Total Market Approach: Improving Service Delivery as Well as Accessibility

Marguerite Farrell

USAID/Washington | Health Officer and Private Sector Team Leader, Office of Population and Reproductive Health

Elaine P. Menotti, MPH

USAID/Washington | Health Development Officer, Office of Population and Reproductive Health, Service Delivery Improvement Division

Total market approach (TMA): A lens for assessing actors and interventions in all three sectors (public, private non-profit, and private for-profit) of the health system. Programs and policies promote and enhance contributions from all sectors and are client-focused.

Why is it important to consider family planning services?

A total market approach for USAID programs considers products but must also consider family planning services. A TMA focused on products might not help us achieve our objectives of expanding method choice, meeting unmet need, and access for all. TMA that includes family planning services can help us do even more:

  • Focus on all contraceptive methods, including the following:
    • Provider-dependent methods like implants and IUDs
    • Methods that don’t have a commodity (but may have surgical supplies or tools) immediately associated with them (tubal ligation, vasectomy, standard days method)
    • New and/or underused methods
  • Consider key issues associated with making contraceptive methods accessible—making a product available is not enough, due to a range of factors including provider capacity, competence, and client demand
Method availability (FP2020)

Method availability: The extent to which the entire population has access to LARCs and short-term methods of family planning (FP2020)

In addition to product availability, TMA efforts to convene stakeholders and address challenges must also consider service delivery challenges and opportunities. The family planning community has achieved great success in getting short-acting methods out of clinics and into communities, places, and villages where people are. In part due to this effort to program “outside of the clinic,” short-acting methods are typically proportionately more available than long-acting reversible contraceptives (LARCs) or permanent methods (image at right). Country-led efforts on financing health care must consider both family planning commodity and service delivery dimensions and requirements. As discussions evolve around Universal Health Coverage (UHC), we want family planning to be included and we want all methods to be covered, regardless of method and provision. We also want to ensure that UHC protects the poor and includes all actors who are providing family planning—both public and private.

USAID envisions service delivery programming in countries considering the following key principles:

  • Provide information, a broad range of contraceptive methods, and high-quality family planning services
  • Use multiple service delivery channels
  • Leverage a range of service delivery partners (public, NGO, commercial)
  • Integrate demand generation for family planning services and products
  • Reach the poorest, most underserved populations
  • Support gender equity
  • Uphold voluntarism and informed choice
FP service delivery in a TMA

Where FP service delivery fits in a total market approach (Abt Associates/SHOPS+)

Service delivery programming must rely on service delivery channels to get the products and services out to clients who want them. Part of enabling access to family planning is ensuring availability through multiple channels, which can also support a total market approach. What are the critical service delivery channels we work through?

  • Static clinics or hospitals (public/private)
  • Mobile outreach services/providers (public/private or both)
  • Community distribution by community health workers (CHWs)
  • Social marketing
  • Retail outlets: drug shops, pharmacies, kiosks, and other alternative delivery points (beauty shops, small community stores, etc.)
  • Other—where else can family planning methods be found or be placed for maximum reach?

One of the most important things we can do in service delivery is to bring services and products closer to clients (where they live, where they go) to make family planning more accessible and acceptable—with the overall aim of maximizing opportunities for voluntary family planning uptake. One channel will generally not serve all clients, nor is it maximizing the human resources available or making the best use of the health system. Do condoms, pills, injectables, and emergency contraception need a doctor or a hospital for provision? One of the ways we have expanded access to short-acting methods has been getting them out of the walls of a clinic. These service delivery channels can be led by any of the various TMA actors. For example, static clinics can be led by NGOs, the commercial private sector, faith-based entities, the government, or even community leaders.

Some of our greatest successes are due to this shift in mentality. CHW provision of injectables has been a game changer. Health extension worker provision of implants has resulted in enormous uptake and increases in access to implants in Ethiopia. Making condoms and pills available in retail outlets outside of the walls of a clinic through community-based distribution has further improved access to the last mile. What can we do to continue to remove barriers to access to voluntary LARCs and permanent methods?

TMA for services in practice?

TMA framework

A framework for TMA for services. How does it all fit together? (JSI/APC)

There is no one-size-fits-all solution, no-fail recipe, or special sauce. Working to achieve a TMA for family planning products and services in a given country context is an aspiration, but concerted efforts to address barriers and gaps and build on strengths, ongoing collaboration and dialogue with stakeholders, and commitment to achieve some common objectives are key ingredients to success. The public sector needs to be part of this process and needs the private sector, both non-profit and for profit, to achieve country Sustainable Development Goals goals for family planning.

Guiding questions can help us come to a better understanding of the family planning players, challenges, and opportunities:

  • Are we maximizing participation of all family planning provision actors?
    • Public sector
    • Not-for-profit NGOs, faith-based organizations
    • Commercial sector
    • Health volunteers
  • What populations do they each serve and where?
    • Can clients pay? Do clients pay? Enough to generate cost recovery?
    • Who can serve those who are poorest?
    • Are any clients not being served?
  • What types of service delivery approaches can each do best?
  • How can we grow the whole family planning market?

Finally, the overall goal of a total market approach to family planning services ensures equity: Clients, both women and men, can access affordable, quality services and real method choice so that they can achieve their reproductive intentions. As a result, TMA supports individual, family, and community development and livelihoods. TMA uses the existing infrastructure, human resources, and equipment of all sectors (public, private including non-profit, faith-based, and for-profit) to meet all family planning needs with the understanding that no one sector can do it alone—there is room for multiple actors to participate in providing and sustaining access to this critical primary health care service and public good.