Botswana: A Total Market Approach. PSI/UNFPA Joint Studies on the Total Market for Male Condoms in Six African Countries.
Publication date: 2013
A TOTAL M A R K E T A P P R O A C H BOTSWANA F O R M A L E C O N D O M S Missions: UNFPA and PSI UNFPA, THE UNITED NATIONS POPULATION FUND, delivers a world where every pregnancy is wanted, every birth is safe, every young person's potential is fulfilled. PSI, POPULATION SERVICES INTERNATIONAL, makes it easier for people in the developing world to lead healtier lives and plan the families they desire by marketing affordable products and services. Recommended citation: Pallin, S.C., D. Meekers, O. Lupu, K. Longfield. November 2013. Botswana: A Total Market Approach. PSI/UNFPA Joint Studies on the Total Market for Male Condoms in Six African Countries. Retrieved from www.psi.org/total-market-approach Contents GREETINGS 1 EXECUTIVE SUMMARY 2 METHODS 3 STATE OF THE MARKET 4 INTRODUCTION 6 Health Context 6 HIV Situation 7 Public Sector 8 Social Marketing Sector 9 Commercial Sector 10 RESULTS 11 Universe of Need 11 Condom Use 12 Market Volume 13 Market Value 14 Subsidy 15 Number of Brands 15 Equity 16 CHALLENGES AND OPPORTUNITIES 17 RECOMMENDATIONS 19 Informed Demand 19 Equitable Distribution 19 Sustainability 19 Product Quality 19 Market Progress 19 Reporting 19 ACRONYM KEY 20 ACKNOWLEDGEMENTS 20 REFERENCES 21 COVER PHOTO: © CORBIS TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 1 M ale condoms offer dual protection against HIV and other sexually transmitted infections (STIs), as well as unplanned pregnancy. All of these factors are important to our two agencies— UNFPA, the United Nations Population Fund, and PSI, Population Services International — and are critical for delivering the health impact we both strive to achieve. This case study is part of a series that UNFPA and PSI have produced over the course of a year. The series takes a critical look at the communities in which we operate and helps us understand how both agencies can improve our support in those communities and our engagement with other stakeholders, to grow and strengthen the total market for condoms. We focused our efforts on six African countries — Botswana, Lesotho, Mali, South Africa, Swaziland, and Uganda — that have large condom social marketing programs, are affected by the HIV epidemic, and have high maternal morbidity and mortality relative to their economic development. This series of case studies is intended to inform appropriate evidence-based decisions that increase condom use equitably and sustainably through actions undertaken in all supply sectors. Employing such a total market approach (TMA) means that all three sectors — public, social marketing, and commercial — work together to deliver health choices for all population segments. We will work together and with other partners to increase condom use and grow the market in a responsible way. Our long-term goal is to offer options to those most in need, people seeking to live their lives free from HIV and unplanned pregnancy. ● Sincerely, BRUCE CAMPBELL Director, Technical Division, UNFPA KIM LONGFIELD Director, Research and Metrics, PSI Greetings A MESSAGE FROM BRUCE CAMPBELL AND KIM LONGFIELD We will work together and with other partners to increase condom use and grow the market to serve those most in need. MALI UGANDA BOTSWANA SOUTH AFRICA LESOTHO SWAZILAND TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 2 Executive Summary T he prevalence of HIV in Botswana is among the highest in the world, with nearly one-fifth of the population infected. Although large-scale HIV prevention efforts have resulted in a decrease in new infections over the past two decades, consistent condom use remains critical for preventing new infections. Male condoms are a vital part of Botswana’s National Strategic Framework for HIV prevention, and because condoms offer dual protection against HIV and unplanned pregnancy, they also play an important role in family planning. In Botswana, the number of condoms needed to protect all sexual acts from HIV infection and unplanned pregnancy (universe of need) is higher than the actual number of condoms on the market (volume). However, public health efforts to improve access to condoms have succeeded in growing the condom market and condom use among both males and females, including those with higher risk behavior. Inequity remains an issue and there is evidence to suggest that condom use is concentrated among wealthier segments of the population. The condom market in Botswana has traditionally consisted of three sectors: the public sector, which distributes fully subsidized (free) condoms; the social marketing sector, which distributes partially subsidized condoms at low cost; and the commercial sector, which sells condoms for a profit. While the role of the public and commercial sectors has not changed, the social marketing sector no longer sells partially subsidized condoms. In 2012, PSI/Botswana, the only social marketing organization in the country, transferred the management of its condom brands to PSI/South Africa, a PSI regional branch for Southern Africa. As a result of this change, socially marketed brands that were previously subsidized are now sold at full cost recovery. Despite these improvements, the market remains heavily subsidized and dominated by free public sector condoms. Concerns about appropriate pricing strategies, “crowding out” the commercial sector, and inefficiencies in the use of public funds, have prompted UNFPA and PSI to adopt a total market approach (TMA) to help manage the condom supply in Botswana. TMA requires that all three sectors work together to “grow the condom market” and meet the needs of different segments of the population. The results of our study yielded several important findings. In order to meet increasing demand, the three sectors must address inefficiencies in condom distribution and promotion. The new National Condom Strategy sets out to improve reporting systems for forecasting and improve distribution to key populations at risk. Efforts should focus on those most in need, including the poor and those living in rural areas, as well as mobile populations and sex workers. While there is some evidence that the commercial sector is growing, free condoms continue to dominate the market, which limits sustainability. Long-term sustainability requires that those with an ability to pay for condoms purchase unsubsidized condoms rather than rely on free condoms. This study presents a picture of the most recent market trends, analyzes past market trends, and provides a series of recommendations intended to help policymakers, donors, and other stakeholders better manage Botswana’s condom market. ● The Total Market Approach (TMA) seeks to maximize market efficiency, equity, and sustainability through the coordination of the public, social marketing, and commercial sectors. * USAID CYP conversion factors provide the units of products needed per one couple year of protection2 **In cases where some condoms are partially subsidized (e.g., socially marketed), the calculation is “For each brand: the difference between market volume multi- plied by COGS, and market volume multiplied by average consumer price.” METRIC DEFINITION CALCULATION The number of products or services needed to reach universal coverage in the market HIV: Male population 15-64 multiplied by average number of risky sex acts per man per year FP: Female population 15-49 multiplied by method mix multiplied by CYP conversion factor* The number of products or services sold, distributed, or provided in a given market The percentage of the population at risk using a product or service, or adopting a behavior Total number of condoms distributed in the public, social marketing, and commercial sectors Percentage of males and females reporting condom use at last sex The dollar value of the total number of products or services in a given market Average consumer price multiplied by market volume The number of distinct brands for a product in a given market Total number of condom brands on the market The value of total subsidies (excludes operating and support costs) For fully subsidized (free) condoms: market volume multiplied by unit cost of goods sold (COGS)** The degree to which products or services are used or adopted across socio-economic strata Percentage of condom users that fall within the bottom two wealth quintiles UNIVERSE OF NEED USE MARKET VOLUME MARKET VALUE MARKET SUBSIDY EQUITY INDEX NUMBER OF BRANDS TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 3 Methods This list of TMA metrics comes from the literature and a set of metrics PSI has committed to measuring across countries.1 TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 4 State of the Market Sources: UNAIDS Investment Framework Study Group3; UN Population Division4, 2010 revision; USAID conversion factors2; Guttmacher Institute. Adding it up: The costs and benefits of investing in family planning and maternal and newborn health (estimation methodology), 2011.5 Sources: BAIS II6, BAIS III 7,8 Percentage of adults aged 18-34 who used a condom at last sex with a non-marital non-cohabiting partner Sources: PSI TRaC Survey 2007 and 20109 UNIVERSE OF NEED CALCULATION: HIV: Male population 15-64 multiplied by average number of risky sex acts per man per year FP: Female population 15-49 multiplied by method mix multiplied by CYP conversion factor MARKET VOLUME CALCULATION: Total number of condoms distributed or sold in the public, social marketing, and commercial sectors USE CALCULATION: Percentage of males and females reporting condom use at last sex 62.2% 57.0% 79.2% 75.7%62.2% 57.0% 79.2% 75.7% Sources: PSI/Botswana10, CMS11 *For 2013, the social marketing sector is considered “commercial sector” because its condoms are profitable. Where official data were unavailable, figures used are best estimates. **2012 public sector distribution figures were used for 2013 Source: BAIS III7 *Wealth quintile data were not available, so education was used as a proxy Sources: PSI/Botswana10, CMS11, PSI/South Africa14 * Includes Trust and Lovers+ brands Source: PSI/Botswana13 TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 5 36.8% 51.7% 43.6% 50.8% 65.0% 55.3% 89.4% 85.9% 84.2% 75.7% NUMBER OF BRANDS CALCULATION: Total number of condom brands on the market ● ● ● ● ● ● ● ● ● ● ● ● ● EQUITY CALCULATION: Percentage of condom users by education level* SUBSIDY CALCULATION: For fully subsidized (free) condoms: market volume multiplied by unit COGS $4,759,943 P40,475,704 $8,113,846 P68,995,286 at least 13 different brands of condoms on the market $815,127 P6.9 million Estimated subsidy for public sector condoms 85% of condoms fully subsidizied 15% commercial sector condoms* MARKET VALUE CALCULATION: Average consumer price multiplied by market volume AVERAGE CONSUMER PRICE MARKET VOLUME MARKET VALUE Sources: PSI/Botswana10, CMS11,PSI/Botswana and PSI/South Africa12 TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 6 Introduction HEALTH CONTEXT The prevalence of HIV in Botswana is among the highest in the world, with an estimated 25% of adults infected.15 Major HIV prevention efforts have succeeded in decreasing new infections by 71% since 2001, and male condoms remain a critical component of Botswana’s HIV prevention strategy.16 Concurrent partnerships, multiple partnerships, and intergenerational sex are common and contribute to the epidemic.17 Other key populations at risk include sex workers, migrant workers, transport workers, and miners. 17 Because of the high prevalence of HIV, it is expected that most new infections will occur among people traditionally considered to be “low risk": heterosexual married couples and couples who live together.17 Consequently, correct and consistent condom use with regular partners is also important. In addition to providing protection against HIV infection, condoms play a role in preventing unplanned pregnancy, and a consistent supply of high-quality condoms is required to fill the need for both HIV prevention and family planning. However, it is clear from our research that the current market falls short of meeting those needs. The National Condom Strategy, implemented in 2012, is taking steps to increase condom use and strengthen the condom market.18 This study provides additional recommendations to strengthen and stabilize the market, help increase condom use and ensure long-term, equitable access to condoms. Male condoms are an important part of Botswana’s national strategy for HIV prevention. IL L U S T R A T IV E O P T IO N S TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 7 Botswana: HIV Situation HIV PREVALENCE IS AMONG THE HIGHEST IN THE WORLD, APPROXIMATELY 25%15,17 NEED FOR CONSISTENT SUPPLY OF HIGH QUALITY CONDOMS RISKY SEXUAL BEHAVIOR REMAINS COMMON15,17 Multiple partnerships Concurrent partnerships Intergenerational partnerships Sex work TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 8 PUBLIC SECTOR The Ministry of Health (MOH) coordinates condom activities in Botswana and is the main source of public sector condoms. Condoms are delivered through Central Medical Stores (CMS), which distribute medicines and health supplies to Botswana’s public sector, including hospitals, clinics, and health posts. CMS also distributes condoms to district health management teams (DHMT), that coordinate condom distribution for each district. Both DHMT and health facilities can order condoms from CMS, and CMS also provides warehousing for the Botswana Defense Force (BDF) condom brand, Sekwata. The National AIDS Coordinating Agency (NACA), a government agency, coordinates the national response to HIV and AIDS, including advocacy related to condoms. In addition to these government agencies, PSI/Botswana assists with free condom distribution by delivering condoms to users in hard-to-reach and informal locations such as shebeens, cattle posts, and high density multiresidential homes. The majority of public sector condoms are the government’s Lorato brand, manufactured in Botswana by a local company. Other free condom brands include Carex, donated by USAID, and Sekwata, a brand distributed by the BDF to members of the military and their families. UNFPA, USAID, and the United States Department of Defense are currently the main donors for public sector condoms in Botswana. The National AIDS Coordinating Agency (NACA) is responsible for condom advocacy and resource mobilization Central Medical Stores (CMS), the MOH pharmaceutical warehouses, deliver government condoms to health facilities UNFPA, USAID, and the US Department of Defense are major donors for condoms in Botswana There are three public sector brands: Lorato, Carex, and Sekwata BOTSWANA ECONOMIC INDICATORS 19 ■ Development category: developing ■ Income level: upper middle ■ GDP:14.4 billion (USD) ■ Population: 2.0 million TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 9 PSI is the only social marketing organization with a presence in Botswana PSI's regional office headquartered in South Africa coordinates procurement, distribution, and marketing for Trust and Lovers+ brands Trust and Lovers+, are the only socially marketed brands, and have been profitable since late 2012 Income from Trust and Lovers+ condoms is used to grow the brands as well as to support public sector distribution PSI/South Africa contracts with a large commercial distributor to deliver Trust and Lovers+ to independent distributors, wholesalers, and retail chains in Botswana SOCIAL MARKETING SECTOR The social marketing sector has changed considerably in the last five years. Prior to 2012, PSI/Botswana sold subsidized Trust and Lovers+ condoms. In August 2012, PSI/Botswana transferred the management of its condom brands to PSI/South Africa, a regional foreign branch office of PSI based in Johannesburg, South Africa. PSI's regional office manages procurement, distribution, marketing, and all other activities related to Trust and Lovers+ condoms in Botswana, South Africa, Lesotho, and Swaziland. PSI sells Trust and its brand extension, Trust Studded. It also sells Lovers+ as well as two extensions of the Lovers+ brand: Lovers+ Coloured and Flavoured and Lovers+ Ribbed and Studded. PST, a commercial entity that sells and distributes condoms along with other fast moving consumable goods, has contracted with PSI to deliver Trust and Lovers+ condoms to independent distributors, wholesalers, and retail chains, which then sell smaller quantities of condoms to retail outlets. Trust and Lovers+ are widely available in shops, pharmacies, kiosks, and petrol stations. Trust is positioned as a lower-end brand positioned for couples, while Lovers+, a higher-end brand, has more modern, bold packaging and is positioned as a playful brand. Since late 2012, steps have been taken to bridge price disparities in the region through price increases for Trust and Lovers+ condoms and to reach full cost recovery. Regional pricing was standardized across all countries and condom brands by April 2013. Consistent price increases over the years, in addition to brand popularity, have allowed Trust and Lovers+ brands to keep pace with inflation and even become profitable. Profits from PSI condom sales in Botswana are not only used to support the Trust and Lovers+ brands, but also to fund PSI's distribution of public sector condoms. The Kingdom of the Netherlands is the main donor for socially marketed condoms; however, a plan to eliminate donor funding is in place and the social marketing sector should become completely self-sustainable by 2015. PUBLIC SECTOR 85% BRAND NAMES: Lorato, Carex PRICE PER CONDOM: Free POSITIONING: None TARGET AUDIENCE: None PLACES AVAILABLE: Public healthcare facilities, some non-medical outlets BRAND NAME: Sekwata PRICE PER CONDOM: Free POSITIONING: Always available, high quality protection TARGET AUDIENCE: Military members and their families PLACES AVAILABLE: Military bases SOCIAL MARKETING 10% BRAND NAME: Trust, Lovers+ PRICE PER CONDOM: from P1.75 for Trust to P3.82 for Lovers+ Coloured and Flavoured ($0.21 to $0.48) POSITIONING: Trust: caring brand; Lovers+: modern, playful brand TARGET AUDIENCE: Trust: couples; Lovers+: middle income, youth PLACES AVAILABLE: Shops, pharmacies, kiosks, and petrol stations COMMERCIAL SECTOR APPROX. 5% BRAND NAMES: Moods, Lifestyles, Ultimate, Power Endura, Durex, Contempo, Dr. Long, Rocky PRICE PER CONDOM: Median: P5.50 ($0.65) POSITIONING: Enhance the sexual experience TARGET AUDIENCE: Middle-income and wealthy individuals PLACES AVAILABLE: Pharmacies, large supermarkets, and liquor stores TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 10 COMMERCIAL SECTOR The commercial sector in Botswana accounts for approximately 5% of the total market and includes at least eight different brands.10,13 Moods is the most popular brand and has recently lowered its prices below those of Lovers+ to capture more of the market. Some other brands, such as Lifestyles, Ultimate, and Power Endura, are also sold at mid- range prices while others like Durex, Contempo, Dr. Long, and Rocky are more expensive. Moods, Durex, and Contempo offer a variety of brand extensions and are primarily positioned as sexual enhancement products. Commercial sector condoms are available in pharmacies, petrol stations, and chain stores, and are mainly available in urban areas. ● MARKET MAP (2012) The commercial sector accounts for approximately 5% of the total market Commercial brands are available in pharmacies, large supermarkets, and liquor stores Moods, Contempo, Durex, Dr. Long and Lifestyles are among the most popular commercial brands S T E P H A N IE O ’C O N N O R TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 11 Results UNIVERSE OF NEED* In 2012, approximately 34.1 million condoms were needed to cover all risky sex acts, approximately 12% more than were needed in 2006. The need for condoms is expected to increase as the population grows. For family planning, the universe of need for condoms increased from 3.8 million in 2006 to 4.1 million in 2012. Currently, Botswana is meeting the need for condoms for family planning. Botswana has also made excellent progress toward meeting the universe of need for condoms for HIV prevention. In 2012, distribution of male condoms met approximately 94% of the need for HIV prevention, compared to just 63% in 2007. Sources: UNAIDS Investment Framework Study Group3; UN Population Division4, 2010 revision; USAID conversion factors2; Guttmacher Institute. Adding it up: The costs and benefits of investing in family planning and maternal and newborn health (estimation methodology), 2011.5 * Total universe of need for condoms could be as low as the number needed for HIV prevention or as high as the sum of the universe of need for HIV prevention and family planning. Most likely, total need falls somewhere between these two figures. A lack of data on dual protection prevents our ability to estimate the total number of condoms needed per year for both HIV prevention and family planning. UNIVERSE OF NEED & TOTAL CONDOMS DISTRIBUTED Botswana has made excellent progress toward meeting the universe of need for condoms. TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 12 CONDOM USE The proportion of the general population that reports using condoms in Botswana is high and has increased over the years. In 2008, more than three-quarters of men and women reported using a condom the last time they had sex.7,8 This is a significant increase from 2004, when approximately 60% of men and women reported condom use at last sex.6 In 2008, condom use was higher among unmarried youth, as well as those who reported having concurrent and multiple sexual partnerships.7,8 More recent nationally representative data on condom use are limited. However, among adults aged 18-34, condom use at last sex with a non-marital, non-cohabiting partner increased from 81% in 2007 to 88% in 2010.9 Sources: PSI TRaC Survey 2007 and 20109 The percentage of males and females using condoms in Botswana increased between 2004 and 2008, but it is unknown if this positive trend has continued. Sources: BAIS II6, BAIS III7,8 62.2% 57.0% 79.2% 75.7% PERCENTAGE OF RESPONDENTS WHO USED A CONDOM AT LAST SEX Percentage of males and females aged 18-34 who used a condom at last sex with a non- marital, non-cohabiting partner Botswana’s condom market is dominated by the public sector. TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 13 MARKET VOLUME From 2007 to 2012, the total market increased from 19.4 to 30.4 million condoms.10,11 After a dramatic increase in 2008, market volume remained steady until increasing again in 2012. Botswana’s condom market has been and remains dominated by the public sector. Free condoms have accounted for between 74% and 86% of the total market since 2007.10,11 Sales of socially marketed condoms reached 5 million in 2010 and have been increasing since 2011.10 Projections for 2013 estimate that 3.7 million socially marketed condoms will be sold. Data on commercial sector sales are not available for most study years, but we estimate that commercial brands had approximately 5% of the market share in all six years of our study. Now that socially marketed condoms are being sold as commercial brands, the commercial sector will account for a greater percentage of the total market. DISTRIBUTION BY SECTOR Sources: PSI/Botswana10, CMS11 *For 2013, the social marketing sector is considered “commercial sector” because its condoms are profitable. Where official data were unavailable, figures used are best estimates. **2012 public sector distribution figures were used for 2013 IL L U S T R A T IV E O P T IO N S TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 14 MARKET VALUE The value of the total market in 2012 was estimated at $8,113,846 or P67,615,385, almost twice the estimated market value in 2007. Price increases for socially marketed condoms took effect in 2011, 2012, and 2013. There is a wide range of price points for condoms. In 2013, prices ranged from P1.75 ($0.21) for Trust to P3.82 ($0.48) for Lovers+ Coloured and Flavoured. Prices for commercial brands also varied a great deal, with a median price of P5.50 ($0.65). AVERAGE CONSUMER PRICE MARKET VOLUME MARKET VALUE The value of the total market for condoms increased by more than 70% between 2007 and 2012. IL L U S T R A T IV E O P T IO N S COST TO CONSUMER PER CONDOM (BWP AND USD) FREE TRUST TRUST STUDDED LOVERS+ SMOOTH LOVERS+ RIBBED & STUDDED LOVERS+ COLOURED & FLAVOURED COMMERCIAL BRANDS INFLATION20 2006 0 - - P1.66 $0.29 - - P0.83-P6.00 $0.15-$1.06 2007 0 - - P1.66 $0.28 - - P0.83-P6.00 $0.14-$1.00 7.08% 2008 0 - - P1.66 $0.25 - P1.85 $0.28 P0.83-P6.00 $0.12-$0.90 12.70% 2009 0 - - P1.85 $0.26 - P1.85 $0.26 P0.83-P6.00 $0.12-$0.86 8.03% 2010 0 - - P1.85 $0.28 - P1.95 $0.29 2.00-P7.65 $0.30-$1.15 6.95% 2011 0 - - P1.85 $0.28 - P1.95 $0.29 P2.00-P7.65 $0.30-$1.14 8.46% 2012 0 P1.50 $0.20 P1.83 $0.24 P2.83 $0.38 - P3.05 $0.41 P1.67-P7.65 $0.22-$1.02 7.54% 2013 0 P1.75 $0.21 P2.08 $0.25 P3.07 $0.38 P3.82 $0.48 P3.82 $0.48 P1.67-P7.65 $0.20-$0.94 N/A Sources: PSI/Botswana and PSI/South Africa12 TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 15 SUBSIDY To ensure sustainability of the market, major changes have been made to the social marketing sector in Botswana. Donor funding for socially marketed condoms has historically come from the Kingdom of the Netherlands; however, in August of 2012, PSI implemented a full cost recovery plan that will eliminate the need for external funding support by 2015. Since the market is dominated by the public sector, the majority of condoms will continue to be fully subsidized at a substantial cost to the government of Botswana as well as international donors like USAID and during acute shortages, UNFPA. Although the exact amount of public sector subsidies is unknown, average cost of goods sold (COGS) give an estimate of P6,931,351 or $815,127.10,11,14 NUMBER OF BRANDS At least thirteen brands were available on the market in 2012, including the two social marketing brands, and government brands Lorato, Carex and Sekwata.13 Several of these brands include brand extensions, which cater to different audiences. Because data on commercial brands are limited, we cannot calculate trends in the number of brands on the market over time or know how many of the commercial brands have had a long-term presence in Botswana. Moods and Contempo are among the most popular commercial brands. Several of the brands available in Botswana are also available in South Africa, such as Contempo, Durex, and Lifestyles. S T E P H A N IE O ’C O N N O R ● ● ● ● ● ● ● ● ● ● ● ● ● at least 13 different brands of condoms on the market $815,127 P6.9 million Estimated subsidy for public sector condoms 85% of condoms fully subsidizied 15% commercial sector condoms* AVERAGE UNIT COGS VOLUME OF FULLY SUBSIDIZED CONDOMS SUBSIDY * Includes Trust and Lovers+ brands TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 16 EQUITY A lack of available socioeconomic data prevents an analysis on equity, the degree to which condoms are used across socioeconomic strata over time. We were, however, able to use education as a proxy. For both men and women, rates of condom use were higher among those with more education. Among men with no formal education, just over half reported using a condom with their last sexual partner, compared to more than 80% of men with secondary education or higher.7 This disparity was even greater among women: only 37% of women with no education reported condom use with their last partner, compared to 85% of those with secondary education or higher.7 Better and more recent population-based data are necessary to further analyze market equity. ● Source: BAIS III7,8 36.8% 51.7% 43.6% 50.8% 65.0% 55.3% 89.4% 85.9% 84.2% 75.7% Evidence suggests that levels of condom use are lower among the poor. CONDOM USE BY EDUCATION STATUS IL L U S T R A T IV E O P T IO N S 51% of men with no education reported using a condom7 37% of women with no education reported using a condom7 TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 17 Challenges and Opportunities S ince 2006, there has been substantial growth in the Botswana condom market, mainly due to the number of free condoms available. There are several opportunities for improvements to meet the country’s need for male condoms while improving equity and sustainability, and increasing informed demand. Two national strategies, the Botswana National Condom Strategy and the National Condom Marketing and Implementation Strategy, were recently adopted, indicating a promising start for bringing stakeholders together to increase informed demand for condoms and strengthen the total market. Although condom use increased between 2004 and 2008, continued high rates of use are necessary to achieve the national goal of no new HIV infections by 2016. This study was limited by a lack of available recent survey data. As a result, we could not analyze trends in condom use over the last five years or make specific recommendations about whom to target or how the market should adapt to reach populations with low levels of use. The market suffers from a lack of consistent promotion and education for condoms. Although behavior change communication campaigns have been implemented in the past, they are not often sustained. This can weaken brand perception and contribute to inconsistent condom use. Condoms are a cornerstone of HIV prevention and it is important that adequate funds are allocated for long-term promotion of free condom brands. GAPS AND BARRIERS ■ Inconsistent promotion of condom use ■ Limited understanding of free condom distribution channels ■ Lack of available survey and distribution data ■ Continued reliance on subsidized (free) condoms ■ Lack of technical capacity to execute targeted campaigns © C O R B IS TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 18 Concerns about sustainability have motivated the social marketing sector to move into the commercial sector, which means that the public sector must adapt and more effectively distribute free condoms to the poor and key populations at risk. Currently, there is little information collected on free condom distribution and it is unclear which consumers are being reached with free condoms. A better understanding of distribution would allow the government to ensure that free condoms are provided to those most in need and unable to pay. The change to a cost recovery model for the social marketing sector indicates progress toward sustainability. Approximately 20% of the market will be self-sustaining in 2015, compared to only 5% in previous years. However, the majority of the market continues to be fully subsidized by the government and international donors. Improved targeting and marketing by the social marketing and commercial sectors could improve willingness to pay for condoms and thereby decrease reliance on free condoms among those who are able to pay. In turn, subsidies would be used more efficiently with the transition of current users of free condoms to commercial brands. ● IL L U S T R A T IV E O P T IO N S TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 19 Recommendations Our research yielded the following recommendations for policymakers, donors and other stakeholders. Recommendations come from a TMA perspective and are intended to support the three sectors – public, social marketing, and commercial – to work together to grow and sustain Botswana’s condom market. INCREASING INFORMED DEMAND Due to the high prevalence of HIV in Botswana, it is critical that rates of condom use remain high. Additional condom promotion and behavior change communication are important. Marketing and promotion of free condom brands is one way to increase informed demand. Additional market research is required to assess the need for a government condom specifically targeted to youth. It is important that adequate funding be allocated for long-term maintenance of the brand. Sustained funding is necessary to strengthen overall brand perception and ensure that levels of condom use remain high. EQUITABLE DISTRIBUTION Free condoms should be targeted at those most in need and unable to pay. Effective targeting and a stable supply of free condoms could improve equity by helping to ensure that subsidies are reaching the poor. IMPROVING SUSTAINABILITY Long-term sustainability of the market requires that those with an ability to pay for condoms purchase unsubsidized condoms rather than relying on free condoms. Private corporations that currently provide free condoms should be encouraged to buy unsubsidized condoms. Data on free condom distribution would help identify which providers should be purchasing condoms. ENSURING PRODUCT QUALITY While the public and social marketing sectors are subject to rigorous quality standards, the commercial sector is not required to meet the same standards. As the market expands, it will be important to ensure that all condoms meet World Health Organization (WHO) quality standards. A national condom regulation protocol and clearly defined requirements for condoms would make it easier for private companies to enter the market. Additionally, condom suppliers that meet quality standards could be prequalified to start distribution and improve market efficiency. MONITORING MARKET PROGRESS To ensure that the condom market is improving, it is important to monitor progress at both the national and district levels. A human resource for condoms within the MOH would allow for ongoing monitoring and reporting of condom activities, but funds are needed for this position. Consistent reporting by all stakeholders is also necessary for monitoring market progress. REPORTING Improved reporting systems are required for forecasting how many condoms are needed on the market. Consistent reporting would facilitate efficient and effective decisions by the government, donors, and other stakeholders. A common data repository might be one way for sectors to work together to share select information that would benefit the total market. Information on dual protection and other TMA metrics should also be collected in national surveys. This information would permit more accurate estimates for the universe of need for male condoms and other market indicators. In addition, information about dual protection could help inform targeted distribution for HIV prevention and family planning sites. ● TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 20 Acronym Key BAIS Botswana AIDS Impact Survey BDF Botswana Defense Forces BWP Botswana Pula CDC United States Centers for Disease Control and Prevention CMS Central Medical Stores COGS Cost of goods sold CSO Botswana Central Statistics Office DHMT District Health Management Team FP Family Planning MOH Ministry of Health NACA National AIDS Coordinating Agency NGOs Non-governmental organizations PSI Population Services International STIs Sexually Transmitted Infections TMA Total Market Approach UN United Nations UNFPA United Nations Population Fund UoN Universe of need USAID United States Agency for International Development USD United States Dollars WHO World Health Organization Acknowledgements We would like to acknowledge those who contributed to this case study, including: Dejus Abreu – Head of Consumer Marketing, PSI/South Africa Goabaone Badisang – Senior Service Delivery Officer, BOFWA, Botswana Doug Call – Regional Director, Southern Africa, PSI Aisha Camara-Drammeh – Country Representative, UNFPA, Botswana Chrissy Carmody – Technical Services Advisor, PSI/Botswana Collin Chengapar – Head of Sales, PSI/South Africa Jennifer Christian – Global Social Marketing Advisor, PSI Adebayo Fayoyin – Regional Communications Advisor for South and East Africa, UNFPA Ghairunisa Galeta – Regional Project Coordinator, PSI/South Africa Anabel Gomez– Technical Advisor for Social Marketing, Southern Africa, PSI Richard Harrison – Executive Director, PSI/Botswana Krishna Jafa – Vice President, Sexual and Reproductive Health and TB, PSI Agai Jones – Regional Representative, PSI/South Africa Kabo Kagiso – Research Manager, PSI/Botswana Elizabeth Koko – Principal Health Officer, Ministry of Health, Botswana Kago Kwadiba – Sales Manager, PSI/Botswana Ben Light – Senior Technical Advisor, UNFPA Brian McKenna – Deputy Regional Director, Southern Africa, PSI Regina Moore – Manager, Communications, PSI David Nowitz – Head of Customer Marketing, PSI/South Africa Maria Sese Paul – Graphic Designer, Streetsense Elena Pirondini – Special Assistant to the Deputy Executive Director, UNFPA Amy Ratcliffe – Senior Technical Advisor, Metrics, PSI Meghan Reidy – Technical Advisor, Metrics, PSI Guy Rogers – General Manager, PSI/South Africa Lillian Setimela – Strategic Partnerships Manager, PSI/Botswana John Stover – President, Futures Institute Kanyanta Sunkutu – Programme Specialist, HIV/AIDS, UNFPA Noah Taruberekera – Regional Researcher, Southern Africa, PSI Kabo Tautona – National Program Officer, Sexual and Reproductive Health, UNFPA, Botswana Renata Tallarico – Project Coordinator, UNFPA Jagdish Upadhyay – Chief, Commodity Management, UNFPA David Walker – Director, Global Social Marketing, PSI Josiane Yaguibou – Technical Advisor, Reproductive Health and Commodities Security, UNFPA TOTAL MARKET APPROACH CASE STUDY | BOTSWANA 21 REFERENCES 1. O'Sullivan G., C. Cisek, J. Barnes, and S. Netzer. May 2007. Moving Toward Sustainability: Transition Strategies for Social Marketing Programs. Bethesda, MD: Private Sector Partner- ships-One project, Abt Associates Inc. 2. USAID. 2011. Couple Years of Protection (CYP). Retrieved from http://transition.usaid.gov/our_work/global_health/pop/ techareas/cyp.html 3. UNAIDS Investment Framework Study Group. 2013.Risky acts estimates. 4. United Nations Population Division, 2010 Revision. 5. Guttmacher Institute. 2011. Adding it up: the costs and ben- efits of investing in family planning and maternal and newborn health. Estimation Methodology. 6. Government of Botswana and the Central Statistics Office. 2009. 2008 Botswana AIDS Impact Survey III. Retrieved from http://www.hiv.gov.bw/sites/default/files/documents/baisiii_ report%5B1%5D.pdf. 7. Government of Botswana and the Central Statistics Office 2008. Botswana AIDS Impact Survey 2008. Permission to use data granted April 2013. 8. Central Statistics Office. 2005. Botswana AIDS Impact Survey II. Retrieved from http://www.hiv.gov.bw/sites/default/files/ documents/stats_report%5B1%5D.pdf. 9. PSI Research Division. 2011. "TRaC Study on Condom Social Marketing Among Adults 18-34 Years: Monitoring, Segmenta- tion, and Brand Analysis, Round Three." PSI Social Marketing Research Series. 10. PSI/Botswana. 2013. Annual distribution reporting data 2006-2012. 11. Central Medical Stores (CMS). 2013. Item consumption by generic items: CON001 condoms male plain, latex, 100's. Unpublished report. 12. PSI/Botswana and PSI/South Africa. 2013. Prices: social mar- keting condoms. 13. PSI/ Botswana. 2012. Review of condom brands. 14. PSI/South Africa. 2013. Cost of goods sold estimates for male condoms. 15. Ministry of Health of the Republic of Botswana. 2011. 2011 Botswana Second Generation HIV/AIDS Antenatal Sentinel Surveillance Technical Report. Retrieved from http://www.hiv. gov.bw/sites/default/files/documents/2011%20ANC%20SS%20 Report.pdf. 16. UNAIDS. 2012. World AIDS Day Report 2012. Retrieved from http://www.unaids.org/en/media/unaids/con- tentassets/documents/epidemiology/2012/gr2012/ JC2434_WorldAIDSday_results_en.pdf. 17. National AIDS Coordinating Agency of the Republic of Botswana. 2012. Progress Report of the National Response to the 2011 Declaration of Commitment on HIV and AIDS. Retrieved from http://www.unaids.org/en/dataanalysis/ knowyourresponse/countryprogressreports/2012countries/ ce_BW_Narrative_Report.pdf. 18. Ministry of Health. 2012. National Condom Strategy and Implementation Plan 2012-2016. Gaborone, Botswana. Retrieved from http://www.hiv.gov.bw/sites/default /filesdocuments/National%20Condom%20Strategy% 202012-2016_0.pdf. 19. World Bank. 2012. Indicators. Retreived from www.data.worldbank. org. 20. TheGlobalEconomy.com. 2013. Economy indicators: Inflation rates. Retrieved from www.theglobaleconomy.com. UNFPA HEADQUARTERS 605 Third Avenue New York, New York 10158 USA Telephone: + 1-212-297-5000 Fax: + 1-212-370-0201 Website: www.unfpa.org UNFPA BOTSWANA United Nations Building, First Floor Cnr Khama Crescent/President's Drive Government Enclave Gaborone, Botswana Telephone: +267-391-4753 Website: botswana.unfpa.org PSI HEADQUARTERS 1120 19th Street, Suite 600, NW Washington, DC 20036 USA Telephone: +1-202-785-0072 Fax: +1-202-785-0120 Website: www.psi.org PSI/BOTSWANA PSI/Botswana Private Bag 00465 Gaborone, Botswana Telephone: + 267-318-5029 Fax: + 267-318-5029 Website: www.psi.org/botswana Botswana
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