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Mali: Strengthening Multi-Sectoral Coordination using a Total Market Approach

Copyright © 2017 PalladiumA pathway for delivering health impact

2 | Mali: Strengthening Multi-Sectoral Coordination using a Total Market Approach

Copyright © 2017 Palladium

Strengthening Multi-Sectoral Coordination using a Total Market Approach Palladium is contributing to global leadership and advocacy around total market approaches (TMA) in developing health markets. TMA is an evidence-based, strategic process that uses data to recognize the comparative strengths of various sectors and apply market-shaping strategies to influence positive, sustainable growth of health markets. There is a role for total market principles in health markets at all levels of development, yet there is less documentation of TMA implementation at the country level.

In Mali, achieving sustainable access to quality reproductive health and family planning (RH/FP) products and services represents a critical challenge for the government due to limited financial and human resources, as well as security issues in some areas. The Ministry of Health (MOH) recognizes the importance of a multi-sectoral approach

for improved planning, investment, and health impact. After more than 25 years of social marketing programs in Mali, there is limited coordination and collaboration between the public and private sectors. Palladium is helping to build multi-sectoral collaboration using a total market approach (TMA), starting with reproductive health and family planning products. As a partner on the USAID-funded Keneya Jemu Kan (KJK) project, Palladium leads the social marketing and TMA portfolio1. The KJK project combines social and behavior change communication (SBCC) and social marketing (SM) to reduce maternal, infant, and child mortality, increase overall contraceptive prevalence, and reduce malnutrition among women and children.

This case study uses the Palladium framework to describe early TMA efforts in Mali, which have focused on understanding market inequities, establishing a TMA platform for stakeholder dialogue, and improving coordination.

1 Palladium is a partner to Johns Hopkins University, Center for Communication Programs, prime on the USAID KJK project.

Mali: Strengthening Multi-Sectoral Coordination using a Total Market Approach | 3


Applying the Palladium Framework Palladium’s TMA framework is designed to capture the complex process of market analysis, multi-sectoral engagement, market-shaping interventions, and market monitoring relevant to TMA, recognizing that not all components would be applied in all situations. As learning around TMA implementation evolves, so has our framework.

Figure 1. Palladium TMA Framework



1. Analyze Market Dynamics.According to the Barnes’ total market initiative framework, Mali would be considered an early contraceptive market, since its overall modern method contraceptive prevalence is low at 10 percent2. Nonetheless, there are opportunities to improve overall coordination in procurement, service delivery, distribution, communications—and to ensure that policies encourage investment in private markets. To understand the overall family planning market, Palladium conducted a segmentation analysis of the 2012-2013 Mali Demographic and Health Survey (DHS) using residence-specific wealth quintiles to understand how poverty and place of residence influence use of contraception3. Not surprisingly, use of contraception is higher among women in urban areas and significantly higher in upper wealth quintiles, suggesting important inequities in access to FP products and services for lower wealth quintiles. In addition, the public sector remains the major source of family planning products: in urban areas, 64% of women accessed their family planning method through the public sector. Surprisingly, more than 50% of women in the highest wealth quintile sourced products through the public sector (Figure 2).

There are still important information gaps in understanding key total market trends for condoms and oral contraceptives (OCs). For condoms, the private market is dominated by a single social marketing brand—the USAID-supported Protector Plus—with more than 87% market share. While a number of commercial brands are available, only a handful maintain a long-term market presence, and there is no quantifiable data on the size of the commercial market. Nonetheless, the private market is heavily subsidized, and since Protector Plus has had relatively few price increases over the years, the market may be

2 Barnes, Jeffrey, Janet Vail, and Dawn Crosby. 2012. Total Market Initiatives for Reproductive Health. Bethesda, MD: Strengthening Health Outcomes through the Private Sector Project, Abt Associates.

3 Foreit, Karen, et. Al. Disentangling the Effects of Poverty and Place of Residence for Strategic Planning. Health Policy Initiative, September 2010.

Figure 2. Sourcing of FP Method by Wealth Quintile in Urban Areas.



more subsidized today than it was 10 years ago4. OCs are the second most widely used method. Palladiums’ segmentation analysis shows, however, that 40 percent of women in the wealthiest quintile in urban areas still supply through the public sector.

2. Understand Comparative Strengths Among Market PlayersThere are still important constraints to gaining consensus around the comparative strengths among market players. Within the MOH, there is a need for clarity among various departments to better understand how social marketing organizations and other NGOs are working, and to reduce skepticism about the role of the for-profit private sector, which also plays a very small role in condom and FP markets. While there is recognized need for better coordination, there is also a need for increased consensus-building about how to maximize each sector’s comparative advantage. These are some of the issues to be addressed during the TMA landscape analysis in late 2017. Nonetheless, market players often have a strong, vested interest in the status quo, which makes for a complex consensus-building process requiring clear incentives and strong stewardship by government and donors.

3. Engage Key Stakeholders.The MOH’s introduction to TMA principles started in 2014 when several government and NGO representatives attended a UNFPA-PATH sponsored TMA conference for Francophone Africa in Dakar, Senegal. During the conference, Malian representatives drafted an initial TMA action plan. In 2015, Palladium began advocating for the integration of TMA principles into multi-sectoral planning. In early 2016, Palladium led a coordination workshop that brought together various donors, MOH representatives, NGOs, and social marketing organizations to discuss commodity coordination in the private sector. In mid-2016, Palladium led a follow-on TMA workshop to present global and

4 Pallin, S.C., D. Meekers, K. Longfield, O. Lupu. November 2013. Mali: A Total Market Approach. PSI/UNFPA Joint Studies on the Total Market for Male Condoms in Six African Countries.

regional TMA case studies and findings from a market segmentation analysis. Stakeholders agreed that TMA required a formal platform, and established a TMA sub-committee as part of the Technical Committee for the Management and Monitoring of Essential Drugs, with members including government institutions, civil society organizations, private importers and distributors of pharmaceuticals, multilateral and bilateral organizations, and global organizations and projects. Stakeholders also agreed to update the 2014 TMA action plan. In July 2017, Palladium supported the Department of Pharmacy and Medicines (DPM) in conducting a validation meeting to approve the updated action plan.

In Mali, there has been limited support among international donors for TMA coordination, possibly due to focus on humanitarian assistance given the country’s fragile economic, health, and security situation. Other donors’ interest in TMA coordination at different times has shifted with priorities and changes in personnel. Some implementing organizations are not fully convinced of the value of TMA in the Malian context.

While the MOH has acknowledged that multi-sectoral coordination with the private sector is needed to improve the overall efficiency and effectiveness, coordination mechanisms are nascent. Social marketing organizations provide information on commodity procurement and sales, but there is little dialogue on priority segmentation, definition of target audiences, supply channels, pricing/subsidy levels, and overall sustainability. Now that there are multiple social marketing organizations operating in Mali, improved coordination is critical. In addition, the MOH has requested information on NGOs’ supply and service delivery channels, direct commodity procurements, and pipelines. There is limited awareness of how the commercial sector can be engaged to support priority health products—and since commercial markets are quite small, there is minimal presence by major multinational manufacturers. Recently the MOH reached out to pharmaceutical distributors to participate in coordination meetings, but they lacked a goal-oriented agenda and these meetings were not well attended by senior managers.



4. Strengthen Stakeholder Stewardship Capacity.The DPM leads the MOH’s application of TMA principles for RH/FP products. The DPM is responsible for leading commodity procurement and forecasting, donations, importation and registration, and quality assurance of all medicines in Mali. DPM’s Head of Training, Information and Communication Section and focal point for Reproductive Health and Pharmacovigilance has coordinated TMA workshops, reviewed the action plan, and chaired validation meetings. DPM officials recognize the value of multi-sectoral coordination and see TMA as a valuable tool in helping to improve efficiency and effectiveness. The most recent milestones include establishment of an official TMA sub-committee and validation of a multi-sector TMA action plan in July 2017. The MOH’s Reproductive Health Division within the National Department of Health has also been actively engaged in early TMA efforts. Starting with the UNFPA and PATH-supported regional TMA workshop in 2014, the slowness of the process is symptomatic of the fact that TMA is not perceived as a clear value added by the MOH’s management bodies and represents an additional responsibility on an already full portfolio. The DPM relies heavily on the USAID KJK project to support the dialogue by financing and supporting logistics for TMA-related workshops and quarterly meetings. Palladium will support the DPM in conducting a TMA market assessment and monitoring the action plan.

Given DPM’s role for registration and quality control of all medicines and health-related products for the overall health market, they are well-poised to address some of the regulatory issues. As is common in Francophone Africa, drug pricing is closely regulated, and the registration process is linked to establishing a maximum consumer price for all products. In 2013 with UNFPA support, Population Services International developed a condom TMA case study for Mali, which mentioned government price controls as a regulatory issue that has hampered

development of the private sector market. These price controls affect the social marketing program and the for-profit commercial sector.5

5. Support Total Market Interventions.Social marketing has played a key role in increasing access for both condom and oral contraceptive products through private sector channels in Mali over the last 20 years, yet little progress has been made in improving overall market sustainability and ensuring that donor-subsidy is reaching the most appropriate target segments. To continue to grow FP markets, there is a need to further increase demand, allow for price increases for social marketing brands, lift price controls on commercial condoms, and ensure that segmentation strategies for free and socially-marketed condoms are targeted to those who cannot pay unsubsidized prices.

6. Total Market Monitoring.After the DPM conducts its TMA landscape assessment, stakeholders will discuss opportunities to improve total market monitoring and incorporate new TMA metrics based on global best practices, with a goal of creating consensus among all market players. This includes tracking total market volume, stock-out levels, number of commercial brands, and cost-recovery levels for all social marketing brands. To further advance TMA dialogue in Mali, Palladium will advocate for ongoing monitoring of market trends.

5 Pallin, S.C., D. Meekers, K. Longfield, O. Lupu. November 2013. Mali: A Total Market Approach. PSI/UNFPA Joint Studies on the Total Market for Male Condoms in Six African Countries. Retrieved from www.psi.org/total-market-approach



ConclusionTMA efforts in Mali started with building stakeholder support for TMA principles and multi-sectoral coordination. Strategic coordination across public, private, and commercial sectors is increasingly recognized as essential to achieving global health goals. Coordination is needed to increase access to high-quality, affordable reproductive health and family planning commodities and services. There are still important information gaps in a solid, evidence-based analysis of market inequities and inefficiencies that must be addressed to improve overall health impact and market sustainability, as well as regulatory challenges around market regulation. TMA is a long-term process that requires strong leadership and cross sectoral coordination. Continued advocacy among donors to increase support for TMA and coordinated interventions—as well as expanding support beyond the DPM to other strategic MOH departments—will be crucial for long-term TMA stewardship in Mali.

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