Reproductive Health Global Program

A total market approach to contraceptive services

Woman and man in pharmacy.

Photo: Richard Lord.

PATH has worked in Nicaragua, Vietnam, Eastern Europe, and Central Asia to create a sustainable model to make contraceptives available to even the poorest citizens. These countries are applying a total market approach (TMA) that directs people who can pay for services to the private sector, freeing up public resources for those most in need and increasing family planning access to consistently underserved populations.

A whole, or total, market approach has been defined as “a coordinated approach that responds to the multiplicity of family planning needs in a country…[and] ensures that the entire market of clients—from those who require free supplies to those who can and will pay for commercial products—is covered.”1

Why a total market approach?

Against a backdrop of the largest cohort in the history of the world entering reproductive age, ministries of health are struggling to provide for the contraceptive demands of their family planning programs. Further, governments are increasingly required to make strategic decisions about these programs without the capacity and expertise for such decision-making. For example, governments in many developing countries historically received sufficient financial and technical support from international donors to provide free contraception to all segments of the population. They have limited expertise with targeted service provision in the context of reduced resources, including how to reach the poorest of the population with services and products and whether to include newly-developed contraceptives.

Increasing demand, availability of new methods, and scarce resources highlight the need for governments to find new ways to provide family planning for all. Meeting family planning needs by ensuring access to contraceptives now and in the future requires recognition and integration of various market sectors—including NGOs, as well as subsidized and self-financing options—in other words, a total market approach. However, it is rare that managers of family planning programs make plans and decisions in the context of the “total market,” in which different provider segments reach different consumer markets. Others have described this role as stewardship, or “setting and enforcing the rules and incentives that define the environment and guide the behaviors of health-system players.”2

Barriers to a total market approach include a lack of information about who uses the private sector, for what services and products, what prices they pay, and consumer perceptions of the services and products available in the private sector. Knowledge gaps between the public and private sectors also persist, as each sector may not be aware of the other’s priorities. Market-oriented research on family planning user needs has yet to be translated beyond recommendations and into concrete programmatic action—including decisions regarding contraceptive selection and resource allocations.

In our work, we partner with government to support its role as the leader and steward of the total market. A deliberate planning process is therefore required to determine which family planning sectors should serve which groups and how, and what other changes are required. The steps in this process are: 1) engaging stakeholders through advisory groups and network analysis, 2) assembling evidence for decision-making, such as determining the needs of private providers to provide family planning, identifying market segments, surveying commercial product availability, and modeling different financial resource scenarios, and 3) building the total market plan.

Related resources


  1. Sarley D, Rao R, Hart C, Patyewich L, Dowling P. Contraceptive security: practical experience in improving global, regional, national, and local product availability. Arlington, VA: John Snow, DELIVER; 2006.
  2. Lagomarsino G, de Ferranti D, Pablos-Mendez A, Nachuk S, Nishtar S, Wibulpolprasert S. Public stewardship of mixed health systems. Lancet. 2009;374(9701):1577–8.