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Case Study: Achieving Success with the M4P Approach in the Public Health Sector Domain: The SuNMaP Nigeria Experience 16 September 2014

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Report to:

Commercial Sector Case Study

Case Study 4

Achieving Success with the M4P Approach in the Public Health Sector Domain: The SuNMaP Nigeria Experience

Revised and Resubmitted by Montrose and Innovision

Writers: Melanie Newman Wilkinson, with review by Rubaiyath Sarwar and Helena Vidalic

Contributions by: Busuyi Okeowo, Commercial Sector Manager and Kabir Lawal, Commercial Sector Analyst, Commercial Sector Interventions, SuNMaP

16 September 2014


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The Support to National Malaria Programme (SuNMaP) is funded and supported by the UK Department for International Development.

It is implemented through a partnership of international and national companies and non-governmental

organisations led by Malaria Consortium.

Johns Hopkins Bloomberg School of Public Health – Center for Communication Programs (Nigeria) (JHU-CCP(N))

Health Reform Foundation of Nigeria (HERFON)

Federation of Muslim Women’s Associations in Nigeria (FOMWAN)

Christian Health Association of Nigeria (CHAN)

CHAN-Medi-Pharm

Pharmaceutical Manufacturers Group of the Manufacturers Association of Nigeria (PMG-MAN)

University of Nigeria, Enugu Campus

GRID Consulting, Nigeria


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Final Approval

Report signed off by:

Date Initials

For Final


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Table of Contents

Section Page No.

Section 1 Title Page 1

Table of Contents 4

Abbreviations and Acronyms 5

Acknowledgements 6

Section 2

2.1 Background 7

2.2 The Market Context 8

2.3 Formulating and Delivering Appropriate M4P Strategies 14

Section 3 3.1 Conclusions and Emerging Lessons Learnt 19


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Abbreviations and Acronyms

ACPN Association of Community Pharmacists of Nigeria

ACT Artemisinin Combination Therapy

AGPMPN Association of General and Private Medical Practitioners of Nigeria

AMFm Affordable Medicine Facility for Malaria

AMLSN Association of Medical Laboratory Scientists of Nigeria

BCC Behavioral Change Communication

BDM Business Development Manager

CS Commercial Sector

CSP Commercial Sector Partners

CSMG Commercial Sector Management Group

LLIN Long Lasting Insecticide Treated Nets

M4P Making Markets Work for the Poor

MOU Memorandum of Understanding

NMEP National Malaria Elimination Programme

NYSC National Youth Service Corps

PPMV Private Patent Medicine Vendor

RDT Rapid Diagnostic Test Kit

SFH Society for Family Health

WHOPES World Health Organization Pesticide Evaluation Scheme


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Acknowledgements

Montrose and Innovision would like to acknowledge and extend their appreciation to the SuNMaP Project team, and the Commercial Sector team especially, for openly agreeing to share information and review earlier drafts by way of contribution to this case study.

The contents of this report are the sole responsibility of its authors and do not necessarily reflect the views of the partners managing SuNMaP or the UK Department for International Development.


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SECTION 2

2.1 Background

Funded by UKAid (Department for International Development (DFID) in Nigeria, the ‘Support to National Malaria Programme (SuNMaP)’ provides support to the National Malaria Elimination Programme1 (NMEP) and participating states to deliver quality malaria control services. The current programme has funding until August 2015. The focus of SuNMaP malaria control initiatives is supporting both public and private sector to reduce the burden of malaria through different interventions in prevention and treatment, which build capabilities and strengthen service delivery for reaching the entire population – and the poor and vulnerable especially. At the core of putting systems and capabilities in place to ensure sustainable service delivery, is the programme’s goal of achieving behavioural change across communities and households nationwide through sustained advocacy and public enlightenment on measures for effective malaria prevention and treatment.

Currently, preventing and treating malaria places huge demands on federal and state level health budgets, and there is significant reliance on donor support. In order to improve product and service delivery and expand outreach, SuNMaP specifically incorporates an experiential Commercial Sector support component, which focuses on establishing private sector markets for long lasting insecticidal nets (LLINs), Artemisinin combination therapies (ACT) and rapid diagnostic tests (RDTs) – the three core commodities at the heart of effective malaria prevention and treatment. The ‘Commercial Sector Support Strategy’ applies ‘Making Markets Work for the Poor’ (‘M4P’) principles and approaches to develop and strengthen commercial sector channels for the manufacture, importation, sale and distribution of LLINs, ACTs and RDTs. There is a small Commercial Sector team dedicated to delivering support in target markets and states. Since 2011, the Commercial Sector team has been supported by market development partners Montrose and Innovision, which work in partnership to provide contextualised technical and advisory support to the programme.

This write up is the fourth in a series of case studies produced by the SuNMaP Commercial Sector team and the technical advisors. The purpose of the case studies is to share SuNMaP’s technical approach for identifying and resolving market system challenges in the commercial malaria commodity markets in Nigeria, and the learning resulting from the tools, approaches and interventions applied. The primary audience is the programme’s key stakeholders. However, the programme is also keen to share learning with the broader audience of funders and practitioners working in public and private sector health system strengthening given that SuNMaP is arguably the first DFID-funded health market programme to apply M4P principles and approaches. The main data sources for the write up are data and analyses drawn from existing project documentation, together with input from the SuNMaP Commercial Sector project team.

1 Formally called the National Malaria Control Programme.


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This particular write up examines the catalytic impact the commercial sector activities have had in the context of the programme’s broader goals for building national capacity for policy development, planning and coordination, harmonised support across the different agencies (both public and private sector), improved population coverage of effective measures for prevention and treatment of malaria, and continually adding to the evidence base for more effective strategies on prevention and treatment.

As the case will show contributing to these high level goals is far from straightforward given the context in which the Commercial Sector activities are taking place. The case study highlights the numerous challenges in the market place, how the Commercial Sector team has dealt with those contextual challenges, and the emerging learning from the field on what has worked and what has not worked and why. Conclusions point to the way ahead and why it is important to continue to encourage commercially driven activities in a highly subsidised sector.

2.2 The Market Context

SuNMaP’s vision for harmonisation in healthcare services stems from its overall goal to achieve progress towards the Millennium Development Goals focused on health by strengthening the delivery of national malaria control efforts in Nigeria. Overall programme success is being measured by how well it contributes to reducing under-five child mortality, and to improved care and treatment of pregnant women and under-fives. To achieve this, the programme has to be able to effectively reach communities, households, caregivers and service providers to bring about sustainable changes in behaviour so they (individually and collectively) adopt ‘best response, best action’ in the prevention, care and treatment of malaria. The programme is doing this by harmonising and improving responsiveness across all those in the supply chain – in both the public and private sectors - through building capabilities across agencies and by harmonising methodologies and tools for malaria control, and mechanisms for better and sustainable public-private partnership coordination. At the grassroots level, this translates into health facilities becoming more effective and resourceful in diagnosing and treating malaria, and more people aware of and taking correct and timely action in preventing and treating malaria.

The Commercial Sector team has designed and conducted regular market studies and rapid scans to guide strategy formulation and decision-making across its LLINs, RDTs and ACTs interventions. Findings are frequently consistent with what one would expect in a sector dominated by large scale, but often sporadic, distribution of free or highly subsidised products. The following dominant factors continue to impact the Commercial Sector team activities.

LLINs

The market situation for LLINs is particularly complex and fluid due to high levels of Government and donor funded programmes that drive policy, product availability, and outreach. Market players’ interests in LLINs are aligned to the status of donor-funded programmes. For example, since 2011, international manufacturers have reduced production of LLINs due to the reduction in funding from


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Global Fund as these producers relied on Global Fund procurement as a main source of business. When funding dips like this, it also reduces the supply of LLINs in the commercial market. The public health market remains the primary business domain and revenue source for LLIN suppliers. Due to limited supply of LLINs, local importers and distributors concentrate further on securing business from the public health domain thus further drawing interest away from ‘commercial’ business. Furthermore, the continued policy of mass campaigning and routine distribution of LLINs through public health channels as well as large volume supply of highly subsidised LLINs to boarding schools and private Ante Natal Care (ANC) facilities together with the persistent challenge of leaked and fake brands of LLINs sold in local market places has led to huge market distortion and very little space for developing commercially driven sales and distribution. The threat of crowding out commercial sector sales and distribution altogether has been intensified in recent months due to plans for free distribution of some 40 million LLINs as part of a net replacement campaign over the next five years.

The programme’s most recent market analysis and impact assessments confirm that lack of consumer awareness does not appear to be such a threat anymore. There is now increased awareness about LLINs and there are increased numbers of brands in the market (though this includes bed-nets that are marketed as LLINs, but are not verified as such). Consumers still perceive LLINs to be free commodities, however, and thus willingness to pay has remained low.

Though commercial sales have picked up since 2011 (mainly due to effective campaigning and the availability of nets in local retail outlets and open markets), there is still a lack of supervisory controls and insufficient coordination and harmonisation among the RBM partners. This is exasperating the proliferation of leaked nets and fake brands, which are now widely seen in retail outlets and open markets. The two figures below provide a comparison of constraints analysis in the LLIN market in 2011 (figure 1a) and as of today (figure 1b).

Interestingly (as the March 2014 LLIN market analysis confirmed) there is a small scale sub sector of local net manufacturing and distribution, which survives by supplying tent nets and larger size family nets (albeit in small quantity; approximately 4000 LLINs a year), using imported LLIN fabric. These local manufacturers are arguably more ‘connected’ to the market than lead producers/importers as local production is very demand-driven - providing affordable products that are not otherwise available in the market. In contrast, most large scale firms focus on public sector tenders (though the programme has successfully incentivised large firms to look at commercial sale channels – see section 2). These large firms have very little if any direct contact with the market, and because for the most part they supply in response to procurement tenders, they have little involvement in establishing effective domestic supply chain linkages and actually lack the marketing and supply chain management capabilities essential to serve the retail market.


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Figure 1a: LLIN Market System Systemic Constraints Analysis from 2011 market analysis.

Low volume of sales of fresh nets through retail outlets

Low demand for fresh nets

LLINs currently marketed do not offer variety in product features (size,

shape, and packaging) meet preferences of all

consumers

LLIN is a slow moving product which reduces the commercial sectors’ capacity to invest on

distribution channel and product development

Consumers in general are not aware of the value of LLIN

Overlaps between free distribution, social marketing and commercial retail market


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Figure 1b: LLIN Market System Systemic Constraints Analysis from 2013-14 market analysis.

CONSTRAINTS IMPEDING GROWTH OF THE RETAIL MARKET FOR LLINs

LOW VOLUME OF FRESH SALES OF LLINs THROUGH COMMERCIAL OUTLETS

LOW DEMAND FOR FRESH NETS UNMET DEMAND

LOW NUMBER OF RETAIL OUTLETS FOR

LLIN

A LARGE POPULATION OWNS LLINs THAT

STILL HAVE 2-3 YEARS OF ORGANIC LIFE

LOW AWARENESS ON THE PRODUCT FEATURES AND BENEFITS REDUCE DEMAND FOR FRESH NETS/

REPLACEMENT NETS

POOR VISIBILITY AT POINT OF SALES (PUBLIC & PVT)

AVAILABILITY OF LEAKED NETS

TRANSITION POINT FROM PUBLIC SECTOR DRIVEN TO PRIVATE SECTOR DRIVEN LLIN DISTRIBUTION REMAINS UNCLEAR AND RISKY

POOR PARTICIPATION OF THE INTERNATIONAL MANUFACTURERS

AND LOCAL IMPORTERS IN DEMAND CREATION

POOR PARTICIPATION OF THE INTERNATIONAL

MANUFACTURERS AND LOCAL IMPORTERS IN DISTRIBUTION AND MARKET DEVELOPMENT

COMMERCIAL MARKET OPPORTUNITIES ARE NOT CONCRETE AND IMMEDIATE TO THE COMMERCIAL

DEGREE OF PUBLIC INTERVENTION FOR RBM REMAINS UNCLEAR DUE TO MDG PRIORITIES

ABSENCE OF LOCAL MANUFACTURERS IN LLIN

INDUSTRY

STRINGENT CERTIFICATION/ CONCERN ABOUT QUALITY AND PUBLIC HEALTH SAFETY

WEAK TRACEABILITY/ MONITORING OF CAMPAIGN NETS

LACK OF PRODUCT DEVELOPMENT AND

BRAND DIFFERENTIATION

CONSUMERS BELIEVE THE PRICE IS HIGH AND THEY CANNOT AFFORD LLIN

PERCEIVED VALUE OF LLIN IS LOW


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ACTs and RDTs

Whilst we have seen changes in LLIN market dynamics, there has been less of a shift with respect to key constraints impacting the ACT and RDT markets. A key contextual factor shaping the market for Artemisinin combination therapies (ACT) has been the on-going presence of the Affordable Medicines Facility for Malaria (AMFm). Since its inception in February 2010, the facility has supported a manufacturers’ price subsidy, which effectively brings down the retail price of ACTs to match that of mono-therapy treatments. SuNMaP’s intervention strategies focus on complementing the efforts of the AMFm programme and as such it actively engages with the AMFm Technical Working Group to monitor the impact of the AMFm on the ACT market. On-going market monitoring has revealed a number of critical constraints at market and intervention level, which undermine efforts, including those of the AMFm, to ensure affordable and sustainable access to ACTs in rural areas – and for the rural poor especially. Applying its M4P lens, the Commercial Sector team has examined the systemic nature of these constraints in order to determine how and where commercial sector support should focus. The market for antimalarials is highly fragmented. This is evident by the high degree of diversified product classification in the market, including WHO pre-qualified ACTs, non-WHO pre-qualified ACTs, artemisinin monotherapy treatments, and basic monotherapy treatments. Free, subsidised and non-subsidised ACTs also frequently converge on the same retail points. Similar to LLINs, market players focus their interests on where there are opportunities for public tender contracts. Another interesting, but challenging factor for the Commercial Sector team to contend with is how the AMFm impacts significantly on the structure of the ACT distribution system, supply levels, market pricing and market share. The positives are that the AMFm has affected the evolution of first line buyers. We see increased numbers of local manufacturers working toward WHO pre-qualification so they can be eligible to access the AMFm, an emerging increased local supply and market share of ACTs, and reduced overall market price of ACTs. On the downside, demand creation is being generated and driven by public sector policies and interventions rather than consumer demand to the extent that donor-backed support has distorted the picture of demand. Similar to LLINs, the market for ACTs (and RDTs) is highly dependent on the supply push, which is being driven by malaria control programmes under the likes of the Global Fund and the Federal Government of Nigeria. However, in recent years, because of continued subsidy and social marketing campaigns, the market for ACTs is expanding without any correlation to RDTs. The presumptive treatment of suspected symptoms of malaria and consumption of Artemisinin mono-therapies remains high among most households in Nigeria. This impacts on the uptake and usage of RDT. As per WHO guidelines, Nigeria adopted the policy that every suspected malaria case must be tested, and every confirmed malaria case be treated with quality-assured antimalarials. However, various critical factors compound to prevent effective RDT commercial sales and distribution. Currently the vast majority of diagnostic tests and treatments are being offered through the public sector and free


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of cost; this means that RDT manufacturers (all of whom are located outside of Nigeria) and the lead Nigerian-based importers (who each appear to work exclusively with just one manufacturer) are focused on securing and supplying to public tenders. Though RDT distribution networks appear to be in place (e.g. between importer/wholesaler and hospitals, clinics, etc.), these are not used for commercial sales. As a result, importer ‘business models’ are unsophisticated – because the bulk of their sales are secured through large volume public tenders, there is no need for direct marketing and promotion to the consumer. With some 77 per cent of consumers not having heard about RDT2, consumer awareness and understanding of RDTs as a diagnostic tool for malaria is extremely limited. In any case, given the price of RDT, the presumptive treatment of malaria remains an economic necessity for many poor households. Healthcare providers in general have poor knowledge of RDTs. There is also widespread skepticism about the efficacy of RDTs (particularly in situations where storage, handling and administration are considered inadequate). In some cases, medical practitioners wrongly perceive RDTs as a proposed replacement for microscopy. Whilst current policy supports the use of tests such as RDT, regulations limit those allowed to conduct tests, and small scale facilities such as a Proprietary and Patent Medicine Vendor (PPMV), which are in many respects ideally located to support in more remote rural areas, are not authorised, and in fact in most cases not qualified, to offer RDT. The constraints described above and the symptoms of market system dysfunctions contribute to improper case management, low consumer demand for ACTs and RDTs, and the prevailing high price of RDTs, and also ACTs in areas not reached by the AMFm. Figure 2 presents the ACT and RDT market system constraints and symptoms matrix. Commercially driven or otherwise, there is a need for on-going intensive action to positively influence consumer behaviour and the high rate of presumptive treatment – the problem being especially acute in rural areas where households remain disconnected from markets and rural caregivers such as PPMVs and community health workers (the first port of call for most poor rural families) are cut off from formal supply chains, and lack the necessary knowledge and skills to advise their clients.

2 ACT – RDT Baseline Survey, November 2013.


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Figure 2: Systemic constraints and symptoms of market dysfunctions in the ACT and RDT markets in Nigeria.

2.2 Formulating and Delivering Appropriate M4P Intervention Strategies

2.2.1 Positioning The challenge: One of on-going challenges for SuNMaP is effectively positioning the Commercial Sector strategy and approach in the context of broader public sector policy and strategy described above, which for the most part focuses on immediate response to malaria control rather than the longer term, systemic change which the M4P approach normally entails. It is not easy to advocate for commercial sales and distribution of LLINs, RDTs and ACTs when there are multiple layers of stakeholders with different vested interests, and where outreach is predominantly driven by public sector programmes and product and market segmentation is evolving based on donor and Government strategy rather than well informed consumer demand.

High degree of fragmentation in the market

High price of ACTs Lack of private channels for RDTs

Poor knowledge and skills of care givers

Policy priority for rapid market penetration

Large informal market trade, which proliferates counterfeits

Low consumer awareness about efficacy of ACTs and RDTs

Low demand for ACTs Low demand for RDTs

Improper case management

Dependence on subsidy to sustain market demand

Dependence on the public sector for market development

Weak private distribution channels at rural markets

High rate of presumptive treatment for adults

Erratic supply and market price for ACTs

High wholesale, distribution and retail mark-ups

High household expenditure on treatment of malaria


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Strategies and what has worked well: The programme has increasingly engaged with key national level partners such as Roll Back Malaria Programme (RBM), National Malaria Elimination Programme (NMEP) with the aim of contributing to policy and planning agendas and at the same time advocating for recognition and space for increasing private sector engagement in these processes. For example, SuNMaP has worked with the NMEP to assist in the development of its private sector engagement policy (2014-2020) and framework (which was under review at the time of compiling this case study). By starting at the top in this way, the programme can shape the case for growing a sustainable commercially driven market for LLINs, ACTs and RDTs. So far programme strategies have helped highlight the need to engage the private sector fully in policy dialogue and strategy formulation – whether this is in support of public or private sector initiatives. The way forward: It is fair to say policy and advocacy work is still at an early stage in respect to creating recognition and space for commercially driven sales of commodities, which would include better coordination and quantification so that the programme can tell with hard evidence what is the need gap that could be met through the commercial sector. This requires a further mind shift on the part of policy makers and private sector partners, but moving ahead SuNMaP will continue to advocate market scenarios that are not ‘all or nothing’ with respect to how consumers access preventative care and treatment. The Programme will increasingly use its market studies and analyses to demonstrate where space exists now and in the future for commercial marketing, sale and distribution of malaria commodities, whilst recognising there is a need for free and subsidised products and services and contributing to strategies for ensuring these get to the right people. This includes plans to share programme learning about how the RBM partners could effectively collaborate with and create better space for the private sector in retail / commercial markets. Section 2.2.2 below describes how SuNMaP has already made good progress in opening up space for commercial sales and marketing through its successful engagement with private sector players and continued efforts to demonstrate the business case. 2.2.2 Engaging Private Sector Partners and Demonstrating the Business Case The challenge: Core objectives of the Commercial Sector strategy include creating the right incentives that bring together market players and demonstrating the business case – in other words to show concretely that there are business opportunities (outside of the public sector domain) for those interested in selling directly to the market. As described earlier, the market for LLINs, RDTs and ACTs is still highly fragmented, which makes it more challenging to explore the market and identify if there are consumers willing and able to pay, who they are, where they are and how to ensure they have access to a quality product whether an LLINs, RDTs or ACT; Quality control remains a major challenge; For example, regular sales (through formal as well as informal channels) of leaked and fake mosquito nets, which undermine credibility of players and product in the market is a challenge; Cheap, non quality assured or expired ACTs are also a common finding in open markets.


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Strategies and what has worked well: Applying its M4P lens, the Commercial Sector team strives to firstly understand the market – players’ interests, motives and capabilities, how products and information flow (or do not flow as is frequently the case) and consumers’ understanding and perception of LLINs, RDTs and ACTs – and continually update that market knowledge as dynamics are always shifting. In the case of LLINs especially, supply and demand are heavily distorted by public sector distribution campaigns; the types of nets, sizes and shapes available are for the most part based on what contractors are producing for mass distribution and/or replacement campaigning. The programme is increasingly able to segment the market based on identified demand, and respond with interventions that effectively harness willingness to supply to market and willingness to pay. For example, Commercial Sector market studies have been able to show that the mass campaigns provide only standardised nets, which are not of use to everyone; significant demand exists for other nets such as conical nets, family size nets, and even nets in different colours. At a practical level, this translates into the Commercial Sector Market Support Officers (MSOs) exploring opportunities for niche markets that are relatively untouched by public sector. For example the project has scored success through its institutional sales – selling to private boarding schools and the National Youth Service Corps (NYSC). It is also partnering with a lead mattress manufacturer to explore the concept of selling LLINs together with new mattresses through the firm’s wholesale and retail network. The programme has also successfully linked a capable overseas LLIN producer with a Nigerian producer to boost capabilities in local production of certified LLINs in order to demonstrate the business case for a locally produced LLINs that is quality assured and affordable in the Nigerian context. SuNMaP Commercial Sector activities have been the catalyst for new and innovative cross sectoral linkages in LLINs, RDTs and ACTs commodity markets. Lead firms are in dialogue with, or are already partnering with, industry associations and pharmacy outlets to strengthen supply through the development of cost effective delivery models that enable outreach to untapped rural markets, and through capacity building in areas such as product detailing and consumer awareness. In the case of ACTs, SuNMaP has successfully partnered with two lead pharmaceutical firms to increase reach to rural areas. With a second round of contracts underway, the programme will effectively be facilitating outreach to 12 Nigerian states. Another important area of success has been the programme’s ability to build relationships with professional bodies such as the Association of General and Private Medical Practitioners of Nigeria (AGPMPN), the Association of Community Pharmacist of Nigeria (ACPN), and the Association of Medical Laboratory Scientist of Nigeria (AMLSN) and in turn facilitate linkages between these Associations and LLIN, ACT and RDT importers and distributors. Getting the buy-in of these professional bodies is critical to developing sustainable supply chain linkages as these industry representatives have a huge influence on policy, opinion and what is permitted by their membership.


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More recently, the programme signed a formal partnership with a lead buyer and distributor of quality assured RDTs (QARDTs) to pilot the sale and distribution of single dose testing kits. These test kits offer a more fail safe option for quick and accurate testing for malaria, but the kits are new to the market and there are still reservations over who can and should administer such tests in rural areas. The pilot brings together the lead firm, relevant industry professional bodies and policy-makers to explore use of a market subsidy to ‘kick start’ supply and demand; the aim being to make the kits as affordable as ACTs to incentivize service providers and consumers to use the test kits rather than simply opting to buy ACTs and treat fever without proper diagnosis. The way forward: The Commercial Sector component has demonstrated that establishing purely commercial supply chain linkages can work if given the space, and where there is a clear business case. It has been able to demonstrate that 1) high volume sales could be generated through strategic collaboration between LLIN distributors and networks of professionals (i.e. pharmacists and medical professionals); 2) even without subsidy, collaboration between LLIN distributors and trade associations (such as the association that oversees private schools) can facilitate institutional sales, and 3) the market is ready enough for international manufacturers to consider investing in technology transfer and a joint venture with one or more local manufacturers with facilitation support from SuNMaP.

Moving ahead, the key will be keeping partner firms engaged, which in essence means ensuring there are viable business opportunities. With respect to RDTs, the programme is keen to engage other quality assured RDT suppliers to ensure effective scale and penetration in rural markets, and to build capacity of end retailers in areas such as product detailing, effective usage and correct disposal of used kits. However, this also requires successfully advocating for a change in policy to allow the likes of capable PPMVs to administer QARDTs in rural areas, a strategic activity that has been incorporated into the National Malaria Strategic Plan 2014-2020. In both LLIN and ACT markets, the programme has to continue to help shape longer term business opportunities for its partners alongside public sector plans for free and subsidised commodities. In the case of ACTs this will include exploring potential to sell RDTs and ACTs together (referred to as ‘bundling’), and supporting with longer term availability, access, and affordability for whenever subsidies are reduced and/or withdrawn. This is wholly linked with establishing supplier responsiveness, cost effective distribution, consumer demand and economies of scale. The opportunity for technology transfer leading to local production of a WHOPES approved LLINs is an important systemic change goal for the programme, as is continuing to exploit market niches through increased and more diverse availability of LLINs.

2.2.3 Best Fit Versus Best Practice in Applying the M4P Approach in SuNMaP The challenge: The SuNMaP Commercial Sector activities are taking place within the framework of the bigger public sector driven programme and contribute to overall log frame targets at output levels and above. Output targets focus on demonstrating quantitative results such as outreach and coverage of LLINs, cumulative number of effective service delivery points and distribution of RDTs and ACTS. In fact,


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many of the activities related to achieving log frame targets require longer term systemic change, which is qualitative in nature – i.e. changes in thinking, policy reform, cross sector partnerships, increased service provider capacities, increased consumer awareness and understanding, etc. A core principle of the M4P approach is that programmes adopt a facilitative rather than hands on role – they act as an agent of change rather than a doer in the market place. The Commercial Sector team is challenged to bring about the type of systemic change it seeks given the time and resources available, and the context in which it is working. Often it has to think and act quickly to maximise on an opportunity and to get players to come to the table. When necessary it opts for a more hands on approach to do so. This trade-off between best fit rather than best practice is often the only means to contribute to longer term goals. Strategies and what has worked well: Rather than using contextual constraints to avoid action, the Commercial Sector has instead developed strategies to work with challenges in target market systems. For example, piggy-backing on the AMFm to incentivise new firms to develop ACT supply chain solutions for rural target markets. The commercial sector has used the opportunity of the AMFm to broaden and deepen supply of ACTs in rural areas. A spin off strategy has been the design of a much smaller scale subsidy support mechanism for introducing and fast tracking commercial sale and distribution of QARDTs. The Commercial Sector team does not have a wide choice of private sector firms to pick and choose from. It has often had to do a lot of leg work to convince LLINs and ACT importers/suppliers to try out commercial channel sales and marketing. Box 2 describes how the Commercial Sector decided to take a more hands on role in approaching and marketing to business corporates in order to ‘test’ the market and ascertain if there was a market opportunity before engaging importers/suppliers more deeply. Rather than being considered at odds with market system development programming, becoming more ‘hands-on’ in key areas is actually an important means to an end in applying the M4P approach. Inevitably, the programme has lost partners along the way due to perceived levels of risk, insufficient sales or the lure of more lucrative public sector procurement contracts. The programme has succeeded however in narrowing down to a portfolio of players that are serious, committed and increasingly willing

Box 2: Door to Door: Under the Malaria Safe Initiative, the Commercial Sector team is involved in promoting the purchase of LLIN by corporates for their workers as means of contributing to malaria safe households. In order to gauge the interest of corporate firms and demonstrate the business opportunity for LLIN importers/suppliers, one Market Support Officer (MSO) took to the streets to proactively canvass local businesses, engage with the heads of human resources departments, and organise workshops where LLIN importers and distributors were able to pitch their products to attending corporates. Unlike a best practice M4P intervention where the LLIN supplier will ideally lead in identifying and selecting potential buyers, organise any promotional event, and pitch directly to the potential client (with the programme supporting in the background), the MSO adopted a very hands on approach to facilitating the market linkages. This is a good example of SuNMaP having to play a more central role to help kick start potential business opportunities.


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to invest their own money to pursue opportunities. The partnership with lead frim RDT importer is a good example as the partner is committing additional resources (e.g. sales representatives, promotional and marketing materials, training events, etc) to get the RDTs pilot off to a strong start. The way forward: With one year of implementation remaining, the Commercial Sector is increasingly prioritising strategies and partnerships that are gaining traction in the market place, and dropping those that are not, whilst continuing to be open and flexible to newly emerging opportunities and playing a hands on role if it looks as though this could pay off as a means to an end. The programme will also increasingly gather and analysis evidence of impact, applying a rigour M4P lens with respect to assessing viability and sustainability and where it can best focus resources to strengthen supply chains as the programme enters its final phase of implementation.

SECTION 3

3.1 Conclusions and Emerging Lessons Learned

Though not internally to the programme, there has been a danger of the Commercial Sector strategy being perceived as an ‘add on’ rather than an integral part of the SuNMaP programme. This, coupled with the fact that early on many stakeholders did not fully grasp the objectives of the Commercial Sector component, has meant the programme has had to work even harder to effectively position the Commercial Sector strategies in a context in which most stakeholders are focused on maximising the impact of limited donor and government funds. Earlier and much broader awareness across stakeholders of planned commercial interventions may have helped early stage planning, design and strategising. The Commercial Sector component has had to effectively compete for private sector players’ attentions in a market where lucrative public health sector tenders take precedence. It has successfully engaged and secured the commitment of producers, importers, wholesalers, retailers and industry service providers, laying the foundations for longer term supply chain linkages by demonstrating that purely commercial supply chain linkages can work if given the space and when based on a clear business case. However, as intervention strategies were put in place on the supply side (i.e. incentivising and fast tracking supply chain development, gaining the buy-in of industry bodies and their membership, and piggy-backing on existing supplier networks), the extreme lack of consumer awareness particularly for ACTs and RDTs meant there was nothing to drive uptake on the demand side; add to this the convergence of free and/or highly subsidised commodities at service delivery points, and the ready availability of fake and leaked products severely compromised credibility, impact and opportunities for growth. In hindsight, more aggressive, comprehensive and harmonised strategies for consumer awareness with strong involvement of private sector players and industry bodies would have helped stimulate demand, which in turn would have stimulated supplier interest.


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The Commercial Sector component has succeeded in meeting its log frame targets for sales of LLINs, ACTs and is likely to meet targets for RDT sales. These results in themselves demonstrate there is a place for commercially driven sales and marketing of quality assured LLINs, RDTs and ACTs. Yet the private sector, beyond SuNMaP support, has remained relatively inactive. The reasons underpinning this need to be examined more closely, but it does suggest that it is because of the programme that the private sector has maintained some presence in the retail / commercial market; this mutual collaboration keeps the promise alive to establish and sustain the commercial market in the longer run when the donor support for free/subsidised distribution is gradually withdrawn. However, what happens next will determine whether strategies continue to bear fruit. Reverting to a market system purely based on free and subsidised commodities is unlikely to be sustainable in the context of Nigeria’s population of 150 million; but it is also important for stakeholders to remain realistic and open to how markets will evolve in the future. Given the current situation in Nigeria, a healthy solution is for continued efforts at both policy and grassroots level to create space for viable commercial activities through the opening up of markets, deepening cross sector dialogue and partnerships, increased quality controls and innovative ways of demonstrating business opportunities. The presence of these elements working together will help drive availability, access and the ultimate goal of affordability for LLINs, ACTs and RDTs.

Documents

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