1. The World Bank Institute in collaboration with O’Hanlon Health Consulting, Tropical Health LLP, and University of California at San Francisco MAY 12, 13, 14, 2014

2. MARKETS FOR HEALTH SESSION 3 Introduction to Markets for Health (II): Health Market Systems April Harding The World Bank Institute in collaboration with O’Hanlon Health Consulting, Tropical Health LLP, and University of California at San Francisco

3. MARKETS FOR HEALTH RATIONALE THE FRAMEWORK NET MARKETS IN TANZANIA SUMMING UP

4. MARKETS FOR HEALTH MARKETS FOR HEALTH (M4H) APPROACH Health Market Systems (HMS) Framework Market Forces (MF) Framework

5. MARKETS FOR HEALTH Health Market Systems framework helps plot a course from here to there

6. MARKETS FOR HEALTH HMS’ “uncle” => Many names & acronyms Markets for the poor (M4P) Market facilitation initiative (MaFI) Market development approach markets systems framework

7. MARKETS FOR HEALTH Development assistance problems motivated “market systems” framework e.g. agriculture markets, financial services markets, business environment, investment climate Private sector development Social sectors e.g. food, health Simplistic unclear contribution to ultimate development objectives Blind to market responses Short time horizons; unthinking resort to direct delivery support; no examination of “crowding out”; low sustainability

8. MARKETS FOR HEALTH Market systems approach: In a nutshell Frames situation analysis in a market (e.g. buyers and sellers interacting) Draws attention to range of actors influencing market operation Compels search for underlying (potential) root causes of performance problems associated with market operation Emphasizes multiplicity of causes & interventions Boils down key factors influencing market operation:  Supporting Functions  Rules environment Dynamic analysis - sustainability Information Skills & Capacity Related Services R&D Rules MARKET OPERATION S D Government Sector Private Sector Not-for-Profit Sector Representative Bodies Supporting Functions Infrastructure Regulations Standards Laws Informal Rules and Norms Problem you see here Cause may lie here …… here Informing and Communicating Setting & enforcing rules

9. MARKETS FOR HEALTH RATIONALE THE FRAMEWORK NET MARKETS IN TANZANIA SUMMING UP

10. MARKETS FOR HEALTH Financing used in most well-managed health markets OPERATIONAL AUTONOMY CUSTOMER COMPETITION PRICE INFLUENCE ENTRY BARRIERS SOCIAL FUNDING PERFORMANCE TENSION FOR/UNDER CONTRACTS 0%100% AdministeredMarket Very High0 100%0 No contractsNo tension 100% 0%

11. MARKETS FOR HEALTH Health Markets Systems Framework R&D Rules Regulations Standards Laws Informal Rules and Norms S D Information Quality Assurance Subsidy Infrastructure Purchase Providers Consumers Related Services Invest Government Sector Private Sector Not-for-Profit Sector Representative Bodies

12. MARKETS FOR HEALTH Increasing access to medicines too few people accessing and using essential medicines; paying out-of-pocket, expensive, impoverishment Option 1: Buy and distribute through public network SD Buyers Invest market Sellers Option 2: Pursue a market management strategy $$$ Situation:

13. MARKETS FOR HEALTH Health Markets Systems Framework R&D Rules Regulations Standards Laws Informal Rules and Norms S D Information Quality Assurance Subsidy Infrastructure Purchase Providers Consumers Related Services Invest Government Sector Private Sector Not-for-Profit Sector Representative Bodies

14. MARKETS FOR HEALTH RATIONALE THE FRAMEWORK NET MARKETS IN TANZANIA SUMMING UP

15. MARKETS FOR HEALTH Malaria in Tanzania (late 1990s) Rampant malaria Innovation: treated nets Potential for substantial health improvement but… low use Policymakers examine opportunities to use a market management strategy to increase use Limited resources for malaria control <$1 million per annum

16. MARKETS FOR HEALTH SD Subsidy Purchase CONSUMERS What can be done? Some people are using nets Few using treated nets Not widely available in retail outlets Why? Which constraints are keeping the “market system” from generating higher treated net use? Could constraints be addressed? To deliver sustainable net use from a market system change? Invest NET RETAILERS NET RETAIL Why aren’t people buying? Why aren’t retailers selling?

17. MARKETS FOR HEALTH Market structuring initiative in Tanzania” Supply Low; quality problems; limited geographic availability -Little profit from treated net sales -Cost -Not packaged w/ insecticide sachet R&D Regulations Standards Laws Informal rules & norms SD Information Quality Assurance Infrastructure Purchase NET RETAIL MARKET Supplies Services Invest RETAILERS BUYERS Demand Low - Cost -Low awareness (value of treatment; link of malaria to child mortality) -Net norms Understanding the Net Market System: Identifying Constraints & Causes

18. MARKETS FOR HEALTH Which market system? RETAILER CONSUMER RETAIL MARKET PRODUCT SUPPLIES WHOLESALE MARKET THE SELLER IN THIS MARKET… IS THE BUYER IN THIS MARKET… RETAILER WHOLESALER

19. Harnessing net markets in Tanzania: chronology A to Z LLIN upgrade & expansion TECHNOLOGY TRANSFER TAX ANALYSIS TARIFF REMOVAL ADVOCACY Build & manage inclusive monitoring & evaluation system Analyze malaria situation including identifying relevant markets ANALYZE NET MARKETS Public-private mix strategy development Social marketing (brand) pilots Adapted demand promotion generic Small voucher pilots Voucher rollout 4 ITN producers TARIFF REMOVAL Manage public private dialogue ↑ discount 1999 2001200220032004200520062000200720082009 A-Z LLIN trial run Subsidies for rural distribution Adapted demand promotion bundled 1 producer Adapted demand promotion LLIN

20. MARKETS FOR HEALTH Tanzania results Three producers have entered market Tariff reductions & competition  price reduction From $6-$10 (1999) to $3-$4 (2007) Network of 200 wholesalers, and 6,400 retailers selling treated nets Much wider and reliable availability

21. MARKETS FOR HEALTH Use steadily increasing..especially among at risk groups

22. Reductions in malaria contribute to child mortality declines Reductions in malaria related illness and death contribute to declines (starting in 2000) in child mortality Strong distribution platform Subsidy targeting mechanism ITN roll-out Under-Five (child) mortality trend with 95% CI; Source: UN Inter-agency Group for Child Mortality Estimation (IGME) http://childmortality.org

23. MARKETS FOR HEALTH RATIONAL THE FRAMEWORK NET MARKETS IN TANZANIA SUMMING UP

24. MARKETS FOR HEALTH M4H approach: insights changing markets to achieve goals (with sustainability) Can work in health in developing countries

25. MARKETS FOR HEALTH How did Tanzanians get there? Broad view of possible solutions Substantial market analyses Multi-faceted interdependent actions Targeting multiple market systems

26. MARKETS FOR HEALTH M4H TimeLongish Public-private consultation Lots Implementation responsibility Multiple, public & private Implementation approach How did Tanzanians get there?

27. MARKETS FOR HEALTH Multiple public &private actors involved in implementation Government Sector Private, commercial Sector Not-for-Profit Sector Representative Bodies MOHSW - Natl Malaria Control Program & Regional & District Health Management Teams; Min of Local Gov’t Producers, distributors, retailers MEDA, STI, PSI, World Vision, TZ Red Cross

28. MARKETS FOR HEALTH M4H TimeLongish Public-private consultation Lots Implementation responsibility Multiple, public & private Implementation approach Monitor & adjust as you go How did Tanzanians get there?

29. MARKETS FOR HEALTH Market structuring strategies require adaptive implementation

30. MARKETS FOR HEALTH M4H versus traditional approach If markets are involved… process is different M4Htraditional TimeLongishShort (2-5 years for impact) Public-private consultation LotsLittle or none Implementation responsibility Multiple, public & private Few, mostly public organizations Implementation approach Monitor & adjust as you go Get planned actions implemented

31. MARKETS FOR HEALTH What’s next? More on mosquito net markets – applying full M4H approach Questions?