Designing a Market Intervention for Equitable Health Outcome

1. Futures Group and the World Bank Institute in collaboration with Abt Associates, O’Hanlon Health Consulting, University of California at San Francisco and Tropical Health LLP

2. SESSION 10Designing a Market InterventionBarbara O’Hanlon Futures Group and the World Bank Institute in collaboration with Abt Associates, O’Hanlon Health Consulting, University of California at San Francisco and Tropical Health LLP

3. DESIGN PROCESS DIAGNOSTICS MARKET INTERVENTION TOOLS

4. Strategic Framework Define equitable health outcome: What is the anticipated health outcome? Who is the target group? Define market change: How can the market address the poor’s health needs? What changes are needed in the health market and enabling environment to better serve the poor? Define broad thrusts: What actions can facilitate the changes in the market and/or operating environment? Equitable Health Outcome Health Market Change Strategic Intervention(s)

5. Strategic Framework / Market Intervention Equitable Health Outcome Step 5 Market #1 Step 4 Step 3 Market #2 Health Market Change Step 2 Market #3 Step 1 Market #4 Strategic Intervention(s) Systemic Change

6. Market Intervention Design Decisions – Inception Report • Market Selection: Which market to intervene? • Market Strategy: Who is the target group? What are the opportunities to serve the poor? • Market Facilitation: How to interact with the private and public sector to unlock this potential?

7. Market Intervention Design Decisions • Market Selection: Which market to intervene? • Market Strategy: Who is the target group? What are the opportunities to serve the poor? • Market Facilitation: How to interact with the private and public sector to unlock this potential?

8. Process to Design a Market Intervention Understand the poor and their context Select a specific market(s) Assess specific market(s) Identify systemic constraints Design Market intervention Health Market Change Systemic Change

9. DESIGN PROCESS DIAGNOSTICS MARKET INTERVENTION TOOLS

10. Step 1: Learn About the Poor What do we want to know in general? • Who are the poor? – Size – Location • What is their socio-economic profile? – Disposable income – Household composition, characteristics – Health decision-making • What is their demand for health? – Demand for specific services and product – Unmet demand for specific services and products – Provider preference

11. Poor and Consumer Research Approaches Overview of Health System Health system assessment, partnership landscape assessment (PLA), Private sector assessment (PSA), other private sector research, consumer use/preference (DHS) Poor and their Context Socio-economic studies, census date, poverty assessments, livelihood analysis and consumer research Private actors and their Context Market research, competitive analysis, and provider research Health Markets Landscape and interviews of market actors ...consumer research explains who are the poor, their health needs and barriers accessing ...consumer research is also the starting point to define the poor and to select markets

12. Step 1: Understand the Poor and their Context • Socio-economic-geographic “picture” • Trends, factors, drivers and barriers to poor’s access to healthcare • Donor priorities • Geographic focus • Service focus • Product focus • Target group focus To identify specific markets which offer sustainable opportunities for the private sector to serve the poor

13. Step 1: Understand the Poor and their Context • KENYA CONSUMER RESEARCH • “Top 5” illnesses cited diarrhea, cancer, HIV, malaria and pneumonia (ARIs) • Barriers to access are high cost drugs, distance, lack of understanding on “healthy behaviors” • Quality issues include self-diagnosis, many counterfeit drugs, drug stock-outs, poor diagnosis • Seek care 1st with drug seller/pharmacists for small problems; • Prefer private sector MARKET IDEAS Diagnostic and treatment of diarrhea Diagnostic and treatment of malaria Drug supply

14. Kenya: Example to Define the Poor 1st: Examine how the government defined the poor • Abject poverty (< $2/day) • Minimum standard of living based on basic needs • Progress Out of Poverty Index (PPI) • Subjective Measures of Poverty • Median monthly income levels v

15. Kenya Example to Define the Poor Using different methods to set realistic definition 2nd: Ask private sector how they segment the market One answer Another answer: 5% Have a lot 65% Have less 35% Have nothing

16. Kenya Example to Define the Poor 3rd: Asked consumers how they defined the poor Characteristics: Work in the formal sector, regular work, some disposable income and savings Below 5,500KHS Above 4,500KHS • Policeman • Teacher • Receptionist Characteristics: Work in the formal sector, regular work, no disposable income or savings • Security guards • Maids • Shop girls • Rose farms • Tea coops • Construction Below 4,500KHS Above 3,000KHS Characteristics: Work in the informal sector, irregular work, no disposable income or savings Below 3,000KHS Above 1,400KHS • Jua Kali – day laborers • Artisans / tradesman • Subsistence farmers • Roadside vendors All are one pay check away from following into poverty

17. Inception Report • Usually occurs six to twelve months into project • Inception Report details • Basic understanding of the health system, health priorities and system gaps • Basic understanding of the poor and their health context • Basic understanding of the private sector’s current activities, capacity and interest in serving the poor • Proposes target group, potential markets and possible interventions • Also reviews and discusses any differences between log frame and more in-depth understanding

18. Step 2: Select Markets Key Factors to Consider SUSTAINABILITY Private sector interest and capacity SCALE Largest # of poor and/or greatest health output “Sweet Spot” SYSTEMIC CHANGE Feasibility of market change

19. Tips in Market Selection How many markets? • Weak or thin market >>> pursue a multiple market approach • Single market approach >>> exposes too much risk • Specialized market >>> maybe difficult to create scale • Multiple market approach >>> creates management burden • Multiple market approach >>> spreads efforts too thinly Calls for “groups” of related markets (e.g. geographic concentration, similar constraints/solutions)

20. Step 3: Assess Market Conditionsand Dynamics • Market structure • How does the market system work? • What are its key functions? • Who are the key players (private, public, formal, information) • What is the relationships between these players? • Market dynamics • What is the flow of goods and services? • What is competition? • What are barriers to entry/ staying? • What are consumer preferences? • What is consumer ability to switch? To identify where and why the market is not working for the poor … “symptoms”

21. Health Market Systems Research Approaches Overview of Health System Health system assessment, partnership landscape assessment (PLA), Private sector assessment (PSA), other private sector research, consumer use/preference (DHS) Poor and their Context Socio-economic studies, census date, poverty assessments, livelihood analysis and consumer research Private actors and their Context Investment climate surveys, competitive analysis and provider research Health Markets Landscaping and interviews of market actors …provider research explains capacity and incentives as well as business setting

22. Step 3: Assess Market Conditions • KENYA CASE • Crowded market – MOH offering “free” services; donor supported FBO/NGOs and now private providers • Stiff competition from multiple sources – informal providers, other small providers, public sector, donors subsidies • Unfavorable business climate to enter and sustain a private health business • Asymmetry of information – government has most, private sector has little • Consumer substitution between sectors – “shopping for a better deal” MARKET SYMPTOMS / CAUSES What do you think?

23. Step 4: Identify Systemic Constraints • Key market functions and players • Inceptives, capacity and relationships • Interconnected markets To identify underlying reasons for market underperformance …… “causes” >>> market interventions

24. Health Market Systems Research Approaches Overview of Private Health Sector “Snapshot” of the private health sector, current use of private services and products and enabling environment Poor and their Context Socio-economic studies, census date, poverty assessments, livelihood analysis and consumer research Private actors and their Context Market research, competitive analysis, and provider research Health Markets Landscape and interviews of market actors …market research identifies the causes why health markets are failing the poor

25. DESIGN PROCESS DIAGNOSTICS MARKET INTERVENTION TOOLS

26. Basic Concepts What is an intervention? • “softest part” of M4P approach • Action taken to improve a situation – Oxford Dictionary Understanding the difference between market and direct interventions FACILITATIVE INTERVENTION • Ideas? DIRECT INTERVENTION • Ideas?

27. Basic Concepts Understanding the difference between market and direct interventions FACILITATIVE INTERVENTION Donor funds Company “Y” to • Identify a local manufacturer producing mosquito nets • Work with the manufacturer to affordably price the mosquito net and re-launch into the market • Help market the product at full price • Use existing channels to distribute the net • Other companies take note and enter into the market DIRECT INTERVENTION Donor funds Company “X” to • Establish an NGO in a developing country to deliver mosquito nets • Staff the country office • Build its own distribution network • Market it own branded mosquito net at a subsidized price

28. Basic Concepts Guiding principles of a market intervention • Flexible • Temporary • Catalytic • Facilitative Elements of a market intervention • “Do no harm” to the market • Commercial partners

29. Design Examples • Faulty diagnosis • Incorrect treatment course • Incorrect prescribing practice • Correct treatment (ZINC) not available • Or too expensive (reliant on imports) • Limited geographic access • Limited types available when in stock • Too expensive • Easy access to counterfeit • No lab facilities • Faulty interpretation of lab test • Incorrect treatment • Easy access to counterfeit drugs • Quality drugs too expensive Diarrhea Drugs Malaria Mothers and children under 5 years in 4 rural counties in / near Mombasa

30. Design Examples Similar constraint • Faulty diagnosis • Incorrect treatment course • Incorrect prescribing practice • Correct treatment (ZINC) not available • Or too expensive (reliant on imports) • Limited geographic access • Limited types available when in stock • Too expensive • Easy access to counterfeit • No lab facilities • Faulty interpretation of lab test • Incorrect treatment • Easy access to counterfeit drugs • Quality drugs too expensive Diarrhea Drugs Malaria Mothers and children under 5 years in 4 rural counties in / near Mombasa

31. Design Examples • Faulty diagnosis • Incorrect treatment course • Incorrect prescribing practice • Correct treatment (ZINC) not available • Or too expensive (reliant on imports) • Limited geographic access • Limited types available when in stock • Too expensive • Easy access to counterfeit • No lab facilities • Faulty interpretation of lab test • Incorrect treatment • Easy access to counterfeit drugs • Quality drugs too expensive Diarrhea Drugs Malaria Common solution Mothers and children under 5 in 4 rural counties in / near Mombasa

32. Example of Market Logic Crowd out counterfeit drug supply in 4 counties Drugs removed from supply Quality drugs accessible Fake drugs detected Drug sellers send results to NQL Drug sellers price affordably Drug sellers use equipment Consumer use appropriate drugs Drug sellers submit drug order Drug sellers skilled/capacitated Consumer switch from fakes Drug sellers properly prescribe Train drug sellers in equipment Consumers test suspicious drugs Drugs sellers use training Drug sellers have equipment Consumer appreciate benefits Drug sellers trained Drug sellers willing to participate Consumer aware of fakes Drug sellers willing to participate Link to gov’t inspectors/NQL Conduct consumer campaigns Train in bulk purchase system Facilitate reporting Train prescribing practices Provide and train in equipment Establish bulk purchasing Form/align with a network- Upgrade drug sellers status

33. DESIGN PROCESS DIAGNOSTICS MARKET INTERVENTION TOOLS

34. Tools to Design Market Interventions Concept Note Partner Agreement Action Plan Measurement Plan • Problem definition • Business Case • Identification of partners • Expected impact • Results chain • Budget/timeline • Objectives • Description of activities • Who will do what • Who will pay for what • Data obligations • Mutual objectives • Activities • Responsible party • Deadline • Expected output • Linkages to log-frame • Results chain • Expected impact • Data requirements • Data collection approach • Responsible party • Timeframe

35. DESIGN PROCESS DIAGNOSTICS MARKET INTERVENTION TOOLS WRAP UP

36. Managing Change and Expectations Portfolio Approach (Start)

37. Managing Change and Expectations Portfolio Approach (Finish)

38. Portfolio Approach