FP). What happens when public sector and donor resources cannot meet demand?

Against a backdrop of 1.8 billion young people entering reproductive age, the largest cohort in the history of the world, many governments across the globe are committing to expanding access to contraceptives and FP services. Yet, public health systems alone cannot keep pace with the growing demand. Beyond the public sector lies the private sector, which consists of nongovernmental organizations (NGOs), a range of social marketing organizations providing subsidized products and services, and the largely untapped potential of the commercial sector. Using the total market -– strategically working across all sectors – is one way to effectively deploy resources to meet FP needs.

A total market approach (TMA) is a strategy for preserving public sector resources for those most in need and most vulnerable by ensuring that people who have the ability to pay do so for a portion or all of their FP products and services. Because what happens in one sector affects another, a TMA also implies ongoing coordination across sectors, as well as an environment in which all sectors can flourish. Each market sector (public and private) has comparative advantages in reaching different market segments or different types of FP users. The goal of a TMA is to empower all sectors to more efficiently reach specific market segments, thereby meeting the increasing demand for FP products and services.

There is no one blueprint for developing a TMA plan. Each country’s political, economic, health system situation and need is different. For example, countries that are approaching middle-income status often have a strong impetus to move toward a TMA as external donors significantly reduce or suspend financial and technical support. This support often allowed governments to build large public sector FP programs that provided free or highly subsidized contraception to anyone. In low-income countries, a TMA can help expand the resource base as well as help to shape a more balanced FP market for the future. The move in many countries toward third-party-payer systems also offers an opportunity to highlight the important role of family planning products and services as preventive care.

What are the barriers to implementing a TMA?

Despite the fact that governments in low- and middle-income countries appear to understand the benefits of working across sectors and have put into place well-intentioned policies that describe public-private collaboration, our research has found that few governments or their private sector counterparts have a good understanding of how to implement public-private partnerships. This lack of understanding is often exacerbated by lack of trust and communication regarding priorities across sectors. Barriers to implementing a TMA also exist in the early landscaping stage of total market work. Good data is an important starting point for a TMA, yet in most countries these data are sorely lacking. For example, typically there is little or no information regarding which market segments use the private sector, for what services/products, what prices they are prepared to pay, and consumer perceptions of the services/products available. This lack of basic data creates barriers to the design of an effective TMA.

Building a TMA

PATH partners with governments to support their role as the steward of the total market. Governments can facilitate or constrain the private sector role in meeting FP needs, for example, through regulatory and taxation policies or through policies affecting NGOs. A deliberate cross-sector planning process is required to determine which sectors should serve which groups and how. The steps in this process are:

1. Situation and network analyses.

2. Engagement with critical stakeholders.

3. Assembling evidence and filling evidence gaps to inform decision making.

4. Building the total market strategy and plan.

What we’ve learned from our work in assisting countries to develop a TMA

We have carried out various stages of TMA planning in middle-income and lower-middle-income countries such as Vietnam and Nicaragua. More recently, we completed landscape assessments in low-income country environments: Democratic Republic of Congo, Myanmar and Uganda. We found that while the country contexts are very different, there were broad overarching issues common across countries:

1. Market segmentation research: In many countries we found a dearth of data about the FP markets; specifically, products, users and prices. Understanding the market is essential in implementing a TMA so that the most vulnerable populations have equitable access to free or subsidized product. In order to fill this data gap, we recommended a range of market research and analyses for each country to inform the development of a national total market plan.

2. Cross-sector coordination: Our analysis showed that while stakeholders were interested in collaboration with other sectors, they did not know how to begin and many questioned the capacity of the government to steward this type of collaboration. Creating or strengthening the existing capacity of a cross-sector coordination mechanism stewarded by the government is a critical step to building a successful TMA.

3. Advocacy: While stakeholders responded positively to the concept of cross-sector collaboration to meet FP demand, due to a lack of experience some were hesitant to proceed. Developing and strengthening advocacy for the concepts behind a TMA, the potential benefits and, in particular, encouraging the idea of cross-sector collaboration are essential to success.

The need for more effective cross-sector collaboration in meeting FP needs will be increasingly pressing as demand for products and services continues to grow. We must draw on all the resources available to ensure that access is increased, particularly for the most vulnerable populations: access in that FP is offered through a range of both public and private service delivery points; equity in that scarce public-sector resources are oriented toward the poorest and most vulnerable population groups. Working together with the public and private sectors, family planning market sustainability can be achieved via a total market approach.