WHAT WAS THE PROBLEM?
International donor support, which accounted for three-fourths of Vietnam’s HIV prevention and treatment efforts, has drastically decreased in size and scope, causing stakeholder concerns about the sustainability of the HIV response in Vietnam. The majority of Vietnam’s 250,000 PLHIV and new infections are among key populations (KPs). Countries where the HIV epidemic is concentrated among KPs are disproportionately affected by decreases in donor funding. Furthermore, stigma and discrimination of these populations inhibit access to all vital HIV services at public facilities, necessitating alternative options outside of the public sector. Recent data suggest that HIV infections are increasing among men who have sex with men () and transgender women (TGW), while prevention interventions only reach a limited proportion of this population.
Until recently, most countries with external donor support provided HIV services free of charge. Declining donor funds require countries to identify other opportunities to mobilize domestic financial resources. Vietnam needed to fill resource gaps and deploy cost-effective strategies to increase prevention efforts and case detection, facilitate immediate enrollment on antiretroviral therapy (ART), and strengthen support services to ensure sustained HIV viral suppression.
WHAT IS THE SOLUTION?
With the realization that the provision of free HIV prevention and treatment services for all was unsustainable, Vietnam’s Ministry of Health (MOH) and partners have applied a total market approach (TMA) to generate cost-effective solutions that leverage public-private partnerships. TMA aims to use the comparative advantages of public, nonprofit, and private sources of health goods to increase access to and the sustainability of priority health products (see market development framework below).
The Healthy Markets (HM) initiative— funded by the U.S. Agency for International Development (USAID) and implemented by PATH—deploys market-based approaches that inclusively consider demand-side factors, policies, and regulatory frameworks, and public and private sector capabilities. This five-year initiative, which began in 2014, focuses on partnering and supporting product manufacturers, commercial distributors, Civil Society Organizations (CSOs), non-traditional outlets (NTOs), and retail outlets.
With significant growth in Vietnam’s economy, there is increased willingness among KPs to pay for a wide array of private health-related goods and service, including: condoms, HIV testing, needles and syringes, pre-exposure prophylaxis (PrEP) and antiretroviral treatment (ART). This is especially true when products are perceived to be of high-quality or the services are KP-friendly. The HM initiative aims to grow a viable market for HIV-related goods and services that is capable of meeting the needs of KPs.
HM employs TMA to align the government and the programs offering free and subsidized products and services with the commercial market. This alignment ensures access and equity across all population segments and provides options for those who are able to pay. Greater efficiencies and targeting lead to a more sustainable approach and allow the commercial sector to grow and thrive while the Vietnam government prioritizes their finite public and donor resources for the most vulnerable population sub-groups.
WHAT WAS THE IMPACT?
Data support the need for models that shift the focus from public-sector, donor-driven programs to market-based approaches. This shift maximizes the use of limited resources and increases the overall impact of reaching KPs by crowding-in the commercial sector, attracting private investment, and leveraging the private sector’s expertise. As of 2017, there were 100 commercial condom offerings at market-determined price ranges, covering 74% of hotspot outlets, compared to only 25% in 2013. According to a KP consumer-willingness-to-pay study from 2015, more than 90% of KPs were willing to pay for condoms. The HM initiative virtually replaced socially-marketed condoms with fully sustainable commercial brands, while ensuring the high coverage required to meet the needs of target populations.
The HM pilot involved private clinics, online platforms, CSOs, and antiretroviral (ARV) manufacturers/distributors, and demonstrated uptake rates that were several times higher when compared to a similar fee-based pilot in Thailand. A 2016 ART preferences and willingness-to-pay study in Vietnam found that 50% of free ART users and 69% of those newly diagnosed were willing to pay USD $20 per month for ART. Two-thirds stated a preference for multi-month exams and ART dispensing. 10% of those interviewed were already enrolled in fee-based ART services, the key reasons for which were a strong preference for confidentiality and convenience.
In the first three years of Healthy Market’s implementation, the commercial sector was able to fill the supply gap and increase sales threefold while ensuring high coverage in traditional and non-traditional outlets (73%), effectively replacing subsidized provision of socially-marketed condoms and resulting in greater equity and sustainability of HIV-related commodity provision. Through marketing and sales advice to condoms companies, local distributors, and KP sales outlets, a total of 14.8 million condoms were sold in the first six months of FY2017, on the 10.87 million condoms sold in FY2016. Additionally, low dead-space syringe (LDDS) sales were high, with 2.29 million pieces sold in FY2017, nearly double the 1.2 million sold in FY2016.
Data sources: USAID/PATH Healthy Markets. Condom Retail Outlet Study, November 2016; USAID/PSI Condom Retail Outlet Surveys, 2011, 2012, 2013.
HOW DOES IT WORK?
HM facilitates a transition from heavily donor-reliant, free and subsidized provision of HIV commodities and services, to a locally sustainable value chain. HM created a landscape of Vietnam’s HIV product and services market, generated data, and deployed strategies that identified and reached KPs and other vulnerable populations that are willing and able to pay through the private sector. The government can then direct its limited financial resources to the most vulnerable and to those unable to pay, resulting in sustained and equitable access to commodities and services. MSM, female sex workers, and people who inject drugs were included as advisors, implementers, and/or participants in focus groups and other forms of market research to inform the design of all HM interventions.
Subsequent to the analysis, TMA framework helps define and deploy program strategies that aim to: increase use of product and services across priority target populations based on epidemiological context; provide equitable access to population segments acknowledging differences across gender, age, geography, wealth quintiles, and risk behaviors; and determine optimal allocation of resources for sustainable programming.
Sources: KP Access Source: PATH/USAID Healthy Markets. Market Research on HIV Commodities & Services Consumer Survey, 2015; KP Willingness to Pay Source: Condom Market in Vietnam, IMS, 2014.
HM provided marketing and communications support using traditional and new media channels to promote partner products and to generate demand for HIV prevention, testing, and treatment products and services. It also established Rainbow Village or Xom Cau Vong, an HIV educational Facebook page for MSM.
Achieving self-sufficiency requires graduating mature aspects of HIV programming to sustainable models, such as facilitating commercial sector’s provision of commodities in an equitable manner. This creates an opportunity to direct limited public resources to correct under-performing functions of the HIV commodities markets to meet the needs of KPs and other vulnerable populations. To do that, TMA uses an inclusive analysis process across potential and current users. It also analyzes the stakeholders involved in performing various functions necessary to achieve a healthy market. While supply and demand functions informed the core of our programming, an enabling environment—including policy and regulation, financing, leadership and coordination—is needed. HM’s private-sector partners in Vietnam invested an estimated USD $861,765 and other private-sector contributions included $354,484 from pharmaceutical, diagnostic, and medical supply companies. Before the launch of HM, there were factors in place that provided an enabling environment for a TMA intervention, such as the Vietnamese government providing collaboration and stewardship in incorporating TMA into their national HIV strategy. The HM initiative also continued to develop KP-led organizations, such as social enterprises and private clinics, and they contribute to program design and are active market participants as well.
The objectives of the HM initiative include: (1) creating a conducive environment for private sector activities and investment, (2) generating demand and improving the sustainability of supplies, which can be achieved by enabling public-private partnerships, (3) integrating with existing systems and services, (4) promoting innovation, (5) capacity-building of the private sector and social enterprises, the Government of Vietnam, CSOs, and KP leaders.. To secure sustained private-sector investment, HM ensures that demand generation and behavior-change communication for HIV-related goods and services address three types of consumers: (1) KPs; (2) FSW clients and their regular sex partners/spouses, and sex partners of KPs/PLHIV (with an emphasis on female partners); and (3) other people who need HIV-related goods and services.
Scaling HM Across Markets
The MOH adopted the HM model into their HIV annual planning and budget tool in 2017 and is now implementing at a national scale with a full range of activities strengthening and/or correcting core and supporting market functions, with active participation by all stakeholders representing public and private sectors. Through these activities, Vietnam’s HIV market is now able to provide sustainable access to condoms, lubricants, and LDDS, effectively replacing reduced external financial support formerly extended to the provision of subsidized commodities. Vietnam’s HIV market also provided a ready platform for successful launch and scale up of PrEP, and has potential for other HIV prevention, diagnostic, and treatment products and services. Factors that influence scale-up include:
- an environment requiring imminent need for TMA interventions;
- government leadership and effective stewardship of the TMA process;
- a coordinated donor response, including alignment of priorities and strategic allocation of resources complementing and supporting national HIV program objectives; and
- active commercial sector and conducive regulatory environment, as well as financing and technical support by donor and/or implementing agencies.
Monitoring HM Implementation
PATH led a consortium of local partners ensuring their full participation throughout the planning, implementation, and monitoring of the project. One of the key components to success is the ability of the implementing partner to engage with the commercial sector, which included in-country manufacturers, distribution chains, CSOs, and NGO partners in the design and implementation of partnership agreements.
The HM project measures the feasibility, acceptability, and sustainability of given models, which informed the transition of the HIV program to domestic financing. The HM monitoring and evaluation (M&E) team has strengthened routine monitoring and reporting systems to effectively monitor the progress of each activity in relation to the project’s goals and objectives. Data from retail outlet surveys, quality audits, willingness to pay, HIV self-testing usability study, and process evaluations have been analyzed to support activity implementation and to improve service. M&E identified trends related to specific products and services, current geographic coverage, distribution channels, and market shares by service providers. The team used pertinent data to better understand the behaviors and preferences of target populations in relation to the HIV services offered by HM’s partners. These findings have been used by HM, government agencies, and private-sector partners. HM findings and indicators can be found in the HM project logical framework, which is linked in the Resources section below. Additionally, USAID/Vietnam holds regular meetings to discuss updates, the implementation of key activities, and receives weekly project accomplishments updates.
Revised by the PEPFAR Solutions Platform team, May 2018