Why the Total Market Approach is the Future of Healthcare in Africa

Somewhere in the mid-2000s, I sat in a government warehouse in Lagos surrounded by thousands of boxes of subsidised insecticide-treated nets. They had been procured with donor funding, shipped in, and distributed to state health facilities. The project looked good on paper. The coverage numbers were impressive. But when I followed the supply chain — actually drove out to the communities they were meant to reach — I found a different story.

Some nets had been sold at markets. Some were being used as fishing nets along the lagoon. Some never left the facility stores. The people who needed them most either didn't know they existed, couldn't get to a health facility to collect them, or had been told they were available but found empty shelves when they arrived.

Meanwhile, in the same communities, commercial pharmacies were stocking nets and selling them at prices most families couldn't afford. There was demand. There was supply. The two were simply failing to meet.

That afternoon in the warehouse was the beginning of my practical education in what would later crystallise, for me, as the Total Market Approach. And it is an education I believe every African health systems leader urgently needs.

The Charity Problem

Let me be direct about something that is uncomfortable to say in certain rooms: the dominant model of healthcare delivery in Sub-Saharan Africa — heavy donor subsidy, parallel supply chains, free distribution — has created an entire generation of health programmes that cannot sustain themselves. When the funding stops, the health outcomes reverse.

I am not arguing against donor support. I have worked within donor-funded programmes my entire career, and the lives they have saved are real and significant. But there is a meaningful difference between emergency humanitarian response — where free distribution makes complete sense — and the long-term architecture of a functional health market. We have confused the two for too long.

The question that should define our work is not "how do we get this product to this person today?" It is "how do we build a market that gets this product to this person, and to their children, and to their grandchildren, whether we are here or not?"

What TMA Actually Looks Like

The Total Market Approach starts with a simple observation: within any health market, not everyone needs the same level of support. There are consumers who have the ability and willingness to pay full commercial prices. There are those who can pay something but need a subsidy to reach affordability. And there are those — the most vulnerable — who genuinely cannot pay at all and require free provision.

The mistake most health programmes make is either treating everyone as if they fall into the third category (which wastes resources and distorts the market), or treating everyone as if they fall into the first (which abandons the people who most need support).

TMA says: understand your market. Map each segment. Work out what mix of commercial, social marketing, and public sector channels will serve each segment sustainably. Then align your programmes, your pricing, your distribution, and your communication to that reality — and coordinate across all three sectors so they reinforce each other rather than cannibalising each other.

In practice, this means the commercial pharmacy and the government health facility are not competitors — they are complementary arms of the same market. When a well-off urban consumer buys an artemisinin combination therapy at commercial price from a private pharmacy, she is not "taking" a subsidised product away from someone who needs it more. She is doing exactly what she should be doing. The subsidy can then flow to the patient in the rural primary health centre who genuinely cannot afford to pay.

What We Saw in Nigeria

During my years at the Society for Family Health, we ran one of the first systematic TMA pilots for malaria commodities in Nigeria. It was not a clean experiment — nothing in public health ever is — but the results were instructive in ways I still draw on today.

When we began working across both public and commercial channels simultaneously — coordinating distribution, aligning pricing tiers, training community pharmacists alongside government facility staff — something unexpected happened. Commercial sales of quality-assured antimalarials grew. And so did access in the lowest-income communities. The two moved together, not against each other.

The reason, when we dug into the data, made sense in retrospect. When the commercial market functions well, it builds awareness. Advertising for commercial ACTs also educated communities about the importance of testing and treating malaria. That demand creation benefited the subsidised channel too. And when the subsidised channel was well-stocked and trusted, it created a baseline of confidence in the treatment category that supported commercial market growth.

Health markets, it turns out, are not zero-sum.

The Skills Gap We Must Address

The greatest barrier to TMA adoption is not technical. It is not even political, though politics certainly plays a role. It is a skills gap at the leadership level. Most African health systems leaders — myself included, at various points in my career — were trained to think in programme management terms: objectives, activities, outputs, outcomes. That is necessary but not sufficient.

What we need in addition is market literacy. The ability to read a supply chain as a market economist would. The ability to design incentive structures that align commercial interests with public health goals. The ability to negotiate with private sector actors as equals, not as problems to be managed.

This is not about becoming business people. It is about having enough fluency in market dynamics to stop building programmes that collapse when the donor leaves the room.

Africa's health challenges are too large, and the need too urgent, for any other approach. The future of healthcare here will be built on sustainable markets. The question is only whether we build them intentionally — or stumble toward them after another generation of wasted potential.

I know which one I am working toward.