Madagascar Total Market Initiative Project- Increasing Private Sector Participation in Family Planning in Madagascar

Publication date: 2010

Madagascar:  Total  Market  Initiative  Project,  2010       Page  1  of  37   Madagascar Total Market Initiative Project INCREASING  PRIVATE  SECTOR  PARTICIPATION                                                  IN  FAMILY  PLANNING  IN  MADAGASCAR   Final Report January  –  December  2010     Soumitro  Ghosha   Debabrata  Satapathyb   Dr.  Odile  Hanitriniainac   Meghan  Bishopd   Miles  Kemplaye                     a  Global  Head  of  Integrated  Marketing,  Marie  Stopes  International   b  Integrated  Marketing  Advisor,  Africa,  Marie  Stopes  International   c  National  Research  Manager,  Marie  Stopes  Madagascar   d  Senior  Policy  Advisor,  Futures  Group   e  Country  Director,  Marie  Stopes  Madagascar   Madagascar:  Total  Market  Initiative  Project,  2010       Page  2  of  37     This  project   is  supported  by  Program  for  Appropriate  Technology  in  Health  (PATH).    The  purpose  of   the   Subgrant   #   GAT.1291-­‐08456-­‐GRT   is   to   support   Marie   Stopes   International   (MSI)   in   building   support   in   the   public   sector   for   a   total  market   approach   to   the   procurement   of   contraceptives   in   Madagascar.  The  Project  will  help  the  Reproductive  Health  Supplies  Coalition  (RHSC)  meet  its  goals  to   mobilize   public-­‐sector   and   total-­‐market   resources   at   the   country   level   and   foster   greater   harmonization  among  stakeholders  at  the  country  level.                                         Madagascar:  Total  Market  Initiative  Project,  2010       Page  3  of  37   Contents   Acronyms Preface Acknowledgments Executive Summary Chapter 1: Project Background, Objectives and Activities Chapter 2: Family Planning Policy Environment and Market Structure in Madagascar Chapter 3: Market Segmentation Opportunities Chapter 4: Conclusions Chapter 5: Recommendations Annexes 1: Detailed DHS Analysis   Madagascar:  Total  Market  Initiative  Project,  2010       Page  4  of  37   Acronyms DHS:  Demographic  Health  Survey  (EDS)   3DS:  District  Health  Development  Department   AMIT:  Inter-­‐Enterprise  Medical  Association   CDS:  Social  Development  Committee     CPR:  Contraceptive  Prevalence  Rate  (TPC)   CRESAN2:  Crédit  Santé  2   CSB:  Health  Centre     CHD  I:  District  Hospital  Office  (level  I)   CHD  II:  District  Hospital  Office  (level  II)   DAMM:  Drug  Registration  Authority  of  Madagascar   DPF:  Family  Planning  Department   DRS:  Regional  Health  Authority   FISA:  Fianakaviana  Sambatra  (IPPF  affiliate)   GoM:  Government  of  Madagascar   GTZ:  Deutsche  Gesellschaft  fûr  Technisch  Zusammenarbeit   KMS:  Kaominina  Mendrika  Salama  (Healthy  and  Deserving  Municipality)   MLD:  Long  term  contraceptive  method     MOH:  Ministry  of  Health   MSI:  Marie  Stopes  International   MSM:  Marie  Stopes  Madagascar   NGO:  Non  Governmental  Organisation   OSTIE:  Tananarive  Inter-­‐Enterprise  Health  Organization   PATH:    Program  for  Appropriate  Technology  in  Health   FP:  Family  Planning   PHAGDIS:  District  Wholesale  Pharmacy     PHAGECOM:  Community-­‐run  Pharmacy   PPP:  Public  Private  Partnership   PSI:  Population  Services  International   RHSC:  Reproductive  Health  Supplies  Coalition   SAF/FJKM:  Development  Service  /Madagascar  Protestant  Church   SALFA:  Lutheran  Health  Service   SSD:  District  Health  Authority   SSPSR:  Office  for  Reproductive  Health  Products  Security   TVA:  Value  Added  Tax   UNFPA:  United  Nations  Fund  for  Population  Activities   USAID:  United  States  Agency  for  International  Development   VIH:  Human  Immunodeficiency  Virus   Madagascar:  Total  Market  Initiative  Project,  2010       Page  5  of  37   Preface Marie  Stopes  International,  Futures  Group  and  UNFPA/Madagascar  jointly  conducted  an  evidence-­‐ based  Total  Market  Initiative  in  Madagascar,  using  Round  2  funding  from  the  Innovation  Fund.  The   eighteen-­‐month  collaborative  effort  aimed  at  advocating  for  a  successful  public-­‐private  partnership   to  increase  contraceptive  security  and  prevalence  in  Madagascar  with  special  emphasis  on  vulnerable   and  poor  populations.     Activities  conducted  under  this  project  include  a  market  segmentation  analysis,  a  literature  review,   and  a  stakeholders  meeting  to  discuss  strategies  and  next  steps.  The  primary  output  of  this  project  is   a  documented  advocacy  strategy  plan  with  necessary  policy  changes,  effective  market  segmentation   and  increased  role  of  the  private  sector  following  a  total  market  approach.       The  researchers  used  the  most  recent  Madagascar  Demographic  and  Health  Survey  and   supplemented  this  survey  by  collecting  quantitative  and  qualitative  data  with  the  help  of  Marie   Stopes  International/Madagascar. Madagascar:  Total  Market  Initiative  Project,  2010       Page  6  of  37   Acknowledgements This  draft  report  is  the  result  of  work  undertaken  by  Marie  Stopes  International  (MSI)  and  Marie   Stopes  Madagascar,  with  technical  advice  and  feedback  from  the  Government  of  Madagascar   Ministry  of  Health  and  Family  Welfare,  the  Futures  Group,  USA,  UNFPA/Madagascar  as  well  as  other   stakeholders  in  Madagascar.       Our  special  thanks  go  to  Dr.  WANOGO  Dotian  Ali,  UNFPA-­‐Madagascar  and  Ms.  Margot  Fahnestock,   formerly  with  the  Futures  Group.  The  authors  greatly  acknowledge  their  time,  support,  comments,   and  suggestions  provided  to  help  improve  this  study.  The  authors  would  also  like  to  thank  the  Futures   Group  for  contributing  the  DHS  2009  Analysis  and  Soumitro  Ghosh,  MSI  Head  of  Integrated   Marketing,  for  revising  the  executive  summary  on  short  notice.  Any  errors  or  omissions  remain  the   responsibility  of  the  authors.                   Madagascar:  Total  Market  Initiative  Project,  2010       Page  7  of  37   Executive  Summary     Madagascar’s  population  has  grown  rapidly  since  the  1950s.  In  1955,  the  population  was  4.8  million;   by   2005,   it   had   reached   18.5  million.   At   the   current   fertility   rate   of   4.8   children   per   woman,   the   population  will  continue  to  grow  exponentially,  putting  a  strain  on  resources  and  hindering  economic   development.     In  recognition  of  this  need  to  address  rapid  population  growth,  the  Government  of  Madagascar  has   shown   strong   commitment   to   family   planning   (FP).     In   September   2007,   the  Government  declared   that   all   contraceptives   would   be   provided   free   of   charge   to   clients   in   the   public   sector.     This   has   resulted  in  some  impressive  gains:  total  fertility  rates  have  decreased,  contraceptive  prevalence  has   increased,   and   unmet   need   has   decreased.     However,   the   recent   policy   change   also   calls   into   question   the   sustainability   of   these   achievements.   Expanding   the   role   of   the   private   sector   (commercial,  NGO  and  other  non-­‐profit  organizations)  in  the  provision  of  contraceptives  could  have   a  significant  impact  in  ensuring  contraceptive  security  in  Madagascar  over  the  long-­‐term.     OPPORTUNITIES  FOR  INCREASING  THE  ROLE  OF  THE  PRIVATE  SECTOR     The   2007   policy   change   has   resulted   in   a   number   of   challenges  for  the  Ministry  of  Health  (MOH)  in  ensuring   contraceptive  security.    Although  the  Government  has  a   line   item   for   procurement   of   contraceptives,   the   overwhelming  majority  of   contraceptives   are  provided   by   donors.     In   addition,   district   authorities   are   still   obligated   to   cover   the   costs   of   transporting   contraceptives   to   health   facilities   but   no   longer   have   the  funds  to  cover  the  costs,  putting  districts  at  risk  of   stockouts.         In   the  past,   the  private  sector  contributed   to  over  1/3   of   the  total  FP  market  share.    The   introduction  of   free   contraceptives   in   the   public   sector   has   resulted   in   a   decline   in   sales   of   contraceptive   products   in   the   commercial   sector   and   a   decline   in   distribution   by   private  sector  providers,  resulting  in  greater  reliance  on   the   limited  public  sector  resources  (see  Figure  1).    The   current   situation   in   Madagascar   presents   a   unique   opportunity  for  the  MOH  to  reengage  the  private  sector   in  supporting  the  Government  to  reach  its  FP  targets     and   ensure   contraceptive   security.     Indeed,   data   from   the  2009  Demographic  and  Health Survey  show  a  clear  role  for  the  private  sector  in  the  FP  market.       Madagascar:  Total  Market  Initiative  Project,  2010       Page  8  of  37   Clients   who   can   pay   use   contraceptives   provided   by   the   public   sector.   With   the   introduction   of   free   contraceptives   in   the   public   sector,   the   use   of   injectables—the   most   popular   FP   method—has   increased  in  every  socioeconomic  group  (see  Figure  2).     This   growth   is   most   dramatic   in   the   two   highest   socioeconomic  groups.    Indeed,  as  Figure  3  shows,  the   public   sector   provides   48%   of   contraceptives   for   the   highest   socioeconomic   group.     Clients   in   the   highest   socio-­‐economic   groups   could   be   targeted   by   the   private   sector,   conserving   public   sector   resources   for   those  most  in  need.     Unmet   need   for   FP   persists   across   all   socioeconomic   groups.  Despite  the  introduction  of  free  contraceptives   in  the  public  sector,  there  is  still  persistent  unmet  need   across   all   groups—including   among   the   highest   socioeconomic   groups,   who   could   be   targeted   by   the   private  sector.     CHALLENGES  TO  PRIVATE  SECTOR  EXPANSION   The   private   sector   faces   a   number   of   challenges   to   entry   in   the   FP   market.     These   challenges   must   be   taken   into   consideration   in   developing   a   plan   to   increase  private  sector  participation.         Taxes   on   contraceptives:   Under   the   current   system,   donors   with   bilateral   agreements   with   the   Government   of   Madagascar   are   exempt   from   taxes   on   FP   commodities,   but   NGOs   without   such   agreements   are   not,   discouraging   private   sector   participation.     In   addition,   these   taxes   raise   the   prices   of   contraceptives   in   the   private   sector,   decreasing   demand   and   affecting   contraceptive   prevalence.         Public   sector   contraceptives   are   free:   That   public   sector   contraceptives   are   free   discourages   the   scaling  up  of  commercially-­‐priced  products.  However,  with  targeted  social  marketing   initiatives,  the   private  sector  can  still  be  successful.     Inadequately  segmented  market:  To  appropriately  target  public  sector  resources  to  those  who  need   them  and  private  sector  products  to  those  who  can  pay  for  them,  the  MOH  must  understand  how  the     market  is  segmented.    This  includes  identifying  current  private  sector  contributions  to  FP,  which  are   currently  not  disaggregated  in  national  results.           Madagascar:  Total  Market  Initiative  Project,  2010       Page  9  of  37   ACTION  PLAN  FOR  THE  MINISTRY  OF  HEALTH     What  are  some  steps  the  MOH  can  take  towards  improving  contraceptive  security  through  increasing   the  role  of  the  private  sector   in  the  provision  of  contraceptives?    Below  are  recommendations  that   were  shared  and  agreed  upon  at  an  October  26,  2010  workshop  with  stakeholders   from  the  MOH,   Ministry   of   Finance,   donor   agencies   and   the   private   sector.     The   Total   Market   Initiative   (TMI)   Technical   Advisory   Group   (TAG)   will   continue   to   provide   support   and   guidance   to   the   MOH   in   developing  and  implementing  a  detailed  advocacy  action  plan  for  these  recommendations.       Recommendation   Actions   Strengthen  public-­‐private   partnerships  (PPP).   • The  MOH  will  invite  TAG  representatives  to  meet  with  the  MOH   Partnership  Director  to  develop  an  action  plan  for  strengthening  PPP   based  on  the  recommendations  made  at  the  October  26  workshop.   • The  Partnerships  Director  will  organize  a  regular  meeting  with  FP  NGOs   to  discuss  ways  to  strengthen  PPP.   • The  TAG  will  support  the  Partnerships  Director  to  finalize  a  formal  policy   paper  on  PPPs  for  FP  services.   Segment  the  market  to   appropriately  target  clients   with  public  and  private  sector   resources.   • The  MOH  must  define  the  reporting  systems  required  from  FP  NGOs.   • Based  on  the  TMI  study  and  NGO  activity  reports,  the  TAG  (including  the   MOH)  will  identify  gaps  in  the  current  market  segmentation  to  determine   where  to  target  and  how  to  utilize  public  and  private  sector  resources.     The  MOH  will  decide  on  a  timeline  for  regular  reporting  on  market   segmentation  so  that  resource  targeting  is  adjusted  as  needed.   • The  MOH  will  work  with  NGOs  providing  FP  to  collect  activity  reports  on   a  monthly  basis  so  that  they  can  be  utilized  by  the  MOH  to  determine   gaps  in  market  segmentation.   Remove  taxes  on   contraceptives.   • The  MOH  Director  of  Safe  Motherhood  (DSM)  will  analyze  the  impact  of   taxation  policies  on  contraceptive  costs  and  Government  revenue  and   develop  recommendations  to  take  to  the  Ministry  of  Finance.   • The  MOH  (DSM)  will  meet  with  the  Director  of  Finance  and  Budget  to   propose  a  law  amendment  and  discuss  the  way  forward  (for  example,   aligning  the  definition  of  tax-­‐exempt  medicines  with  the  MOH  definition).   Promote  social  marketing   initiatives.   • Prior  to  the  Council  of  Ministers  meeting,  the  Director  of  Safe   Motherhood  will  frame  the  design  of  a  draft  social  marketing  policy.   • The  MOH  will  disseminate  TMI  results  at  the  Council  of  Ministers   meeting  before  end  of  2010  to  demonstrate  the  role  of  the  private  sector   and  potential  for  social  marketing.   Increase  public  sector   funding  for  contraceptive   procurement  and   transportation  to  strengthen   total  market  approaches.   • The  MOH  (DSM)  will  develop  an  action  plan  that  outlines  how  increased   public  sector  funding  will  facilitate  total  market  approaches  for  FP.     • The  DSM  will  present  an  advocacy  brief  to  the  Director  of  Finance  and   Planning,  for  the  MOH.   • The  MOH  will  develop  objectives  for  funding  –  including  line  items  for   transportation  costs  related  to  supply  of  contraceptives  to  the  CSB-­‐level   –  that  are  in  compliance  with  Ministry  of  Finance  and  Budget  formats.   Madagascar:  Total  Market  Initiative  Project,  2010       Page  10  of  37   Chapter  1:  Project  Background,  Objectives  and  Activities     Based   on   documented   evidence   collated   by   the   proposed   consortium   consisting   of   Marie   Stopes   Madagascar   (MSM),   a   clinical   program   of  Marie   Stopes   International,   the   Futures   Group,   and   the   UNFPA   country   office   in   Madagascar,   Madagascar   has   made   impressive   progress   in   promoting   reproductive   health   and   family   planning.   The   Demographic   Health   Survey   (DHS)   shows   modern   method   contraceptive   use   increased   from   5.1%   in   1992   to   18.3%   in   2003.   In   addition,   the   Government   of   Madagascar’s   (GoM)   national   strategy   has   an   objective   of   reaching   28%   modern   method  prevalence  by  2009.  Since  2002  the  GoM  has  shown  strong  commitment  and  demonstrated   leadership  in  family  planning  and  reproductive  health.  A  Strategic  Pathway  to  Achieving  Reproductive   Health   Commodity   Security   Assessment   conducted   in   2003   resulted   in   a   national   family   planning   strategy.  This  strategy  included  policy  and  operational  changes  that  increased  collaboration  between   the   public   and   private   sectors,   facilitated   establishment   of   public-­‐private-­‐partnerships   (PPP)   in   the   procurement  and  distribution  of  contraceptives,  and  actions  on  the  part  of  the  public  sector  to  target   the   distribution   of   free   contraceptives.   This   represented   the   beginning   of   a   targeted   approach   for   improving  contraceptive  security  by   increasing   the   role  of   the  private  sector,   including  a  sharing  of   costs  by  the  public  and  private  sector.         In   2007   the  GoM  changed   course  and  determined   that   all   public   sector   contraceptives  were   to  be   provided   for   free.   Anecdotal   evidence   suggests   that   this   action   resulted   in   a   decline   in   sales   in   contraceptives   in   the   commercial   sector   and   a   decline   in   distribution   by   private   sector   providers.     Currently,  donors  provide  most  of  the  contraceptives  in  Madagascar.  The  GoM  has  a  line  item  in  the   health  budget   to  procure   contraceptives.  While   this   represents  a  noteworthy  achievement,   it   does   not  generate  sufficient   funding   to  meet   the  needs  of   the  country.  Reaching   the  objective  of  a  28%   modern  method   contraceptive  prevalence   rate   (CPR)  will   require   significantly  more   resources  on  a   sustainable   basis.   Prior   to   the   2007   decision,   district   authorities   sold   contraceptives   on   a   cost-­‐ recovery   basis.   The   money   collected   went   into   a   fund   used   to   cover   the   transport   costs   of   the   contraceptives   from   the   central  medical   stores.   A  USAID-­‐funded   study   into   operational   barriers   to   contraceptive  security,  conducted  in  December  2008  by  JSI/Deliver  and  Futures  Group  HPI  (Futures),   found   that   with   the   loss   of   this   income,   district   transport   funds   are   close   to   depletion.   This   fund   depletion  could  result   in  stock-­‐outs  of  contraceptives  at  the  point  of  service  delivery.  Another  issue   identified  is  that  some  districts  had  been  using  their  previous  income  to  procure  contraceptives  from   social  marketing  organizations   to  avert   stock-­‐outs.   The  current   situation   in  Madagascar  points   to  a   contraceptive   supply   that   is   highly   vulnerable,   but   is   one   that   offers   an   opportunity   to   influence   policy  change  and  increase  the  role  of  the  private  sector  in  meeting  this  challenge.     Though  Madagascar’s  family  planning  program  has  been  successful,  showing  significant   increases   in   modern  method   CPR,   the   2003/2004   DHS   indicate   significant   disparities   between   rural   and   urban   areas,   by   education   levels   and   among   different   socioeconomic   groups.   According   to   PRB’s   2008   World  Data  Sheet,  24%  of  married  women  in  the  richest  quintile  and  only  2%  of  married  women  in   the  poorest  quintile  are  using  modern  contraception.  Unmet  need  is  estimated  at  25.6%.  At  the  same   time,  a  market  segmentation  study  in  Madagascar  carried  out  by  Futures  in  2004  found  that  25%  of   women  accessing   services   from   the  public   sector   and  56%  of  women  accessing   subsidized   services   Madagascar:  Total  Market  Initiative  Project,  2010       Page  11  of  37   from  non-­‐governmental  organizations  (NGO)  were  in  the  highest  income  segments.  This  information   clearly   indicates  a  gap   in   service  provision   to  poorer  women.  Early   indications  of   the   results  of   the   2007  policy  change  make  it  reasonable  to  conclude  that  these  disparities  are  regrettably  increasing.   This  proposal  application  is  for  an  evidence-­‐based  advocacy  project.  When  submitted  in  the  previous   round   the   proposal   evoked   valid   concerns   over   the   relevance   of   the   project   under   the   rapidly   changing   political   situation   in   Madagascar   from   the   review   committee.   The   consortium,   after   consulting   several  partners   in-­‐country   including   the  Ministry  of  Health  and  UNFPA,  has  established   that   major   technical   departments   of   the   government   are   functioning   and   district-­‐level   resource   personnel  are  not  expected  to  change  even  with  further  political  instability.  Therefore,  it  will  still  be   possible   to   implement   and   complete   the   project   in   a   timely   manner.   The   proposed   market   segmentation/equity  analysis,  which  will  provide  essential  input  into  the  subsequent  policy  dialogue   and  advocacy  efforts,  is  contingent  on  the  availability  of  data  from  the  2008-­‐2009  DHS.    Thus,  delays   in  finalizing  the  data  collection  under  the  DHS  will  inevitably  result  in  delays  in  the  implementation  of   the  current  proposal.  MSM  activities  and  partnership  initiatives  with  government  officials  have  been   largely  unaffected  throughout  the  political  crisis.  However,  appropriate  risk  management   is  needed   to   ensure   project   delivery   in   the   light   of   further   eventualities.   As   such,   the   project   time   frame   is   revised  from  originally  proposed  9  months  to  a  15  month  period,  project  start-­‐up  will  coincide  with   the  availability  of  DHS  data,  and  a  partnership  with  UNFPA  is  developed  to  complement  and  reinforce   the  consortium’s  advocacy  capacity.       Project  goal  and  objectives   Overall  Goal     The   goal   of   the   project   is   to   build   support   in   the   public   sector   for   a   total  market   approach   to   the   procurement  of  contraceptives  in  Madagascar  (Focus  Area  1.1  and  3.2).       Objectives:       1. Demonstrate  how   increasing   the   role  of   the  private   sector   can   contribute   to  GoM’s   goal  of   increasing  modern  method   CPR  while   reaching  more   of   the   country’s   vulnerable   and   poor   populations,  thus  reducing  disparities  in  family  planning  access.     2. Influence   the   political,   programmatic,   and   country   scene   through   the   promotion   of   Total   Market   approaches   through   the   sharing   of   relevant   primary   and   secondary   data   from   in   country  and  global  experiences.       3. Update  and  expand  market  based  evidence  prior  to  the  2007  contraceptive  policy  change  and   afterwards  to  influence  proposed  policy  modifications.   Project  activities   Summary  of  activities  performed  and  results:     Madagascar:  Total  Market  Initiative  Project,  2010       Page  12  of  37   Date   Activities   Results   December   2009   Terms  of  Reference  (TDR)  preparation   and  tasks  planned  for  MSM  and  Futures   Group  (meeting  made  by  MSM  and   UNFPA).       -­‐  TDR  developed  with  task  distribution   between  MSM  and  Futures  Group;   -­‐  Contract  Futures  Group  developed  and   signed;   -­‐  Authorisation  received  from  the  Ministry   of  Health.   January   2010   -­‐  Development  of  questionnaires   concerning  market  segmentation  and   equity  achieved  inquiry    (for  NGO,  FP   service  providers,  FP  distributors  and  FP   services  in  the  Ministry  of  Health);   -­‐  Organisation  and  realization  of  the   inquiry  by  MSM.       -­‐  Questionnaire  for  data  collection;   developed,  multiplied  and  distributed  to   stakeholders  (16  institutions);   -­‐  Data  collection  completed.     February   -­‐  March   2010   -­‐  Survey  on  PF  political  change  in   Madagascar;   -­‐  Arrival  in  Madagascar  of  Technical   Advisors  from  MSI  and  Futures  Group;   -­‐  Organization  and  facilitation  meetings   held  with  the  target  FP  stakeholders.   -­‐  TAG  meeting  with  representatives  of   UNFPA,  MoH  Department  of  Safe   Motherhood  and  Child  Health,  Taxation   Directorate,  FARMAD,  Santénet2,  USAID,   PSI,  ordre  des  pharmaciens,  ordre  des   médecins,  ordre  des  sages-­‐femme;   -­‐  Report  and  survey  completed  and  made   available  by  Futures  Group  concerning  FP   policy  change.     April  –   mey  2010    (Technical  Advisor  Group)   -­‐  Preparation  of  the  first  TAG  meeting;   -­‐  Realization  of  the  TAG  meeting.     -­‐  Meeting  of  TAG  members  conducted  on   20  May  2010  (18  institutions  represented,   45  participants  at  the  meeting);   -­‐  The  TAG  TDR  is  developed  and  validated.           July-­‐ August     2010   -­‐  Preparation  and  Presentation  to  the   TAG  members  of  the  market   segmentation  and  equity  survey  results   produced  and  directed  by  MSM;     -­‐  Share  the  first  draft  of  the  survey   results    during  the  meeting.     -­‐  Document  partagé  et  présenté  durant  la   réunion  des  membres  du  TAG  à  l’enceinte   de  l’UNFPA  (02  August  2010).     August   2010   -­‐  Analysis  of  market  segmentation  and   equity  based  on  DHS  data  by  Meghan   Bishop  of  Futures  Group;   -­‐  Report-­‐writing  on  the  compilation  of   the  results  of  the  two  surveys  conducted   by  MSM  and  Futures  Group;   -­‐  Preparation  for  results  dissemination.     -­‐  Report  of  the  two  surveys  compiled  by   MSM.   Madagascar:  Total  Market  Initiative  Project,  2010       Page  13  of  37   September   2010   -­‐  Meeting  with  the  TAG  members  for   sharing  the  compiled  document  and   collecting  of  their  feedback.         -­‐  Meeting  made  at  the  MSM  office  on  the   02  of  September  2010.  10  TAG  members   were  present).     October   2010   -­‐  Presentation  of  the  study  results  during   meeting  of  reproductive  health  partners   organized  by  the  Ministry  of  Health  /   Department  of  Safe  Motherhood.     -­‐  A  powerpoint  prepared  by  MSM  and   presented  by  Dr  Lucie  Ramanandraibe,   (expert  on  Reproductive  Health  –  UNFPA)   during  the  meeting  of    Reproductive  Health   partners  on  the  8  October  2010  (under  the   leadership  of  the  MoH).     October   2010   -­‐  Preparation  of  the  official  final  results   dissemination  of  the  study;   -­‐  Soumitro  Ghosh  (MSI)  and  Meghan   Bishop,  Senior  Policy  Advisor  (Futures   Group)  arrival  for  the  official   dissemination;   -­‐  Group  work  with  TAG  members  during   the  official  dissemination  workshop  to   complete  development  of  the  advocacy   document.     -­‐  Official  Dissemination  conducted  the  26   of  October  2010  with  the  patronage  by  the   Minister  of  Health;   -­‐  Minutes  of  the  meeting  available;   -­‐  Advocacy  document  finalised,  made   available  and  disseminated.     December   2010   -­‐  Advocacy  document  presented  during   the  Reproductive  Health  coordination   meeting  organised  by  the  MoH.       -­‐  Powerpoint  prepared  by  MSM  and   presented  by  UNFPA  (Dr  Lucie   Ramanandraibe).   Madagascar:  Total  Market  Initiative  Project,  2010       Page  14  of  37   Family  Planning  Environment  in  Madagascar   Since  2002,  the  Government  of  Madagascar  has  demonstrated  a  strong  commitment  to  reproductive   health  and  family  planning.    In  2003,  Madagascar  adopted  its  first  National  Strategy  for  Family   Planning,  with  a  goal  to  reach  a  contraceptive  prevalence  rate  of  29.2%  by  2008.  This  strategy   included  political  and  operational  changes  that  helped  improve  collaboration  between  public  and   private  sectors  and  facilitated  the  establishment  of  a  public-­‐private-­‐partnership  (PPP)  in  the  purchase   and  distribution  of  contraceptives.    In  this  sense,  this  strategy  represented  the  beginning  of  a   targeted  approach  to  improve  contraceptive  security  by  increasing  the  role  of  the  private  sector,   including  cost  sharing  by  the  public  and  private.    As  a  result,  Madagascar  saw  great  improvement  in   FP  indicators,  including  an  increase  in  the  use  of  modern  contraceptive  methods  increased  from  5.1%   in  1992,  18.3%  in  2003  to  29.2%  in  2008.       In  2007,  demonstrating  further  commitment  to  improving  FP,  the  Malagasy  government  declared   that  all  contraceptives  be  provided  free  of  charge  to  all  clients  served  by  the  public  sector.    However,   this  action  has  resulted  in  some  unintended  negative  impacts,  especially  for  the  private  sector.    For   example,  this  policy  change  has  resulted  in  a  decline  in  sales  of  contraceptive  products  in  the   commercial  sector  and  a  decline  in  the  distribution  of  contraceptives  by  private  sector  suppliers.       The  Government  faces  several  challenges  to  sustaining  and  improving  upon  contraceptive   prevalence.    Although  the  Government  created  a  budget  line  for  procurement  of  contraceptives,  the   bulk  of  public  sector  procurement  is  done  by  the  donors.  Prior  to  the  2007  policy  change,  authorities   at  the  district  level  used  a  cost-­‐recovery  system  to  cover  their  cost  of  transporting  contraceptives   from  the  central  warehouse  to  the  district  health  service  delivery  points.    District  authorities  charged   a  nominal  fee  on  contraceptives,  commensurate  to  the  cost  of  transportation.    However,  a  December   2008  USAID  study  on  operational  barriers  to  contraceptive  security  showed  that  with  the  policy   change    districts  no  longer  have  funds  to  the  transportation  of  contraceptives,  increasing  the  risk  of   product  stock  outs    at  delivery  service  points       Although  contraceptive  prevalence  in  Madagascar  has  steadily  increased,  thanks  to  the  favorable  FP   policy  environment,  DHS  data  (2003/2004)  demonstrates  significant  disparities  in  the  use  of  modern   contraceptive  methods  between  rural  and  urban  areas,  levels  of  education  and  different   socioeconomic  groups.    According  to  the  World  Population  Reference  Bureau  (PRB)  2008  datasheet,   24%  of  married  women  in  the  highest  wealth  quintile  and  only  2%  of  married  women  in  the  lowest   wealth  quintile  use  modern  contraception.      Unmet  need  for  family  planning  was  estimated  at  25.6%   across  all  quintiles.     In  addition,  a  study  conducted  by  Futures  Group  in  2004  indicates  that  the  FP  market  is  sub-­‐optimally   segmented:    25%  of  women  in  the  highest  wealth  quintiles  were  accessing  public  sector  FP  services   and  56%  were  accessing  services  subsidized  by  non-­‐governmental  organizations  (NGOs).  This  context   suggests  that  the  private  sector  could  play  a  greater  role  in  contraceptive  distribution  and  provision   of  FP  services  to  reduce  disparities  and  to  reduce  reliance  on  the  public  sector  by  clients  who  can   afford  to  pay  for  private  sector  services  and  products.       Madagascar:  Total  Market  Initiative  Project,  2010       Page  15  of  37     Market  Segmentation  Analysis  Objectives   In  line  with  the  Government  of  Madagascar’s  efforts  to  address  the  issue  of  contraceptive  security  in   the  country,  the  MSI  led  consortium  advocate  a  participatory  process  aimed  at  identifying   appropriate  roles  for  public,  NGO,  and  commercial  sectors  in  providing  family  planning  products  and   services.  The  first  objective  of  the  market  segmentation  analysis,  explained  in  more  detail  in  this   report  to  help  identify  opportunities  for  improving  resource  allocation  in  family  planning  in  favour  of   promoting  contraceptive  security.  Second,  the  analysis  will  serve  as  the  common  information  source   that  feeds  into  the  dialogue  process  among  stakeholders.  Finally,  the  market  segmentation  analysis   and  the  accompanying  dialogue  process  can  facilitate  collaboration  among  key  stakeholders  from   public  and  private  sectors.     Intended  Use  of  Market  Segmentation  Analysis  in   Madagascar   The  market  segmentation  analysis  is  supporting  the  policy  process  to  improve  resource  allocation  by   addressing  the  contraceptive  security  challenge  in  Madagascar.  This  final  report  has  been  shared  with   key  stakeholders  from  the  public  and  private  sectors;  and  has  stimulated  discussions  about  their   respective  roles,  information  needs,  and  interests  in  specific  market  segments.     The  feedback  obtained  from  stakeholders  during  the  October  2010  market  segmentation  workshop   has  helped  tailor  the  analysis  to  address  specific  information  needs,  and  has  also  identified  potential   opportunities  for  each  sector  in  particular  for  the  private  sector.   This  final  report  should  inform  subsequent  discussions  among  stakeholders  about  appropriate   strategies  to  improve  efficiency  and  effectiveness  of  the  national  family  planning  program.  This   collaborative  approach  will  facilitate  identification  of  appropriate  roles  for  the  public  and  private   sector,  allowing  each  sector  to  maximize  its  contribution  and  impact.     Applying  Market  Segmentation  Analysis   Definitions   Market  segmentation  analysis  is  a  useful  analytic  tool  for  donors,  governments,  and  other   stakeholders  that  are  striving  to  achieve  greater  contraceptive  security  through  a  more  efficient  and   effective  allocation  of  resources.  In  its  broadest  sense,  market  segmentation  analysis  refers  to  the   process  of  using  survey  data  and  statistical  analysis  to  divide  the  reproductive  health  market  into   subpopulations  whose  reproductive  health  needs,  characteristics  (including  ability  to  pay),  or   practices  might  require  distinct  service  delivery  or  marketing  strategies.  Typically,  a  market   segmentation  analysis  of  the  family  planning  market  will  include  an  examination  of  contraceptive   Madagascar:  Total  Market  Initiative  Project,  2010       Page  16  of  37   users  by  method,  method  source,  and  economic  status  (e.g.,  income  quintile).  By  using  that   information,  it  will  be  possible  to  determine  the  extent  to  which  the  family  planning  market  is  well-­‐ segmented;  that  is,  whether  the  contraceptive  sources  used  by  different  economic  groups  are   consistent  with  an  efficient  use  of  public  and  private  resources.   Market  Segmentation  as  a  Policy  Tool   In  many  countries,  a  limited  resource  for  family  planning  is  a  primary  obstacle  to  contraceptive   security.  Sources  of  funding  for  family  planning  include  government,  donors,  and  the  private  sector.   The  GOM  contributes  significantly  to  the  national  family  planning  program.  What  is  the  GOM’s  ability   to  meet  the  increased  funding  required  as  both  contraceptive  demand  rises  while  donor  funding   decreases?  Donor  funding  for  contraceptives  is  declining.  This  means  that  the  private  sector  needs  to   contribute  significantly  to  meet  the  funding  gap.  In  Madagascar,  as  in  most  developing  countries,   virtually  all  private  sectors  spending  for  family  planning  comes  from  households.  The  challenge  is  to   increase  payments  from  households  without  putting  an  unfair  burden  on  the  poor  families  of   Madagascar.  Therefore,  an  efficient  use  of  resources  means  that  payments  from  households  reflect   what  those  households  are  able  to  pay,  as  a  way  to  maximize  private  sector  resources.  Such   segmentation,  however,  requires  coordination  among  public  and  private  sector  stakeholders.     When  used  as  a  policy  tool,  market  segmentation  analysis  creates  opportunities  for  various  public   and  private  sector  stakeholders  to  coordinate  their  efforts  to  meet  the  country’s  family  planning   needs.  This  assumes  greater  significance  in  a  resource  scarce  environment  where  such  coordination  is   a  necessity  for  achieving  national  program  objectives.  Given  the  different  objectives  of  the  public,   NGO,  and  commercial  sectors,  it  should  be  possible  to  identify  each  sector’s  complimentary  roles  in   providing  family  planning  products  and  services  in  a  given  country.  In  most  countries,  the  initiation  of   the  process  inevitably  coincides  with  planned  donor  phase  out  or  an  expected  decline  in  donor   supplied  free  contraceptives.  However,  several  factors  are  important  in  implementing  such  a   collaborative  process  that  involves  all  the  key  stakeholders.  Some  key  factors  include  continued   commitment  by  the  MoH  to  involve  private  sector  stakeholders,  existence  of  distinct  market   segments,  and  willingness  of  the  private  sector  to  invest  resources  needed  for  serving  its  target   population.     It  is  important  to  recognize  that  with  the  growing  demand  for  family  planning  in  the  country,  a  well   segmented  market  will  not  necessarily  reduce  the  role  of  any  particular  sector.  In  fact,  the  proposed   collaboration  will  enhance  the  overall  impact  of  the  national  family  planning  efforts  and  will  enable   efficient  and  equitable  targeting  of  resources.  This  market  segmentation  analysis  will  provide  data  to   key  stakeholders  to  help  them  better  understand  the  socioeconomic,  demographic,  and  behavioural   profile  of  the  target  population  in  terms  of—     • use  of  contraceptive  method  mix   • use  of  contraceptive  supply  source  mix   • unmet  need  for  contraceptives   • reasons  for  non-­‐use  of  contraceptives   Madagascar:  Total  Market  Initiative  Project,  2010       Page  17  of  37   Market  Segmentation  Methodology   Data   The  present  study  relies  on  data  from  the  Madagascar  Demographic  and  Health  Survey  (DHS)  2009.     Wealth  Index   The  authors  used  the  asset-­‐based  wealth  index  developed  by  ORC  Macro  and  the  World  Bank  to   classify  currently  married  women  of  reproductive  age  according  to  socioeconomic  status.     The  wealth  index  was  developed  explicitly  for  use  with  DHS  data  sets  to  compute  a  standard  of  living   index  for  each  woman  in  the  DHS  data  set  (Gwatkin  2000).  The  asset  or  wealth  information  is   gathered  using  the  DHS  household  questionnaire  with  questions  typically  posed  to  the  head  of  the   household  concerning  the  household’s  ownership  of  a  number  of  items,  such  as  a  fan,  television,  and   car;  dwelling  characteristics  that  are  related  to  wealth  status,  such  as  flooring  material,  wall  material,   and  roofing  material;  type  of  drinking  water  source;  type  of  toilet  facilities;  and  other  characteristics,   such  as  electricity  in  the  home.     A  weight  or  factor  score  generated  through  principal  component  analysis  is  assigned  to  each   household  asset  for  which  information  was  collected  through  the  DHS.  The  resulting  asset  scores  are   standardized  in  relation  to  a  standard  normal  distribution,  with  a  mean  of  zero  and  a  standard   deviation  of  one.  Each  household  is  assigned  a  score  depending  on  whether  or  not  the  household   owns  particular  assets  included  in  the  asset  index.  The  sample  is  then  divided  into  population   quintiles—five  groups  with  approximately  the  same  number  of  households  in  each  group,  with  the   first  quintile  being  the  poorest  and  the  fifth  quintile  representing  the  wealthiest.   Analysis  of  Data   The  family  planning  market  can  be  segmented  in  a  variety  of  ways,  and  there  is  no  best  approach.  In   this  preliminary  report,  we  used  cross-­‐tabulation  to  segment  the  family  planning  market,  primarily   along  socioeconomic  and  geographic  lines.     Madagascar:  Total  Market  Initiative  Project,  2010       Page  18  of  37   Chapter  2:  Family  Planning  Policy  Environment  and  Market   Structure  in  Madagascar   Based  on  documented  evidence  collated  by  the  proposed  consortium  consisting  of  Marie  Stopes   Madagascar  (MSM),  a  clinical  program  of  Marie  Stopes  International,  the  Futures  Group,  and  the   UNFPA  country  office,  Madagascar  has  made  impressive  progress  in  promoting  reproductive  health   and  family  planning.  The  Demographic  Health  Survey  (DHS)  shows  modern  method  contraceptive  use   increased  from  5.1%  in  1992,  to  18.3%  in  2003,  to  29.2%  in  2008.  The  GoM’s  national  strategy  has  an   objective  of  reaching  28%  modern  method  prevalence  by  2009.  Since  2002  the  GoM  has  shown   strong  commitment  and  demonstrated  leadership  in  family  planning  and  reproductive  health.  A   Strategic  Pathway  to  Achieving  Reproductive  Health  Commodity  Security  Assessment  conducted  in   2003  resulted  in  a  national  family  planning  strategy.  This  strategy  included  policy  and  operational   changes  that  increased  collaboration  between  the  public  and  private  sectors,  facilitated   establishment  of  public-­‐private-­‐partnerships  (PPP)  in  the  procurement  and  distribution  of   contraceptives,  and  actions  on  the  part  of  the  public  sector  to  target  the  distribution  of  free   contraceptives.  This  represented  the  beginning  of  a  targeted  approach  for  improving  contraceptive   security  by  increasing  the  role  of  the  private  sector,  including  a  sharing  of  costs  by  the  public  and   private  sector.         In  2007  the  GoM  changed  course  and  determined  that  all  public  sector  contraceptives  were  to  be   provided  for  free.  Anecdotal  evidence  suggests  that  this  action  resulted  in  a  decline  in  sales  in   contraceptives  in  the  commercial  sector  and  a  decline  in  distribution  by  private  sector  providers.     Currently,  donors  provide  most  of  the  contraceptives  in  Madagascar.  The  GoM  has  a  line  item  in  the   health  budget  to  procure  contraceptives.  While  this  represents  a  noteworthy  achievement,  it  does   not  generate  sufficient  funding  to  meet  the  needs  of  the  country.  Reaching  the  objective  of  a  28%   modern  method  CPR  will  require  significantly  more  resources  on  a  sustainable  basis.  Prior  to  the  2007   decision,  district  authorities  sold  contraceptives  on  a  cost-­‐recovery  basis.  The  money  collected  went   into  a  fund  used  to  cover  the  transport  costs  of  the  contraceptives  from  the  central  medical  stores.  A   USAID-­‐funded  study  into  operational  barriers  to  contraceptive  security,  conducted  in  December  2008   by  JSI/Deliver  and  Futures  Group  HPI  (Futures),  found  that  with  the  loss  of  this  income,  district   transport  funds  are  close  to  depletion.  This  fund  depletion  could  result  in  stock-­‐outs  of   contraceptives  at  the  point  of  service  delivery.  Another  issue  identified  is  that  some  districts  had   been  using  their  previous  income  to  procure  contraceptives  from  social  marketing  organizations  to   avert  stock-­‐outs.  The  current  situation  in  Madagascar  points  to  a  contraceptive  supply  that  is  highly   vulnerable,  but  is  one  that  offers  an  opportunity  to  influence  policy  change  and  increase  the  role  of   the  private  sector  in  meeting  this  challenge.     Though  Madagascar’s  family  planning  program  has  been  successful,  showing  significant  increases  in   modern  method  CPR,  the  2003/2004  DHS  indicate  significant  disparities  between  rural  and  urban   areas,  by  education  levels  and  among  different  socioeconomic  groups.  According  to  PRB’s  2008   World  Data  Sheet,  24%  of  married  women  in  the  richest  quintile  and  only  2%  of  married  women  in   the  poorest  quintile  are  using  modern  contraception.  Unmet  need  is  estimated  at  25.6%.  At  the  same   time,  a  market  segmentation  study  in  Madagascar  carried  out  by  Futures  in  2004  found  that  25%  of   Madagascar:  Total  Market  Initiative  Project,  2010       Page  19  of  37   women  accessing  services  from  the  public  sector  and  56%  of  women  accessing  subsidized  services   from  non-­‐governmental  organizations  (NGO)  were  in  the  highest  income  segments.  This  information   clearly  indicates  a  gap  in  service  provision  to  poorer  women.  Early  indications  of  the  results  of  the   2007  policy  change  make  it  reasonable  to  conclude  that  these  disparities  are  regrettably  increasing.     The Policy Environment for Family Planning in Madagascar   Madagascar’s  national  vision  is  to  become  a  prosperous  nation,  with  a  high  growth  economy  and  a   strong  role  as  a  competitor  in  the  global  marketplace.  To  achieve  this  status  in  the  global  economy,   Madagascar  understands  that  it  must  pay  special  attention  to  population  growth  and  its  negative   impact  on  economic  development  and  prosperity.  Madagascar’s  population  size  has  grown  rapidly   since  the  1950s.  In  1955,  the  population  was  4.8  million;  by  1985,  the  population  had  ballooned  to   10.4  million.  Twenty  years  later,  in  2005,  Madagascar’s  population  had  reached  18.5  million  people;   experts  predict  that  that  number  will  reach  78  million  by  2050  at  the  current  fertility  level  (4.8   children  per  woman  according  to  the  2009  Madagascar  Demographic  and  Health  Survey).       Even  with  rapid  population  growth,  Madagascar’s  family  planning  program  has  been  highly   successful;  undoubtedly  the  population  would  have  grown  faster  than  it  did  in  the  last  10  years  if  the   country  had  not  made  great  strides  in  improving  access  to  family  planning  services.  The  1997,  2004   and  2009  Madagascar  Demographic  and  Health  Surveys  (DHS)  show  that  use  of  all  contraceptive   methods  increased  significantly  from  19.4  percent  to  27.1  percent  to  39.9  percent  of  all  married   women  of  reproductive  age.    Madagascar’s  CPR  is  still  relatively  low,  however,  when  compared  with   other  sub-­‐Saharan  African  countries.  The  Government  of  Madagascar  expects  that,  given  its  recent   efforts  to  strengthen  and  prioritize  family  planning,  CPR  among  currently  married  women  will   continue  to  increase.     History  of  Family  Planning  Policy  in  Madagascar     In  1967,  seven  years  after  Madagascar  gained  independence,  an  affiliate  of  International  Planned   Parenthood,  called  Fianakaviana  Sambatra  (FISA)  began  offering  family  planning  services.    Despite  the   early  availability  of  family  planning  services  in  the  private  sector,  Madagascar’s  public  sector  family   planning  program  wasn’t  created  until  1986.    In  1990  the  country  developed  and  adopted  the  first   national  Population  Policy.    The  government  further  strengthened  the  family  planning  program  with   the  development  of  norms,  standards  and  guidelines  for  family  planning  services  in  1992  and  a   national  Reproductive  Health  Policy  in  1993.     Beginning  in  2002,  Madagascar’s  government  began  to  place  a  high  priority  on  family  planning  to   help  address  population  growth.  In  fact,  in  January  2004,  the  Ministry  of  Health  changed  its  name  to   Ministry  of  Health  and  Family  Planning  (MOHFP).  The  name  change  demonstrated  the  high  level  of   political  commitment  to  family  planning.  By  December  2004,  the  ministry  had  launched  its  first   National  Family  Planning  Strategy  for  2005–2009  and  adopted  a  repositioning  family  planning   initiative  to  increase  demand  for  and  access  to  family  planning  services  and  reduce  the  high  unmet   need  for  these  services  (23.6  percent  of  all  married  women  expressed  an  unmet  need  for  family   planning  services  according  to  the  2004  DHS;  in  2009  this  number  has  decreased  to  18.9  percent).  In   Madagascar:  Total  Market  Initiative  Project,  2010       Page  20  of  37   September  2006,  the  Ministry  began  efforts  to  reposition  family  planning  in  Madagascar  in  view  of   the  country’s  development  plan,  the  Madagascar  Action  Plan  (MAP).  The  ministry  introduced  the  Plan   Sectoriel  en  Planning  Familial  2007–2012  (Sectoral  Plan  for  Family  Planning)  in  order  to  achieve  the   MAP’s  objectives  through  increased  family  planning.  The  ministry  also  created  an  Executive   Secretariat  for  Family  Planning  within  the  ministry  and  a  Family  Planning  Steering  Committee.       In  September  2007,  to  further  prioritize  family  planning  in  the  country  and  increase  access  to   contraceptive  commodities,  the  Government  of  Madagascar  declared  that  all  contraceptives  would   be  provided  free  of  charge  to  clients  in  the  public  sector.  Prior  to  September  2007,  the  government   charged  clients  in  the  public  sector  for  contraceptives—at  amounts  commensurate  with  the   government’s  cost  of  procurement  and  transportation.       These  policy  efforts  have  paid  off  for  Madagascar:  the  country  reported  only  2  percent  stockout  rates   for  injectable  contraceptives  at  service  delivery  points  in  2007.  Many  stakeholders  in  Madagascar   propose  that  the  PAIS  initiative  greatly  improved  warehousing  and  distribution  of  all  essential   medicines,  including  contraceptives.    In  2008,  there  were  no  stockouts  reported  for  injectable   contraceptives  at  service  delivery  points  at  the  district  level.f  Injectable  contraceptives  continue  to  be   the  most  popular  modern  contraceptive  method  (61%  of  all  married  women  using  modern   contraceptives  used  injectable  contraceptives,  according  to  the  2009  DHS);  thus,  a  low  rate  of   stockouts  is  critical  to  maintaining  a  strong  family  planning  program.       The  Ministry  coordinates  forecasting  and  procurement  of  contraceptives  through  a  logistics   committee.    For  coordination  issues  regarding  the  family  planning  program,  the  Ministry  hosts  a   family  planning  steering  committee  that  consists  of  donors,  implementing  partners,   nongovernmental  organizations,  Government  and  pharmaceutical  industry  members.    As  a   commitment  to  the  important  of  family  planning  in  Madagascar,  the  Ministry  has  a  budget  line  item   to  purchase  contraceptives.    Even  though  the  amount  is  much  smaller  than  the  contribution  from   donors,  the  Government  makes  an  annual  government  allocation  of  funds  for  contraceptives.         Public  Sector  Sources  of  Contraceptives     Since  the  September  2007  policy  decision,  women  have  been  able  to  obtain  all  contraceptive   methods  free  of  charge.  At  the  central  level,  Madagascar’s  central  medical  stores,  SALAMA,  procures   and  distributes  essential  medicines  to  the  district  level.    SALAMA  was  created  in  1996  to  implement   provisions  of  the  Bamako  Initiative.    Madagascar’s  health  system  is  decentralized,  with  seven  health   regions,  111  districts,  and  more  than  1,597  communes  within  those  districts.  At  the  district  level,   women  can  obtain  contraceptives  at  the  Pha-­‐G-­‐Dis,  or  district  pharmacy  that  is  typically  managed  by   an  NGO;  at  the  commune  level,  women  can  obtain  contraceptives  at  the  centre  de  santé  de  base   (health  center)  that  has  a  Pha-­‐G-­‐Com  or  pharmacy  based  at  the  health  center.  The  public  sector   system  provides  injectable  and  oral  contraceptives,  intrauterine  devices,  spermicide,  and  CycleBeads.   While  condoms  are  available  at  the  Pha-­‐G-­‐Dis  and  Pha-­‐G-­‐Com  levels,  the  national  family  planning   program  does  not  consider  them  a  family  planning  commodity.  The  study  team  learned  that  condoms   f SanteNet I Project, Public Sector Contraceptive Stockout Surveys for 2006, 2007, 2008. Madagascar:  Total  Market  Initiative  Project,  2010       Page  21  of  37   are  handled  by  the  National  AIDS  Control  Committee  (Comité  National  de  Lutte  Contre  le  SIDA— CNLS)  separately  from  the  family  planning  commodity  supply  chain.     In  2007,  the  Programme  d’Action  pour  l’Integration  des  Intrants  de  Sante  (PAIS):  Plan  Strategique   2008  –  2012  was  launched  based  on  principles  in  the  Madagascar  Action  Plan  (MAP)  and  the  Plan  de   Developpement  du  Secteur  Sante  et  de  la  Protection  Sociale  (PDSSPS).  The  PAIS  was  meant  to   integrate  commodities  Madagascar’s  multiple  distribution  systems  to  avoid  overstock,  multiple   logistics  systems.    Family  planning  was  one  of  the  first  programs  (along  with  STI  treatment)  integrated   into  the  SALAMA  procurement  and  distribution  system.    PAIS  was  also  meant  to  control  prices  across   the  country  –  cites  as  on  the  benefits  the  opportunity  to  have  the  same  product  available  for  the   same  price  across  the  country.         The  PAIS  also  reinforced  the  FANOME  system  (Financement  pour  l’Approvisonment  Non-­‐stop  en   Medicaments),  a  system  at  the  community  level  to  which  users  participate  financially  created  in  2004   to  consolidate  the  Participation  Financiere  des  Usagers  (PFU)  put  in  place  in  1998  –  this  must  be  the   cost  recovery  system  for  essential  medicines.    In  2005,  Madagascar  also  created  an  equity  fund  for   financing  services  for  the  poorest  of  the  poor,  funded  by  a  portion  of  receipts  from  the  FANOME   system.    Unfortunately,  no  strategy  currently  exists  to  best  target  the  resources  in  the  equity  to  the   neediest.         Private  Sector  Sources  of  Contraceptives     In  addition  to  public  sector  health  services,  Madagascar  has  several  private  sector  sources  for   contraceptives  and  family  planning  services.  Population  Services  International  (PSI)  has  had  a  social   marketing  program  for  contraceptives  in  Madagascar  since  1998.  The  PSI  contraceptive  portfolio   includes  oral  and  injectable  contraceptives,  implants,  CycleBeads,  condoms,  and  intrauterine  devices.   PSI  relies  on  the  5,000–7,000  agents  de  santé  de  base  in  Madagascar  (community  health  workers)  to   sell  and  distribute  contraceptives.  PSI’s  last  point  of  sale,  however,  is  the  depot  de  médicaments   (medicine  warehouse).  The  community  health  workers  are  managed  and  trained  by  local   nongovernmental  organizations  and  are  permitted  to  sell  the  contraceptives  for  a  small  price.  PSI   receives  its  commodities  from  USAID,  the  Institute  for  Reproductive  Health  at  Georgetown  University,   central  medical  stores,  and  a  pharmaceutical  wholesaler  (FARMAD).       Marie  Stopes  International’s  local  affiliate,  Marie  Stopes  Madagascar  (MSM),  has  15  clinics  across  the   country  that  provide  maternal  and  reproductive  health  services,  including  family  planning.  MSM  has   operated  in  Madagascar  since  1992  and  is  known  for  increasing  access  to  long-­‐term  and  permanent   family  planning  methods  through  an  additional  11  mobile  clinics  with  trained  doctors  and  nurses  who   work  through  rural  community  health  centers.  In  addition,  MSM  manages  a  social  franchise  of   approximately  100  private  reproductive  health  providers  under  the  BlueStar  brand.  MSM  obtains  its   contraceptive  commodities  from  Marie  Stopes  International  and  directly  from  district  health   authorities.     The  International  Planned  Parenthood  Federation  also  has  a  local  affiliate  in  Madagascar,  called   Fianakaviana  Sambatra  (FISA).  FISA  has  operated  in  Madagascar  for  45  years  and  as  mentioned  earlier   was  the  first  nongovernmental  organization  in  Madagascar  to  provide  contraceptives  and  family   Madagascar:  Total  Market  Initiative  Project,  2010       Page  22  of  37   planning  services.  Through  its  several  clinics,  FISA  provides  family  planning  services,  treatment  of   sexually-­‐transmitted  infections,  HIV  testing  and  counseling,  and  post-­‐abortion  care.  The  organization   does  charge  a  small  fee  for  contraceptives  and  family  planning  services  and  gets  its  commodities  from   the  International  Planned  Parenthood  Federation  as  donations,  FARMAD,  the  central  medical  stores,   PSI,  and  other  sources.       Despite  their  contributions  to  increasing  access  to  family  planning  in  Madagascar,  neither  PSI  nor  FISA   has  tax-­‐exempt  status  for  importing  contraceptives  into  Madagascar.  USAID  and  United  Nations   agencies  are  both  exempt  from  taxes  for  all  pharmaceuticals,  including  contraceptives,  imported  into   the  country.  Currently,  PSI  and  FISA  rely  on  their  donors  to  pay  the  import  taxes  for  any  commodities   imported  into  Madagascar.  With  different  tax  treatment  between  the  public  and  social  marketing   sectors,  organizations  such  as  PSI  may  be  required  to  account  for  this  tax  payment  in  the  cost  of  their   products.    Only  commodities  imported  for  the  Red  Cross,  organizations  for  orphans  and  vulnerable   children  and  other  nongovernmental  organizations  are  free  of  duties  and  import  taxes  at  the  decision   of  the  Director  General  of  Customs.     Community-­‐based  Distribution  of  Contraceptives       Madagascar  is  also  recently  making  efforts  to  expand  access  to  popular  contraceptive  methods   through  a  community-­‐based  distribution  program  that  allows  agents  de  santé  de  base  to  sell  and   administer  injectable  contraceptives.  In  2007,  Family  Health  International  (FHI)  began  implementing  a   program  that  allowed  community  health  workers  to  sell  oral  contraceptives,  CycleBeads,  spermicide,   and  condoms  and  administer  injectable  contraceptives.       The  community-­‐based  distribution  program  that  included  the  administration  of  injectable   contraceptives  began  just  prior  to  the  September  2007  MOHFP  decision  to  make  all  contraceptives  in   the  country  free  of  charge.  For  a  time  after  this  decision,  there  was  confusion  about  whether  the   programs  run  by  FHI,  PSI,  and  FISA  could  charge  anything  for  contraceptives.  The  government  finally   settled  with  the  social  marketing  organizations  to  allow  social  marketing—and  charging  for   contraceptives  and  family  planning  services—to  continue.  For  the  community-­‐based  distribution   program,  the  Malagasy  government  decided  to  allow  community  health  workers  to  charge  a  small  fee   to  cover  their  transport  fees  necessary  to  restock  their  supply  of  contraceptives,  but  that  the   contraceptive  commodities  themselves  should  still  be  free.  Today,  community  health  workers  that   the  study  team  visited  charge  200  Ariary  (approximately  10  cents)  for  one  administration  of  injectable   contraceptives  and  50  Ariary  for  one  month’s  supply  of  oral  contraceptives  (approximately  3  cents).       The  source  for  commodities  for  the  community-­‐based  distribution  program  has  changed  to   accommodate  the  new  environment  for  development  aid  after  the  coup.    Currently,      USAID  works   closely  with  SanteNet2,  PSI  and  local  nongovernmental  organizations  to  use  private  sector   distribution  channels  to  resupply  the  CSBs  with  contraceptives  for  community-­‐based  distribution.       Policies  that  Affect  Family  Planning  Commodities     1. Plan  d’Achat   2. Tax  codes  (Arrete  from  Ministry  of  Finance)   3. Purchasing  permission  for  private  sector  from  SALAMA  (arête  from  MiniSante)   Madagascar:  Total  Market  Initiative  Project,  2010       Page  23  of  37   Taxes   • OPHAM  pays  a  tax  à  l’importation  (import/duty  tax);  the  Government  made  a  policy  decision   in  2007  to  tax  condoms  and  contraceptives  (though  FARMARD  reports  that  this  decision  was   made  in  2005);  the  pharmacies  heavily  protested  this  policy,  and  now  there’s  a  government   “tolerance”  for  not  paying  this  tax.     • In  the  current  system,  for  those  donors  such  as  UNFPA  and  USAID  that  have  bilateral   agreements  with  the  Government  of  Madagascar  to  exempt  them  from  taxes,  the  Ministry  of   Health  must  pay  the  Ministry  of  Finance  for  duty/customs  taxes  for  family  planning   commodities.    For  those  organizations  (MSI,  FISA)  that  import  family  planning  commodities   without  a  bilateral  agreement,  this  taxation  and  barriers  at  the  port  in  Tamatave  can  pose   serious  challenges.   • UNFPA  even  had  challenges  in  2009  when  a  stock  of  family  planning  commodities  was  stuck  at   Tamatave  for  six  months  because  the  Ministry  of  Health  could  not  pay  the  tax  amount  to  the   Ministry  of  Finance.    There  were  stockouts  resulting  from  this  shipment  delay  in  three  or  four   districts.   • Both  UNFPA  and  SALAMA  mentioned  that  they’ve  been  trying  to  advocate  to  the  government   that  contraceptives  be  exempt  from  import  duties/customs  –  this  obviously  hasn’t  been   successful  yet.   Transportation   • UNFPA  is  planning  to  conduct  a  study  on  the  impact  of  transportation  costs  and  logistics  on   the  distribution  system  for  family  planning  commodities  in  the  public  sector  in  Madagascar.     What  are  the  key  problems  and  challenges?   • UNFPA  is  considering  bringing  family  planning  commodities  all  the  way  into  the  country  and   depositing  them  centrally  at  SALAMA  (UNFPA  may  even  reinstate  some  regional  drugs  deports   for  the  public  sector).       • UNFPA  suggested  to  the  Ministry  that  it  pays  for  transport  of  family  planning  commodities  to   district  and  commune  levels  –  this  proposal  hasn’t  yet  been  accepted.   • By  contrast,  the  USAID  SantéNet  2  Project  –  which  works  directly  at  the  community  level  with   community  agents  linked  to  public  and  private  sector  supply  points  for  commodities  –   believes  that  “transportation  is  a  non-­‐issue”  and  “the  [distribution]  system  is  working”.   • SALAMA  contends  that  the  problem  of  stockouts  in  the  country  has  primarily  been  caused  by   delivery  problems  to  the  central  level  –  which  may  be  solved  temporarily  if  UNFPA  is   successful  in  bringing  commodities  all  the  way  to  SALAMA,  instead  of  to  the  port.   • UNFPA  is  also  planning  to  incorporate  private  sector  contraceptive  logistics  and  distribution  in   a  ‘’channel  survey’’.   District  Purchasing   • Private  sector  providers  and  nongovernmental  organizations  are  allowed  to  purchase   contraceptive  commodities  directly  from  the  PhaGDis  (district  pharmacy)  level  for  all  products   that  are  not  socially  marketed  (e.g.,  implants).   • UNFPA  and  others  (including  FISA),  however,  have  been  trying  to  advocate  to  the  Direction  of   Family  Planning  that  private  sector  organizations  and  NGOs  should  be  able  to  obtain  these   products  at  the  PhaGDis  free  of  charge  and  sell  them  to  consumers  for  a  highly-­‐subsidized   price.         Madagascar:  Total  Market  Initiative  Project,  2010       Page  24  of  37   Government  Purchasing   • The  government’s  share  of  direct  funding  for  contraceptive  commodities  is  diminishing,   though  the  Vice  Primature  (Ministry)  of  Health  is  still  making  an  effort  to  provide  its  own   funds  for  purchasing  family  planning  commodities.   • In  2007  and  2008,  the  Ministry  of  Health  and  Family  Planning  purchased  injectable   contraceptives  (DMPA  called  Petogen);  in  2009,  the  Ministry  purchased  spermicide.     • Dr.  Bako  said  that  the  government’s  participation  in  purchasing  contraceptive  commodities   continues,  but  that  the  amount  has  “diminished”.       Current  Stock   • PSI  and  SantéNet  2  are  collaborating  at  the  community  level  to  provide  two  sources  of  supply   to  community  agents.    Community  agents  can  now  provision/procure  contraceptives  from   either  a  CSB  in  the  public  sector  or  a  PSI  supply  point  for  socially-­‐marketed  contraceptives.    PSI   has  apparently  lowered  its  prices  on  oral  and  injectable  contraceptives  to  equal  the  prices  that   the  community  agents  are  allowed  to  charge  now  for  these  products  (100  Ariary  for  one  pack   of  orals  and  200  Ariary  for  one  dose  of  DMPA).   • As  USAID  has  “reprogrammed”  its  funding  for  contraceptives  and  essentially  given  what  was   formerly  50%  of  funding  for  contraceptives  in  the  public  sector  to  PSI,  and  UNFPA  has  taken   over  provision  of  contraceptives  for  the  public  sector,  there  may  be  approximately  one  and   half  times  the  amount  of  contraceptives  in  the  country  in  2010  as  compared  to  2009.    No  one   seems  clear  about  the  impact  of  this  increase  in  commodities.   Regulations   • OPHAM  reports  having  to  seek  an  autorisation  de  mise  sur  marché  for  all  contraceptive   products;  this  involves  registering  drugs  with  the  AMM  but  there  are  only  three  pharmacy   inspectors  in  all  of  Madagascar.     Policies  that  Affect  Family  Planning  Services     1. Code  de  la  Santé   2. Code  de  Deontologie  Medicale   3. National  Reproductive  Health  Policy   4. Sectoral  Plan  for  Family  Planning,  2007  –  2012     Regulations     • Ordre  des  Sage  Femmes  mentioned  that  matrons  –  or  auxiliary  midwives/traditional  birth   attendants  –  were  providing  much  of  the  maternal  care  in  Madagascar  but  that  they  were  not   regulated  and  not  legal  to  provide  these  services.    (The  matrons  may  be  an  interesting  cadre   to  consider  providing  family  planning  services  –  with  the  right  training  and  supervision.)   • Sage  femmes/midwives  in  Madagascar  can  be  licensed  to  own  their  own  private  clinics  –  there   are  approximately  100  of  these  clinics  in  the  country  that  provide  family  planning  and  other   services,  primarily  in  Antananarivo.       Madagascar:  Total  Market  Initiative  Project,  2010       Page  25  of  37   • Pharmacies  must  be  owned  by  a  pharmacist  –  which  could  be  a  barrier  because  of  the  lack  of   trained  pharmacists  currently  in  the  country  (though  with  the  new  pharmacy  program  in   country,  this  will  likely  change).   • Dispensaires  (or  clinics  that  provide  both  services  and  drugs,  which  can  include  family   planning)  are  typically  run  by  a  nurse  or  sage  femme  –  which  isn’t  legal  but  tolerated  by  the   government  because  of  a  lack  of  doctors  and  pharmacists  in  rural  areas.     Policy  Issues/Barriers   • Free  product/gratuité.   • SantéNet  2  believes  that  there  is  some  ability  to  pay  for  contraceptives  at  the  community  level   and  that  this  demand  is  not  as  elastic  as  policy  makers  may  have  thought.       • Lack  of  involvement  of  private  sector  in  any  government-­‐level  decision-­‐making  and   mechanism  for  coordination  between  public  and  private  sector.    Dr.  Bako  at  the  Direction  of   Family  Planning  admitted  that  sometimes  private  sector  organizations  such  as  FARMARD  are   forgotten  from  the  planning  and  policy  development  process  (though  FARMARD  specifically   said  that  PSI  always  represents  them  in  these  venues,  so  leaving  them  out  is  somewhat   understandable).   • Tax  (value  added)  and/or  customs  issue;  seems  to  be  a  big  issue  for  non-­‐bilateral  donor   organizations,  except  that  UNFPA  also  had  a  problem  last  year  with  a  shipment  stuck  for  six   months  at  the  port  in  Tamatave.         The  “shifting  sands”  of  the  policy/political  environment;  while  program  policy  may  not  have  changed   for  the  health  sector,  it’s  still  very  unclear  how  government  prioritizes  family  planning  given  the   reorganization  at  the  Vice  Primature  for  Public  Health  and  the  elimination  of  “family  planning”  from   the  name  of  the  health  ministry.    Dr.  Bako  did  mention,  though,  that  because  of  the  government’s   acknowledgement  of  the  need  to  attain  the  2015  MDGs  that  it  may  emphasize  family  planning  as  a   means  to  reduce  maternal  mortality.     In  terms  of  a  total  market  initiative,  Madagascar’s  dominant  public  and  social  marketing  sectors  for   family  planning  leave  no  room  for  a  truly  commercial  sector  for  family  planning;  tax  laws  provide  few   incentives  for  local  product  manufacturing  and  the  prices  in  the  public/social  marketing  sectors  (or   lack  thereof)  discourages  scaling  up  commercially-­‐priced  products  and  services.     Major  barriers  to  new  entrants  to  Madagascar’s  family  planning  market   • Lack  of  coordination  between  the  sectors;  no  clear  definition  of  public  and  private  sector  roles   • Onerous  drug  registration  process;  lack  of  enforcement  of  drugs  that  do  enter  the  market;   leakage  from  public  sector   • No  transparency  or  application  of  tax  laws/policies   • Price  of  contraceptives  and  free  provision  in  the  public  sector   • Labor  laws  (highly  favorable  towards  employees,  little  labor  reform  )   • Restrictions  on  advertising  contraceptives  (which,  because  they  require  prescriptions,  are   regulated)     Madagascar:  Total  Market  Initiative  Project,  2010       Page  26  of  37   • Not  a  friendly  business  environment  (especially  in  this  business  environment  when  business   could  be  afraid  of  government  appropriation  of  assets)   Madagascar:  Total  Market  Initiative  Project,  2010       Page  27  of  37   Chapter  3:  Market  Segmentation  Opportunities   This  section  presents  an  analysis  of  findings  from  the  segmentation  study.  The  data  indicate  impact  of   change  in  FP  policy  in  Madagascar  and  potential  areas  where  clients’  needs  are  not  being  fully  met,   where  different  sectors  offer  services  to  the  same  clients,  or  where  the  efficiency  of  resource   allocation  can  be  improved.  The  data  also  provide  information  on  current  and  potential  clients  that   each  of  the  sectors  can  use  to  reach  their  target  audiences  more  effectively.  These  findings  are   combined  with  the  qualitative  information  from  stakeholders  who  participated  in  the  September   2010  workshop  to  review  preliminary  results  from  this  market  segmentation  study.  From  the  data   and  stakeholder  input,  the  authors  have  developed  a  list  of  opportunities  to  improve  the   segmentation  of  the  contraceptive  market  in  Madagascar.     Impact of change of policy   Prior  to  September  2007,  the  government  charged  clients  in  the  public  sector  for  contraceptives—at   amounts  commensurate  with  the  government’s  cost  of  procurement  and  transportation.  In   September  2007,  GoM  changed  course  and  determined  that  all  public  sector  contraceptives  to  be   provided  for  free.  As  a  result  of  change  in  policy,  PAIS  initiatives  greatly  improved  warehousing  and   distribution  of  all  essential  medicines,  including  contraceptives.  Unmet  need  also  dropped   substantially  as  well  TFR  levels  dropped  to  4.8.     2004 2009 Source: 2004 and 2009 Madagascar DHS % M ar rie d W om en Figure  1:  Unmet  Need  among  currently  married  women Socio Economic Groups   Figure  1:  Unmet  need  comparison  between  DHS  2004  and  2009  clearly  demonstrates  that,  there  is  a   significant  drop  in  unmet  need  across  all  socio  economic  groups.           Madagascar:  Total  Market  Initiative  Project,  2010       Page  28  of  37   Total Fertility Rate Source: 1997, 2004, 2009 Madagascar DHS N um be r o f l iv e bi rth s pe r w om an Figure  2:  Total  Fertility  Rate  (TFR)   Figure  2:  As  a  result  of  change  in  policy  TFR  levels  also  dropped  to  4.8     Further  analysis  of  DHS  2009  shows  gaps  in  inequitable  distribution  of  contraceptives  across  various   socio-­‐economic  groups.   Public Private Other Figure  3:  Sources  of  Family  Planning  for  Married  Women  by  Standard  of  Living  Index Source: 2009 Madagascar DHS Data % M ar rie d W om en   Figure  3,  reflects  that  drop  in  TFR  and  reduced  unmet  need  is  achieved  at  the  cost  of  increasing  share   of  public  sector  and  diminishing  share  of  private  sector  across  all  socio-­‐economic  groups.  Even  “very   high”  (48.3%)  wealth  quintiles  also  use  public  sector  for  accessing  contraceptives  and  equal  section   (42.3%)  use  private  sector.  This  clearly  demonstrates  that  FP  commodities  are  not  targeted  well  to   the  groups  who  need  FP  the  most.       The  case  is  similar  in  both  urban  (figure  4)  and  rural  (figure  5)  areas  of  Madagascar.   Madagascar:  Total  Market  Initiative  Project,  2010       Page  29  of  37     Public Private Other Source: 2009 Madagascar DHS Data Figure  4:  Sources  of  Family  Planning  for  Married  UrbanWomen % M ar rie d U rb an W om en       Public Private Other Source: 2009 Madagascar DHS Data Figure  5:  Sources  of  Family  Planning  for  Married  RuralWomen % M ar rie d Ru ra l W om en   Implications:  There  is  a  substantial  opportunity  to  increase  acceptance  to  modern  contraception   among  women  with  unmet  need.  Both  the  public  and  private  sectors  have  a  role  in  addressing  this   need.  Because  the  need  is  substantial  across  quintiles,  public  and  private  sectors  should  divide  the   market  according  to  the  sector  that  can  reach  different  groups  within  the  target  audience  and  has  the   comparative  advantage  to  meet  their  needs.     Madagascar:  Total  Market  Initiative  Project,  2010       Page  30  of  37       Although  the  recent  policy  change  has  undoubtedly  contributed  to  improved  access  to  FP   contraceptives,  it  has  also  raised  a  number  of  unintended  consequences  which  threaten   contraceptive  security.     First,  ensuring  contraceptive  security  will  require  substantially  more  resources  than  is  currently   budgeted  for  in  the  public  sector.    Although  the  Government  has  a  budget  line  item  for  procurement   of  contraceptives,  most  contraceptives  for  the  public  sector  are  provided  by  donors  (UNFPA  and   USAID).    Second,  prior  to  2007,  authorities  at  the  district  level  charged  a  cost-­‐recovery  fee  for  the   contraceptives  they  procured.    This  fee  was  used  to  cover  the  transportation  costs  of  contraceptives   to  the  district  health  delivery  points,  but  now,  without  this  revenue,  district  pharmacies  will  not  have   the  funds  to  cover  these  costs  but  will  still  have  the  financial  responsibility  to  transport   contraceptives.    This  puts  districts  at  risk  of  having  stock-­‐outs.         Finally,  the  fact  that  contraceptives  are  now  available  for  free  in  the  public  sector  has  resulted  in  a   decline  in  sales  of  contraceptive  products  in  the  commercial  sector  and  a  decline  in  distribution  by   private  sector  suppliers.         So,  while  the  recent  policy  change  has  resulted  in  some  exciting  improvements,  the  concern  is  that  in   the  long  run,  it  will  hurt  access  to  contraceptives  because  health  centers  have  no  resources  for   transporting  contraceptives  from  the  district  level  and  it  discourages  private  sector  entrants  to  the   contraceptive  market.   Source: 2004 and 2009 Madagascar DHS Data 2004 2009 Figure  6:  Comparison  of  Sources  of  Contraceptives  2004  vs.  2009           Madagascar:  Total  Market  Initiative  Project,  2010       Page  31  of  37       U R B A I N R U R A L 2004 2009 Figure  7:  The  public  sector  wins  largely  in  the  rural  sector   Figure  7,  shows  between  2004  and  2007  public  sector  in  Madagascar  has  gained  market  share  largely   in  rural  Madagascar.           Opportunities  for  Increasing  role  of  Private  Sector  in  Madagascar     The  current  situation  in  Madagascar  presents  a  unique  opportunity  for  the  private  sector  to  support   the  Government  in  reaching  its  FP  targets  and  ensuring  contraceptive  security.           Madagascar:  Total  Market  Initiative  Project,  2010       Page  32  of  37   Source: 2009 Madagascar DHS Figure  8: Modern  Method  Use  by  Married  Women   Injectable  contraceptive  is  the  most  dominant  method,  as  this  is  freely  available  in  public  sector.       Source: 2009 Madagascar DHS LAM Norplant Male Sterilization Female Sterilization Condom Injections IUD Pill Female Condom % M ar rie d W om en Figure  9: Modern  Contraceptive  Method  Mix  -­‐2009   Injectables  are  still  the  most  preferred  contraceptive  option  across  all  the  socio-­‐economic  groups,   including  wealthier  women.   Madagascar:  Total  Market  Initiative  Project,  2010       Page  33  of  37   2009 2004 % M ar rie d W om en Source: 2004 and 2009 Madagascar DHS Figure  10:  Public  Sector  Use  for  Injectables Increased  among  Higher  Socioeconomic  Groups Wealth quintiles   With  the  introduction  of  free  contraceptives  in  the  public  sector,  the  use  of  injectables  has  increased   in  every  wealth  quintile  –  and  the  growth  is  most  dramatic  in  the  two  highest  wealth  quintiles.    These   are  the  people  who  are  most  likely  to  have  the  means  to  pay  for  contraceptives.         Public Private Other Figure  11: Sources  of  Family  Planning  for  Married  Women  by  Standard  of  Living  Index Source: 2009 Madagascar DHS Data % M ar rie d W om en Socioeconomic Groups   Figure  11:  Public  Sector  is  still  a  prominent  source  in  highest  socioeconomic  groups:  The  public  sector   still  provides  48%  of  the  highest  wealth  quintile’s  FP  methods.    By  comparison,  the  private  sector’s   role  in  the  highest  and  middle  quintiles  is  rather  small,  although  there  may  be  clients  within  these   quintiles  who  are  willing  and  able  to  pay  for  FP.  The  customers  in  the  lowest  quintiles  are  least  able  to   pay  for  contraceptives  and  should  be  targeted  by  the  public  sector.   Madagascar:  Total  Market  Initiative  Project,  2010       Page  34  of  37     Implications:   The  market  analysis  shows  that,  with  the  introduction  of  free  contraceptives  in  the  public  sector,   many  clients  who  can  pay  are  now  using  public  sector  products.    These  are  the  people  who  could  be   served  by  the  private  sector  and  allow  the  public  sector  to  better  target  its  limited  resources  to  those   people  who  cannot  afford  to  pay  for  contraceptives.         To  understand  how  to  increase  private  sector  participation,  we  need  to  understand  the  challenges   the  private  sector  faces.     First,  for  private  sector  expansion  to  be  successful  and  to  help  create  a  favorable  policy  environment   for  private  sector  participation,  there  must  be  a  strong  partnership  with  the  public  sector  to  ensure   needs  are  being  met  and  each  sector  it  targeting  the  appropriate  clients.  But  currently,  there  is  no   mechanism  for  coordination  between  the  public  and  private  sectors;  and  there  is  limited  involvement   of  the  private  sector  in  any  government-­‐level  decision-­‐making.           Second,  under  the  current  system,  donors  with  bilateral  agreements  with  the  GoM  are  exempt  from   taxes  on  family  planning  commodities,  but  other  organizations  without  such  agreements  are  not.     This  likely  discourages  private  sector  participation.       Madagascar:  Total  Market  Initiative  Project,  2010       Page  35  of  37   Chapter  4:  Conclusions     Based  on  key  findings  and  opportunities  identified  in  the  previous  sections  of  the  report,  there   appears  to  be  a  meaningful  role  for  private  sector  that  would  help  improve  contraceptive  security  in   Madagascar.     Following  are  the  main  conclusions  that  can  be  drawn  from  this  market  segmentation  analysis.     First,  for  private  sector  expansion  to  be  successful  and  to  help  create  a  favorable  policy  environment   for  private  sector  participation,  there  must  be  a  strong  partnership  with  the  public  sector  to  ensure   needs  are  being  met  and  each  sector  it  targeting  the  appropriate  clients.    But  currently,  there’s  no   mechanism  for  coordination  between  the  public  and  private  sectors,  and  there  is  limited  involvement   of  the  private  sector  in  any  government-­‐level  decision-­‐making.           Second,  under  the  current  system,  donors  with  bilateral  agreements  with  the  GoM  are  exempt  from   taxes  on  family  planning  commodities,  but  other  organizations  without  such  agreements  are  not.     This  is  likely  discourages  private  sector  participation.         Third,  registration  of  medicines  and  drugs  are  an  onerous  process  in  Madagascar.    Providers  must   seek  an  authorization  de  mise  sur  marche  for  all  contraceptive  products;  this  involves  registering   drugs  with  the  AMM,  but  there  are  only  three  pharmacy  inspectors  in  all  of  Madagascar.    This  affects   both  the  public  and  private  sectors.     Fourth,  and  perhaps  most  obviously,  public  sector  commodities  are  free  –  which  discourages  scaling   up  commercially-­‐priced  products.  With  appropriate  targeting  through  marketing  and  advertising,  the   private  sector  can  be  successful,  but  there  are  currently  restrictions  on  advertising  for  contraceptives.         In  summary,  the  operating  environment  in  Madagascar  is  not  particularly  conducive  towards   expanding  private  sector  provision  of  contraceptives.  Despite  this,  the  GoM  does  acknowledge  the   legitimate  role  of  private  providers  in  expanding  access  to  family  planning  services.  The  following   recommendations  have  been  developed  between  all  members  of  the  TAG,  including  active   participation  by  relevant  government  departments. Madagascar:  Total  Market  Initiative  Project,  2010       Page  36  of  37   Chapter  5:  Recommendations     Strengthen  public-­‐private  partnerships  (PPP)   • The  MOH  to  invite  TAG  representatives  to  meet  with  the  MOH  Partnership  Director  to   develop  an  action  plan  for  strengthening  PPP  based  on  the  recommendations  made  at  the   October  26  workshop.   • The  Partnerships  Director  to  organize  a  regular  meeting  with  FP  NGOs  to  discuss  ways  to   strengthen  PPP.  The  TAG  to  support  the  Partnerships  Director  to  finalize  a  formal  policy  paper   on  PPPs  for  FP  services.   Segment  the  market  to  appropriately  target  clients  with  public  and  private  sector   resources   • The  MOH  must  define  the  reporting  systems  required  from  FP  NGOs.   • Based  on  the  TMI  study  and  NGO  activity  reports,  the  TAG  (including  the  MOH)  to  identify   gaps  in  the  current  market  segmentation  to  determine  where  to  target  and  how  to  utilize   public  and  private  sector  resources.    The  MOH  to  decide  on  a  timeline  for  regular  reporting  on   market  segmentation  so  that  resource  targeting  is  adjusted  as  needed.  The  MOH  to  work  with   NGOs  providing  FP  to  collect  activity  reports  on  a  monthly  basis  so  that  they  can  be  utilized  by   the  MOH  to  determine  gaps  in  market  segmentation.   Remove  taxes  on  contraceptives   • The  MOH  Director  of  Safe  Motherhood  (DSM)  to  analyze  the  impact  of  taxation  policies  on   contraceptive  costs  and  Government  revenue  and  develop  recommendations  to  take  to  the   Ministry  of  Finance.  The  MOH  (DSM)  to  meet  with  the  Director  of  Finance  and  Budget  to   propose  a  law  amendment  and  discuss  the  way  forward  (for  example,  aligning  the  definition   of  tax-­‐exempt  medicines  with  the  MOH  definition).   Promote  social  marketing  initiatives   • Prior  to  the  Council  of  Ministers  meeting,  the  Director  of  Safe  Motherhood  to  frame  the   design  of  a  draft  social  marketing  policy.  The  MOH  to  disseminate  TMI  results  at  the  Council  of   Ministers  meeting  before  end  of  2010  to  demonstrate  the  role  of  the  private  sector  and   potential  for  social  marketing.   Increase  public  sector  funding  for  contraceptive  procurement  and  transportation   to  strengthen  total  market  approaches   • The  MOH  (DSM)  to  develop  an  action  plan  that  outlines  how  increased  public  sector  funding   will  facilitate  total  market  approaches  for  FP.       • The  DSM  to  present  an  advocacy  brief  to  the  Director  of  Finance  and  Planning,  for  the  MOH.   • The  MOH  to  develop  objectives  for  funding  –  including  line  items  for  transportation  costs   related  to  supply  of  contraceptives  to  the  CSB-­‐level  –  that  are  in  compliance  with  Ministry  of   Finance  and  Budget  formats.       Madagascar:  Total  Market  Initiative  Project,  2010       Page  37  of  37   Annex  1:  Detailed  DHS  Analysis    

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