CMS- The Commercial Market Strategies Project: Final Report 1998-2004

Publication date: 2004

The Commercial Market Strategies Project Final Report 1998–2004 The CMS Project, in partnership with the private and commercial sector, contributes to improved health by increasing the use of quality family planning and other health products and services. The Commercial Market Strategies Project Final Report Robert Bonardi Ruth Berg, PhD Susan Mitchell COMMERCIAL MARKET STRATEGIES Commercial Market Strategies (CMS) is the flagship private-sector project of USAID’s Office of Population and Reproductive Health. The CMS project, in partnership with the private sector, works to improve health by increasing the use of quality family planning and other health products and services. In partnership with: Abt Associates, Inc. Population Services International THIS PUBLICATION FINANCED BY USAID This publication was made possible through support provided by the Bureau of Global Health, Office of Population and Reproductive Health, United States Agency for International Development (USAID) under the terms of Contract No. HRN-C-00-98-00039-00. The views and opinions of authors expressed herein do not necessarily state or reflect those of USAID or the US Government. ADDITIONAL COPIES Commercial Market Strategies Project 1001 G Street NW, Suite 400W Washington, DC 20001-4545 Tel: (202) 220-2150 E-mail: DOWNLOAD Download copies of CMS publications at: ABOUT THE AUTHORS All of the authors are CMS project staff. Robert Bonardi is the Project Director; Ruth Berg is Director of Research, Monitoring, and Evaluation; and Susan Mitchell is Director of Country Programs. ii ACKNOWLEDGMENTS Many thanks to the entire CMS team, who contributed to the success of the project’s programs, special projects and initiatives, and research activities. We also wish to acknowledge the guidance and support of USAID’s Private- and Commercial-Sector Team at the Office of Population and Reproductive Health, comprising Susan Wright (Cognizant Technical Officer) and Shyami deSilva, Maggie Farrell, and Barbara Addy (Senior Technical Advisors). In addition, this report was made possible with the oversight and nurturing provided by Christine Prefontaine, CMS’s Communications Manager, and the editorial assistance of Rosemarie Phillips. PHOTO CREDITS Cover text Detail from a Goli ke Hamjoli advertisement in Northern India. Between 1999 and 2002, CMS’s Goli ke Hamjoli (Friends of the Pill) campaign increased the use of low-dose oral contraceptives among young urban women. Sales of all commercially available oral contraceptive brands increased by 42 percent, and surveys revealed positive changes in attitude and knowledge among both providers and consumers. Page 1 Curt Carnemark/World Bank. Page 13 © Guy Mansfield/Panos Pictures. Page 45 © CMS/Frank Feeley. Julius, the CMS/Health Partners Marketing Coordinator in Uganda’s Gulu district, talks to members of a rock-breaking co-op who have joined the community health plan. Page 59 Youth in Jamaica, courtesy of the Pan American Health Organization. Page 67 © Jeremy Horner/Panos Pictures. People peer out the window of their highland home in Fianarantsoa, Madagascar. Page 77 CMS/Elizabeth Gardiner. A drama performance raises awareness about the dangers of unsanitary birth practices and promotes CMS’s New Maama clean-delivery kit. In addition to brand-specific advertising for its social marketing products, the CMS project develops behavior change communications activities like this community drama. ABSTRACT The Commercial Market Strategies (CMS) project was the flagship private-sector project of USAID’s Office of Population and Reproductive Health (G/PRH). CMS was designed to increase the use of family planning and other health products and services through the private sector. From 1998 to 2004, CMS worked in 29 countries to develop and implement a wide range of country programs, technical assistance projects, new initiatives, and global research — all with the aim of expanding access of family planning products and services through commercial approaches and private-sector partnerships. The CMS Final Report provides a comprehensive examination of the technical strategies, accomplishments, results, and lessons learned from the project’s programs and activities. A major finding is that commercial organizations are a key resource for donors and development projects in accomplishing health sector objectives, particularly for family planning and reproductive health care. CMS programs involved partnerships with the private sector in a broad range of countries (including India, Morocco, Jordan, Senegal, Uganda, Ghana, Madagascar, Nepal, Nicaragua, and the Philippines), which resulted in improved access to, and quality of, family planning products and services. Through these programs, CMS provided consumers with valuable information about, and access to, essential health products, such as modern contraceptives, oral rehydration therapies, insecticide-treated malaria nets, treatment kits for sexually transmitted infections, and voluntary testing and counseling services for HIV/AIDS. This report also provides detailed information on the various technical strategies used by CMS, including social marketing, support for provider networks, health financing, sustainability for health care non-governmental organizations, corporate social responsibility, and policy. KEY WORDS Commercial Market Strategies, CMS, USAID, population, private sector, commercial sector, family planning, contraceptives, reproductive health, public-private partnerships, social marketing, sustainability, private providers, provider networks, social franchising, corporate social responsibility, policy, health financing. RECOMMENDED CITATION Bonardi, R; R Berg; and S Michell. 2004. Commercial Market Strategies Project Final Report. Washington, DC: USAID/Commercial Market Strategies Project. iii CONTENTS Abbreviations and Acronyms .v 1 Introduction .1 Purpose of the CMS Project .2 Results Framework.3 Technical Strategies.4 The CMS Portfolio of Program Activities.9 2 Country Programs: Achievements and Results .13 Madagascar: Private Distribution of Contraceptives .14 Senegal: NGO-Based Social Marketing .17 Morocco: Social Marketing Through Commercial Partnerships .20 Uganda: Integrated Private-Sector Program.23 India: Integrated Behavior Change Campaign.28 Nepal: Provider Networks.31 Nicaragua: Integrated Clinic Network.34 Ghana: NGO and Corporate Programs .37 The Philippines: Contraceptive Security and Private-Sector Strategies.41 3 Technical Assistance Projects .45 Technical Assistance to NGOs.46 Contraceptive Security Assessments .49 Summa Loans to Private Providers.51 Health Financing .53 Corporate Partnerships.54 The Commercial Market Strategies Project Final Report September 2004 iv Contents 4 Findings From CMS Global and Technical Research .59 Contraceptive Security.60 Health Financing .61 Behavior Change Communications and Social Marketing .61 Youth.63 Corporate Social Responsibility .63 5 Lessons Learned.67 Social Marketing.68 Private Providers .70 NGO Sustainability.71 Health Financing.71 Corporate Social Responsibility .73 Improving the Policy Environment.73 References .77 FIGURES 1 The CMS project results framework .5 2 Protector, Pilplan, and Confiance CYPs (in thousands) .17 3 Morocco: Sales of Kinat Al Hilal oral contraceptives, 1992 to 2003 .21 4 Uganda: Sales of SmartNets, 2000 to 2003 .27 5 (a–c) Uganda: Likelihood of using contraception, by whether respondent recalled CMS ad, 2002.28 6 Nepal: Average daily client flow .34 7 Nicaragua: Clinic Network Structure.35 MAPS 1 Countries where the CMS project worked, 1998 to 2004 .10 2 Countries with CMS country programs and technical assistance initiatives (funded by USAID Missions) .11 3 Countries with CMS core-funded initiatives.11 4 Countries with Summa Foundation loans.11 5 Nine CMS countries that demonstrate the project’s technical breadth and strategic synergies.15 vFinal Report ABBREVIATIONS AND ACRONYMS ADEMAS Agency for the Development of Social Marketing (Senegal) ADOPLAFAM Asociación Dominicana de Planificación Familiar (Dominican Republic) AIDS Acquired Immune Deficiency Syndrome AIDSMark Acquired Immune Deficiency Syndrome Social Marketing project ARV Antiretroviral BCC Behavior change communications BEMFAM Sociedade Civil Bienestar no Brasil CA Cooperating agency CAPS Commercial- and Private-Sector Strategies CELSAM Centro Latinoamericano Salud y Mujer (Mexico) CMS Commercial Market Strategies CSR Corporate social responsibility CYP Couple year of protection DHS Demographic and Health Survey EC Emergency contraception ECOP Employer’s Confederation of the Philippines EMP Empresas Medicas Previsionales (Nicaragua) FCFI Friendly Care Foundation, Inc. (Philippines) FOGSI Federation of Obstetricians and Gynecologists of India FP Family planning FPOP Family Planning Organization of the Philippines HAART Highly active antiretroviral therapy HIV Human Immunodeficiency Virus HMO Health maintenance organization IEC Information, education, and communication IFPS Innovations in Family Planning Services (India) INSS Nicaraguan Social Security Institute IR Intermediate result ITN Insecticide-treated net IUD Intrauterine device JHUCCP Johns Hopkins University Center for Communications Program JSI–WFC John Snow, Inc.–Well Family Clinic KSM Key Social Marketing (Pakistan) LAC Latin and Central America MCH Maternal and child health MOH Ministry of Health MUCH Mothers Uplifting Children’s Health (Uganda) NFCC Nepal Fertility Care Center NFPB National Family Planning Board (Jamaica) NGO Non-governmental organization OC Oral contraceptive ORS Oral rehydration salts PACT–CRH Program for Advancement of Commercial Technology–Child and Reproductive Health (India) PAI PharmAccess International (Netherlands) PBC Philippine Business Conference PCCI Philippine Chamber of Commerce and Industry PHRPlus Partnerships for Health Reform Project Plus PMAC Population Management Action Center PMAP Personnel Management Association of the Philippines PRH USAID Office of Population and Reproductive Health PROFIT Promoting Financial Investments and Transfers project PSI Population Services International PSSN Parivar Swasthya Sewa Network (Nepal) PTC Post-test club (Uganda) RH Reproductive health RHAC Reproductive Health Association of Cambodia RPMCHAP Responsible Parenthood and Maternal and Child Health Association of the Philippines SIFPSA State Innovations in Family Planning Services Agency (India) SMC Social Marketing Company (Bangladesh) SO Strategic objective SOMARC Social Marketing for Change Project SPARCHS Strategic Pathways for Reproductive Health Commodity Security SPHC San Pablo Hospital Complex (Peru) STI Sexually transmitted infection TA Technical assistance TAG Technical Advisory Group TIPPS Technical Information on Population for the Private Sector project UHC Ugandan Health Cooperative UNFPA United Nations Population Fund UNICEF United Nations Children's Fund UPMA Uganda Private Midwives Association USAID United States Agency for International Development VCT Voluntary counseling and testing WHO World Health Organization WHO–ORS World Health Organization–oral rehydration salts Introduction 1 Introduction INTRODUCTION The Commercial Market Strategies (CMS) Project is the United States Agency for International Development’s flagship project to increase the use of quality family planning and other health products and services through private-sector partners and commercial strategies. CMS began operations in October 1998 under a five-year contract (HRN-C-00-98-000-39-00) issued by the United States Agency for International Development (USAID) to the Emerging Markets Group of Deloitte Touche Tohmatsu. With strong private-sector development experience, Deloitte pro- vided overall management for CMS. Additional consortium members included Abt Associates, Inc., which provided expertise in the areas of research, monitoring and evaluation, and health care finance; and Population Services International (PSI), which implemented innovative social marketing programs that encouraged healthy behavior and promoted access to affordable health products. CMS also collaborated with other health sector cooperating agencies (CAs) to implement country programs and technical initiatives, including The Futures Group International, Meridian Group International, Family Health International, Tulane University, and EngenderHealth. This final project report covers the original contract period through September 2003 and contract exten- sions through September 2004. Due to the extensive scope of the CMS project, this document does not detail every project activity, but instead focuses on key results and contributions of the CMS project in three main areas: the larger and more significant country programs, technical assistance and core-funded initia- tives, and CMS global research and technical studies. For more details about activities, readers may refer to the CMS technical, research, and other publications contained in a special CD-ROM to be issued in September 2004. (Publications may also be down- loaded from the CMS web site, PURPOSE OF THE CMS PROJECT USAID’s Office of Population and Reproductive Health designed the CMS project in 1998, under the Commercial- and Private-Sector Strategies (CAPS) Results Package. CMS was designed to address a pro- jected global surge in demand for family planning and reproductive health services that is expected to exceed available public-sector and donor resources. According to United Nations Population Fund (UNFPA) estimates, the number of people in the developing world who will need family planning goods and services by 2015 will increase dramatically — by an estimated 217 million people. Donors and govern- ments already have difficulty meeting developing countries’ reproductive health needs. To meet the anticipated increased need for products and services, additional resources are needed from such sources as private households, employers, and insurers. USAID has long recognized the private sector’s sig- nificant potential both to enhance the supply and use of quality family planning and reproductive health (FP/RH) goods and services and to advance popula- tion and health goals. USAID began promoting the delivery of family planning services through the pri- vate sector in the mid-1980s, supporting both non- profit and commercial-sector approaches. From 1985 to the present, the numerous USAID projects making voluntary family planning goods and services available through private and commercial channels have included efforts to expand the demand and supply of family planning products through social marketing programs, the creation and promotion of provider networks to expand clinical services, and support for employer-financed and other work-based family planning programs.1 USAID also provided financing and credits to private providers and hospitals to expand the supply of family planning and maternal and child health (MCH) services. These efforts underscored the importance of expand- ing the private sector’s role in the provision and financing of FP/RH and other health services world- wide. In many developing countries, the private sec- tor already delivers most basic preventive and curative health services. Traditionally, however, the provision of family planning and other basic health services in developing countries was regarded as the concern of the public sector and the donor community. Although the commercial sector now provides a dom- inant share of health care services for consumers in developing countries, including those with lower 1 Predecessor private-sector family planning projects to CMS included Social Marketing for Change (SOMARC), Enterprise, Technical Information on Population for the Private-Sector (TIPPS), and Promoting Financial Investments and Transfers (PROFIT). 2 Commercial Market Strategies Project Introduction 3Final Report incomes, only an estimated 33 percent of family plan- ning users outside China and India obtain contracep- tives from commercial sources. With the onset of global health care reform, opportunities have emerged for the commercial sector and non-governmental organizations (NGOs) to play a more pivotal role in delivering such services. Seizing this opportunity, USAID designed CMS to implement programs and strategies that go beyond the traditional social marketing of contraceptives by forging new partnerships with the commercial organ- izations involved with health care service provision. For example, CMS was to expand the delivery of reproductive health services through private provider networks, explore new health care financing mecha- nisms to expand access to services, and broaden social marketing strategies by diversifying commercial health products and creating demand. Moreover, CMS was given a mandate to improve the policy environment to enable the private sector to have a more significant role in delivering basic health and family planning services in underserved markets, as well as to new consumers. By increasing the quality and affordability of private reproductive health products and services, CMS was to “shift” clients away from free or subsi- dized services in the public sector — thereby reducing the financial burden on governments and donors and allowing them to better address the needs of poor and underserved populations. RESULTS FRAMEWORK The CMS project had a dual focus: • to respond to USAID Mission country-specific needs and resources, as well as to support their strategic objectives, and • to support USAID Office of Population and Reproductive Health (PRH) mandate to provide technical leadership and develop effective, inno- vative responses to health needs. To fulfill this dual mandate, CMS developed and implemented • broad-based country programs, in response to USAID Missions’ objectives, • technical assistance projects, to support USAID Missions and local private-sector organizations active in the field of reproductive health, and • initiatives and research activities funded by the Office of PRH, to test new approaches and private-sector mechanisms for achieving repro- ductive health outcomes and to disseminate the findings from these initiatives and research. The CMS strategic objective (SO) was increased use of high-quality family planning and other health products and services through private- sector partners and commercial strategies. To achieve this SO, the CMS framework outlined three strategies: creating demand for family planning and other health products and services, managing supply, and improving the environment for private- sector participation. CMS was to create partnerships with both commercial (for-profit) and non-profit organizations, which together encompass the “pri- vate” sector. Building on the social marketing models implemented under predecessor USAID projects, CMS was to expand the “product” focus of family planning programs to develop private provider net- works and employer-based services and to explore health financing alternatives as a way of addressing family planning and reproductive health within the context of broader service delivery. To achieve its SO, the project pursued three inter- mediate results (IRs): IR 1: Increasing the demand for family planning and other health products and services from the pri- vate sector, IR 2: Increasing the supply of quality family planning and other health products and services through commercial approaches, IR 3: Improving the environment for the sustainable delivery of family planning and other health products and services through the private sector. IR 1 sought to increase demand for family planning and other health products and services through sus- tainable partnerships with the private sector. The proj- ect was to develop activities that (1) generated demand, (2) were consistent with the particular country’s social and cultural values, and (3) reflected consumers’ abil- ity to purchase or access these products and services. The cornerstone for increasing demand was to apply tested social marketing techniques and to focus on changing consumers’ behaviors to consider utilizing health products and services. Additional approaches involved making products and services more afford- able and getting users who were able to pay for servic- es to switch from the public to the private sector. IR 2 addressed issues related to the supply of health products and services. These included (1) improving the quality of products and services delivered through the private sectors; (2) developing new sources of sup- ply (wholesalers, retailers, distributors, and providers) and service methods in order to increase geographic access and expand the variety of products in under- served urban and rural markets; (3) creating third- party payment mechanisms to shift the burden for payment from consumers to insurance or employ- ers; and (4) helping for-profit and non-profit providers improve their ability to sustain their pri- vate practices. IR 3 entailed addressing policy, legal, and regulatory barriers impeding the involvement of the private and commercial sectors in the delivery of health products and services. The thrust of this IR was to create the necessary conditions that would motivate the com- mercial sector to enter new markets or deliver new products and services without undue restraints or regulation from the government. The ultimate aim was to create the “enabling” environment for private- sector participation and to allow demand and supply mechanisms to work in developing markets. IR3 called upon CMS to address policy, legal, and regula- tory barriers affecting demand (e.g., free or subsi- dized products from the public sector, regulation on brand advertising, and restrictions on dissemination of information) as well as supply (e.g., import regu- lations and taxes, policies on provider licensing and quality of care, access to credit or foreign exchange, and laws impacting the creation of third-party pay- ment mechanisms for family planning and other health products and services). TECHNICAL STRATEGIES To address the key issues and challenges posed by the SO and three IRs , CMS defined an integrated approach that combined a range of technical strate- 4 Commercial Market Strategies Project gies. These technical strategies were utilized to design country program interventions implemented with funding from USAID Missions. CMS also utilized core funding from USAID/Washington to develop innovative pilot programs and initiatives, all of which were organized around these technical approaches. The technical strategies involved the following major areas of activity: social marketing, working with pri- vate providers and networks, strengthening NGOs, developing new sources of health financing, promot- ing corporate social responsibility, and improving the policy environment. In addition, the CMS project provided loans to commercial providers and health care NGOs through the Summa Foundation, in order to improve quality of services and the financial sustainability of providers. The relationship of these seven strategies, discussed below, to the intermediate results is shown in Figure 1. SOCIAL MARKETING In many CMS country programs, social marketing was the principal means for creating demand and increasing the use of products and services in the pri- vate sector, as called for under the SO and IR 1. Social marketing had been validated as a proven tech- nique for promoting the use of modern family plan- ning products in a broad range of developing coun- tries. From its inception, CMS was called upon to take over a large number of existing social marketing programs that had been part of the SOMARC Project, including programs in Uganda, India, Morocco, Jordan, Nepal, Madagascar, Ghana, Jamaica, Turkey, Kazakhstan, and Uzbekistan. In these countries, CMS continued to implement and support social marketing programs to increase accessibility to a large range of health products and services and to promote the use of contraceptives and other products through behavior change campaigns, in order to achieve health impact in developing countries. CMS programs socially marketed a wide range of contraceptive products, including condoms, oral and injectable contraceptives, intrauterine devices (IUDs), oral rehydration salts, insecticide- treated nets, clean-delivery kits, and kits to treat sex- ually transmitted infections (STIs). Because expanding social marketing into FP/RH serv- ices was part of its mandate, CMS quickly began to use social marketing to promote not just products, but also Introduction the concept of private provider networks, which offered clinical contraceptive methods, such as IUDs and injectables, and clinics that provided voluntary counseling and testing services for HIV/AIDS. As had the predecessor projects, CMS used a continuum of social marketing models that reflected both the coun- try’s economic and social conditions and the realities of the market for family planning. In countries with low disposable incomes, primarily sub-Saharan African countries, CMS adopted the “distribution model,” working in partnership with a local NGO, or by direct distribution through a dedicated sales force, to distrib- ute and market products. In middle-income countries, with more vibrant and established private health sec- tors, CMS partnered with pharmaceutical manufactur- ers and local distributors and retailers to promote affordable products through established commercial channels, while conducting generic demand-creation activities. Social marketing programs were the starting point to establish or strengthen networks of private providers, both commercial and non-profit, and to work directly with private providers to improve the quality of their services. The CMS social marketing work also led to CMS’s involvement in contraceptive security issues confronting a number of countries. PRIVATE PROVIDERS AND NETWORKS In order to increase the supply of quality products and services under IR 2, CMS worked with a wide range of private providers, including physicians, midwives, nurses, and pharmacists. Strengthening their capacity and improving their technical capabili- ties was seen as essential for increasing the supply of FP/RH services and for increasing the demand among consumers for these services. Private providers are widely used for a range of child, reproductive, and communicable health problems. A number of studies have suggested that they are more responsive, conveniently located, and sometimes less costly than public providers, and they are used by patients from all socioeconomic groups. Private providers offer opportunities to draw in additional resources for scaling up access to essential health interventions and may allow public-sector resources to be better targeted to priority services and popula- tion groups. However, studies of malaria, STIs, tuberculosis, and reproductive health services have documented a range of problems with private provision of services. The technical quality of care provided varies widely; the distribution of certain types of providers is biased toward urban areas; and private providers are con- strained to work within a commercial logic. There is mutual mistrust between the public and private sec- tors; government relations with the private sector are characterized by a history of strategies of control, rather than partnership and collaboration. Private providers are a diverse group: They have both for-profit and non-profit motivations; they may be highly trained and specialized professionals or less than fully qualified or unqualified; their 5Final Report Strategic Objective Increased use of high-quality family planning and other health products and services through private-sector partners and commercial strategies. Figure 1. The CMS project results framework Intermediate Result 1 Increased Demand Social Marketing Health Financing Intermediate Result 2 Increased Supply Private Providers & Networks NGO Sustainability Corporate Social Responsibility Summa Foundation Loans Intermediate Result 3 Improved Environment Policy > > > 6 Commercial Market Strategies Project organizations may be simple or complex; what they offer ranges from comprehensive services to simple provision of public health products; and the bound- ary with the public sector may be blurred due to vari- ous forms of dual practice. A clear challenge for expanding the supply of products and services in developing countries is the lack of organized groups of individual providers, many of which operate as small proprietorships with limited resources, poor management, and limited access to information or training to offer quality family planning services. In addition to providing technical training on family planning counseling and improving providers’ ability to dispense contraceptive methods, CMS also sought to increase their ability to attract new clients. CMS helped providers establish group practices and creat- ed and strengthened provider networks and franchis- es, operating under an umbrella brand name and offering a defined package of services at known prices. CMS also provided access to training, business management skills, linkages to reliable sources of contraceptives, and the promotion of services through branding and marketing. NGO SUSTAINABIL ITY The CMS contract put heavy emphasis on strengthen- ing NGOs. As providers of health products and servic- es to underserved and at-risk populations, NGOs pro- vide reproductive health products, services, and infor- mation to millions of individuals. They are a key com- ponent of civil society, pioneering innovative repro- ductive health approaches in their communities and launching services where governments are reluctant to do so. Many family planning and reproductive health NGOs face an uphill struggle for survival. Most are heavily dependent on donors; although donor funding levels for population programs have held relatively steady over the past two decades, the number of repro- ductive health NGOs has grown, leading to intense competition for funds. CMS’s philosophy for providing assistance on NGO sustainability was strongly business oriented: In order to support and maintain quality programs, it was essential to have a healthy financial base, solid governance, and long-term planning processes. CMS defined NGO sustainability as an organization’s ability to • improve its institutional capacity to continue its activities among target populations over an extended period of time, • minimize financial vulnerability and develop diversified sources of institutional and financial support, and • maximize impact by providing quality services and products. CMS helped NGOs gain business and financial man- agement skills essential for long-term financial sus- tainability. For example, NGOs learned to diversify sources of revenue, develop new product or service lines, restructure pricing, and reduce internal costs. Since organizations often lack the structure and over- sight systems to operate as money-making endeavors, CMS also helped managers and directors improve business systems and strengthen institutional stability. Assistance was tailored to the local economic and political environment, organizational priorities, and the specific circumstances of individual NGOs. CMS’s technical assistance therefore included indi- vidual consultations, workshops and training ses- sions, and user-friendly planning tools that included strategic plans, business plans, and feasibility studies. CMS’s goal was to leave each NGO with a set of busi- ness-oriented tools that the organization could use in working toward long-term sustainability. In providing this support, CMS not only had to con- front issues about reconciling the social missions of NGOs with taking a business-like approach for oper- ating their organizations, but also the question of how NGOs could avoid trade-offs between serving lower-income populations while trying to recover more costs in order to survive. Many NGOs also had to face the realities of their marketplace in order to retain clients, who were being drawn to free services from the public sector. Thus CMS was often called upon to resolve critical questions for NGOs faced with curtailed donor funding and little experience in com- peting in the marketplace to attract and retain clients. HEALTH FINANCING Solving payment and financing issues was a critical challenge for increasing both demand for and supply of family planning and other health services and prod- ucts. Under IR 1, CMS was to identify ways in which Introduction products and services could be made more affordable to consumers through various payment structures and service delivery models being implemented under health care initiatives in many developing countries. Such measures were key for attracting consumers with an ability to pay to the private sector. CMS was also tasked with identifying new third-party payment mechanisms to shift the burden of payment from consumers to other parties, such as employers or insurance models based on U.S. health maintenance organizations (HMOs). In addition, CMS looked at the specific issues related to payment for family planning, which traditionally has been regarded as a preventive health intervention falling under the auspices of public health systems or subsidized social marketing programs. Thus, it is unusual for family planning to be covered under pri- vate insurance plans, and even less so in developing economies, where private insurance plans are fairly new concepts or are only available to those working in the formal sector. An additional factor is that most of the target populations (low- and middle-income) for private-sector interventions still lack access to private insurance plans and the means to pay for coverage. CMS initially focused on expanding the coverage of FP/RH services through risk-pooling mechanisms – social, private, or community health insurance. CMS identified, developed, or assisted health financing schemes to expand the availability of private-sector services or to reduce the financial burden to con- sumers. CMS worked with providers, private insurers, community-based plans, and governments to explore ways of adding family planning as a covered benefit, or to improve the utilization of FP/RH services where coverage was available, but not widely utilized. For example, where commercial or community insurance plans were already in operation, CMS analyzed the costs and benefits of adding reproductive health serv- ices to the benefit package. CMS also provided tech- nical assistance to establish or expand community health insurance plans and worked with health care practitioners and provider networks to establish new services and pricing for family planning and repro- ductive health care. CMS also conducted research on the impact of health insurance coverage on family planning usage patterns, to determine how existing plans were influencing consumers’ FP practices. CORPORATE SOCIAL RESPONSIBIL ITY All over the world, companies are realizing that busi- ness means more than selling products or services. With the advent of the Internet and increased media focus on corporations, consumers have become more informed about companies’ social and environmental practices. Companies are recognizing that giving back to their employees, and to the communities in which they operate, is critical to long-term success; they are responding by incorporating outreach activities into their core business agendas. Growing corporate social responsibility (CSR) is causing corporations to look at their relationships with all stakeholders, including customers, employees, communities, owners/investors, governments, suppliers, and competitors. CMS pursued CSR opportunities to expand on the established practice of work-based and employer-sup- ported family planning programs implemented by predecessor projects such as Enterprise and TIPPS, among others. Unlike those early models, CSR pro- grams were designed to take advantage of corporate competencies, such as marketing and distribution resources, and to leverage them on behalf of develop- ment projects. CMS strategies to involve companies in 7Final Report All over the world, companies are realizing that business means more than selling products or services. With the advent of the Internet and increased media focus on corporations, consumers have become more informed about companies’ social and environmental practices. 8 Commercial Market Strategies Project CSR included technical assistance to help companies develop CSR policies, MCH programs at the work site, community outreach activities, and cause-related marketing campaigns. CMS also identified ways to involve NGOs in implementing CSR projects with local partners and to help companies establish rela- tions with local governments by addressing public health problems. CMS designed and implemented CSR activities for corporations and private organizations in a number of countries, with a focus on expanding family plan- ning and reproductive health services. Some of these efforts were initially small in size, such as developing corporate policies for women’s health benefits for Brazil’s largest association of corporations (Ethos). CMS managed to develop a broader, more cohesive CSR program in Ghana that involved a large number of companies and different models of participation, including technical assistance to several industry associations. In addition, corporate interest in addressing the HIV/AIDS epidemic in many devel- oping countries provided CMS with ample opportu- nity to create new partnerships with corporations as a way of supporting HIV/AIDS prevention and treat- ment programs. POLICY CMS’s policy activities supported IR 3 — improving the environment for the sustainable delivery of family planning and other health products and services through the private sector. Activities to change exist- ing laws, regulations, and policies included reform- ing laws and regulations, registering new products, and seeking exemptions for categories of products or providers, among others. Activities to make the envi- ronment more conducive to the private sector included promoting public-private dialogue and partnerships, clarifying the intent or impact of poli- cies, disseminating information about policies, and promoting dialogue on policy issues. Unlike other USAID projects, CMS worked in both public and private sectors, rather than just with the public sector. In the public sector, for example, it worked to reduce legal and regulatory barriers and improve governmental regulations for quality of care. In the private sector, CMS worked to involve private companies in population issues and in raising their awareness of their responsibilities to their employees and communities. On some issues — such as facilitat- ing government outsourcing of insurance or health services to the private sector — CMS worked in both the public and the private sector. This approach of working with private and commercial sectors to implement public policy is standard in the developed world, but still rare in the developing world. CMS worked on broader policy issues than simply reproductive health policy. This was important because very little of what impacts family planning is explicitly called “family planning policy.” For example, whether family planning is mandated for inclusion in health insurance programs is a matter of health policy. The issues impacting on this may have to do with policies on prevention or primary health care, rather than policies on family planning or reproductive health. The CMS policy approach targeted many categories of policy that had an impact on family planning. At CMS, policy activities were rarely stand-alone; they typically accompanied activities in other technical areas, as policy change could be crucial in allowing the technical activity to achieve its expected impact. CMS also linked policy to innovations in financing, sup- portive social marketing campaigns, and other inter- ventions related to a number of CMS technical areas. For example, product registration was often a necessary prerequisite to social marketing, and training of providers in clinical methods was dependent on the regulatory environment. These types of linkages led to more comprehensive, sustainable programs. THE SUMMA FOUNDATION Expanding access to financing for commercial providers and NGOs was an integral, cross-cutting tool of CMS. This was achieved through investments made by the Summa Foundation, an independent non-profit organization that provides loans and technical assistance to expand maternal and child health care and family planning. The Summa Foundation was established under the USAID- funded PROFIT project in 1992 and was designed to facilitate socially responsible investments in the private and commercial health sectors in developing countries, with an emphasis on family planning and reproductive health. The Summa Foundation, which worked jointly with CMS, supported commercial and private providers in a dozen countries to improve the quality of their services and to add MCH and family Introduction planning as part of their services. Summa expanded the supply of affordable family planning and other health products and services available to lower- and middle- income population groups. Summa used both finan- cial and technical assistance to accomplish this goal and leveraged other funds and resources for commercial family planning and health activities. Summa was a unique financial mechanism because of the variety of financing mechanisms at its disposal: direct loans, equity investments, and revolving loan funds. These various financing mechanisms enabled Summa to reach a broad range of companies, organi- zations, and individuals working in the private and commercial health sector. Summa was able to make direct loans to commercial companies, such as private clinics, HMOs, insurance companies, and product distributors. The intent of these investments was to expand and improve existing activities within the lower- and middle-income mar- kets or to encourage a company to enter these mar- kets for the first time. Summa also made direct loans to NGOs involved in product distribution or service provision to help them expand activities and increase their income-generating ability and thus improve sustainability and impact. In addition, Summa designed and financed revolving loan funds that pro- vided small or micro loans to individual health care providers, such as midwives, doctors, and pharma- cists. These revolving loan funds were established in partnership with local financial institutions and provider associations, thus giving Summa a mecha- nism to reach multiple borrowers with smaller loans. In order to maximize impact and ensure the success of its investments, Summa provided technical assistance along with its financing. Summa’s package of technical assistance – which addressed financial and institution management, health service delivery, and family plan- ning – distinguished it from other investment funds. THE CMS PORTFOLIO OF PROGRAM ACTIVITIES From October 1998 through September 2004, CMS worked in 29 countries, implementing integrated country programs, technical assistance projects, and core-funded initiatives. CMS also conceived and executed an innovative agenda of global and country- specific research studies, in addition to producing numerous technical papers on issues affecting the private sector’s role in family planning and repro- ductive health (see Map 1). The CMS program portfolio comprised • Country Programs. Larger, multi-year programs funded by USAID Missions usually were charac- terized by the presence of a CMS country office and resident advisors. Many of these programs involved implementation of several technical strategies over the course of the contract. • Technical Assistance. Smaller projects funded by USAID Missions were limited in duration or involved only one or two technical areas. Usually, these projects were implemented through short- term technical assistance and did not involve the presence of permanent CMS field staff. (Map 2 shows activities funded by USAID Missions — country programs and technical assistance.) • Core-Funded Initiatives. As part of its mandate to develop innovative approaches for sustainable health partnerships, CMS implemented core (PRH)-funded new initiatives. These initiatives included conducting country-specific assessments and special studies (e.g., market segmentation) and launching new partnership models that could be scaled up with USAID Mission resources. In addition, CMS received “special initiative” fund- ing to implement activities and research in certain cross-cutting topics, such as contraceptive security and adolescent reproductive health. (Map 3 shows core-funded initiatives.) Summa Foundation loans were part of many of these activities. Summa worked in tandem with CMS proj- ect staff in various countries (see Map 4) to provide financial resources and technical assistance to both commercial and NGO providers. In the pages that follow, Chapter 2 discusses selected country pro- grams in detail; Chapter 3 focuses on technical assistance projects and core-funded initiatives, and Chapter 4 summarizes findings from CMS global and technical research. 9Final Report 10 Commercial Market Strategies Project Introduction Map 1. Countries where the CMS project worked, 1998 to 2004 Armenia Bangladesh Brazil Cambodia Cameroon Dominican Republic El Salvador Ghana Honduras India Jamaica Jordan Kazakhstan Madagascar Mexico Morocco Namibia Nepal Nicaragua Nigeria Pakistan Paraguay Peru Philippines Senegal Tanzania Turkey Uganda Uzbekistan Over the course of the project, CMS worked in 29 countries: 11Final Report Map 2. Countries with CMS country programs and technical assistance initiatives (funded by USAID Missions) Map 3. Countries with CMS core-funded initiatives Map 4. Countries with Summa Foundation loans Armenia Bangladesh Brazil Cambodia Dominican Republic Ghana Honduras India Jamaica Jordan Kazakhstan Madagascar Morocco Namibia Nepal Nicaragua Pakistan Paraguay Peru Philippines Senegal Turkey Uganda Uzbekistan Bangladesh Brazil Cameroon El Salvador Ghana Jamaica Mexico Morocco Nicaragua Nigeria Pakistan Senegal The Summa Foundation disbursed loans in Cambodia, Dominican Republic, Ghana, Nicaragua, Peru, Tanzania, and Uganda. USAID Missions funded CMS country programs and technical assistance initiatives in 24 countries: CMS implemented core-funded initiatives in 12 countries: Country Programs: Achievements and Results 2 Country Programs: Achievements and Results 14 Commercial Market Strategies Project COUNTRY PROGRAMS: ACHIEVEMENTS AND RESULTS CMS worked in 29 countries over the life of the proj- ect, implementing both familiar approaches and newer, integrated programs that combined a number of technical strategies in order to maximize the poten- tial impact and achieve desired health outcomes. This section highlights nine country programs that demon- strated technical breadth and synergies in working with diverse private-sector partners (see Map 5). Although each program responded to the health needs of its country, and must therefore be understood in its par- ticular context, these programs are discussed here because they illustrate how the CMS technical strate- gies were utilized to address health conditions and challenges under the three IRs. The programs in Madagascar, Senegal, Morocco, Uganda, and India exemplify various approaches for implementing social marketing programs and achiev- ing results primarily under IR 1 (increasing demand) with respect to distribution models and collaboration with private-sector organizations. These programs dealt with supply-side issues by working with private providers and pharmaceutical firms. The programs in Nepal and Nicaragua focused primarily on IR 2 goals. They emphasized improving and increasing the sup- ply of products and services by implementing provider network models. CMS programs in Uganda, Ghana, and the Philippines featured collaboration with private companies, using the corporate social responsibility model. Health financing activities were prominent in Uganda and Nicaragua, while pol- icy initiatives were undertaken in Morocco, India, the Philippines, and Uganda (focusing on IR 3 goals). Summa Foundation activities were undertaken in Ghana, Uganda, and Nicaragua. MADAGASCAR: PRIVATE DISTRIBUTION OF CONTRACEPTIVES Madagascar is one of the least-developed countries in the world. Approximately three-quarters of the pop- ulation are poor and rural, and almost half are under 15 years old. Access to mass media is low, and only 10 percent of homes have electricity. Women have an average of six children. Access to contraception and other reproductive health services is limited, and people do not have information about family plan- ning options. As a result, there is a tremendous unmet need for family planning (the modern contra- ceptive prevalence rate was only 7 percent in 1997). CMS worked in Madagascar from November 1998 until March 2001 to improve reproductive health through private-sector strategies and programs. It worked to decrease HIV/AIDS and other STIs and to increase the use of modern methods of family plan- ning. While the official HIV-infection rate was only about 1 percent in 2000, it is believed to be underre- ported. Yet it is a potentially explosive problem. Conditions are ripe for the rapid spread of HIV/AIDS: In addition to widespread poverty and an increasingly transient population, the country has some of the world’s highest STI rates. The active syphilis rate for the population is close to 40 percent, and some three- quarters of high-risk women have at least one STI. CMS’s goal in Madagascar was to increase consistent condom use to prevent STIs and HIV/AIDS and to increase the use of modern family planning methods obtained from the private sector by using a compre- hensive approach to address both demand- and supply-side barriers to modern contraceptive use. The project focused on (1) improving product distri- bution; (2) developing behavior change and infor- mation, education, and communication (IEC) cam- paigns; (3) reaching high-risk youth; (4) increasing community-based sales and education; and (5) strengthening contraceptive supplies. IMPROVING PRODUCT DISTRIBUTION CMS revamped and expanded distribution systems for condoms and hormonal contraceptives. When CMS took over the project in 1998, Protector con- doms were sold directly to some 8,000 retailers, pri- marily in the capital of Antananarivo. CMS revamped the system so that retailers could purchase condoms from local wholesalers. This change allowed the project sales team to concentrate on other activities, such as merchandising, opening up new sales points and ensuring better coverage in non-traditional outlets that serve high-risk groups. CMS used mass media advertis- ing to improve awareness of the wholesaler network. The project also installed a new information system to measure sales by province and to assess the effec- tiveness of the distribution network. As a result of these activities, the project met its goal of increasing the availability of condoms by the end of March Country Programs: Achievements and Results 15Final Report Map 5. Nine CMS countries that demonstrate the project’s technical breadth and strategic synergies Madagascar Social marketing Supported private providers Improved contraceptive security Senegal Social marketing Improved the policy environment Morocco Social marketing Supported private providers Partnerships with pharmaceutical companies Improved the policy environment Uganda Social marketing Health financing Improved the policy environment Supported private providers Summa loans to midwives and three commercial firms India Social marketing Partnerships with pharmaceutical companies Improved the policy environment Nepal Assisted social marketing NGO Established and supported private provider networks Nicaragua Assisted social marketing NGO Established and supported private provider networks Summa loans to four organizations Ghana Technical and sustainability assistance to social marketing NGO Corporate social responsibility New health financing program for HIV treatment Summa loan to social marketing NGO Philippines Assisted social marketing NGO Assisted private providers Corporate social responsibility Improved the policy environment Assessed contraceptive security Commercial Market Strategies Project Country Programs: Achievements and Results 2001. The number of Protector retailers increased from 8,000 to 21,273, serviced by 639 wholesalers. Between 1998 and 2000, Protector sales increased more than 55 percent — from 3.4 million to 5.3 million. The CMS project also worked to expand the distribu- tion of socially marketed hormonal contraceptives. In 1998, distribution of Pilplan oral contraceptives (OCs) and Confiance injectables was limited to three cities. CMS took over promotion of the products from the distributor, which continued to oversee distribution with a focus on avoiding stock outages. CMS’s pro- motion strategy targeted providers, such as doctors, midwives, and pharmacists, and worked to improve their ability to offer accurate information on hor- monal contraceptives. CMS hired and trained a team of medical detailers to visit providers with informa- tion on Pilplan and Confiance. Point-of-sale materials were developed and given to providers and retailers to increase their motivation to stock the products and to indicate their availability to consumers. By March 2001, more than 1,000 providers had been trained in contraceptive technology and more than 16,000 detailing visits had taken place. More significant, Pilplan and Confiance were available in almost every pharmacy in the country. Between 1998 and 2000, annual sales of Pilplan more than quadrupled from 56,581 to 239,764 cycles. Sales of Confiance increased from 10,011 to 78,082 vials. BEHAVIOR CHANGE/ IEC CAMPAIGN CMS created a comprehensive behavior change cam- paign (BCC) to address the lack of knowledge about STI/HIV/AIDS. It worked to increase personal risk perception for HIV/AIDS, improve knowledge about the transmission and prevention of STIs and HIV/AIDS, and increase condom use. An IEC cam- paign was developed to promote hormonal family planning methods. It focused on providing accurate information and dispelling rumors about hormonal contraceptives. Both campaigns promoted healthy sexual choices by stressing abstinence before mar- riage, monogamy, and condom use – for the preven- tion of HIV/AIDS and unwanted pregnancy. TARGETING YOUTH Malagasy youth ages 15 to 24 are at particularly high risk for HIV/AIDS and unwanted pregnancy. CMS designed several program components to target this vulnerable group. Messages were conveyed through mass media and interpersonal communications (peer educators, providers, and mobile video) and empha- sized the importance of • abstinence before marriage, • being faithful to one partner, and • the correct and consistent use of condoms. In addition, CMS repositioned Protector condoms to target sexually active youth. CMS conducted focus groups with adolescents to identify barriers to condom use and preferences for a logo and package design. COMMUNITY-BASED SALES AND EDUCATION CMS increased the role of community-based sales and educational activities to expand the distribution network for contraceptives, as well as to increase access for underserved populations. CMS recruited a community-based sales coordinator who created edu- cation programs for military personnel, commercial sex workers, and employees of various organizations (including company doctors). Peer educators and community-based sales agents conducted educational sessions that reached over 13,200 high-risk people. CONTRACEPTIVE SECURITY As in many developing countries, fostering contra- ceptive security (assuring a reliable, long-term supply of contraceptives) was an important aspect of CMS’s activities in Madagascar. As a first step in promoting contraceptive self-reliance, CMS conducted a study examining the feasibility of supplying the 10 largest members of ASSONG, a Malagasy family planning association, with social marketing condoms, pills, and injectables. At the time, ASSONG clinics received free contraceptives from USAID. Following the rec- ommendations of the CMS study, however, USAID stopped providing free products and instead encour- aged ASSONG clinics to purchase and distribute CMS’s socially marketed products. To support this 16 change, CMS conducted contraceptive technology training sessions for doctors affiliated with the family planning clinics. As a result, ASSONG clinics moved from being passive recipients of donated products to active buyers — a key step toward developing the capacity for sustainable contraceptive management. For example, ASSONG clinics used their community health worker networks to distribute the socially mar- keted contraceptives to people in remote areas. PROGRAM RESULTS CMS’s creative and comprehensive strategy to address both demand- and supply-side barriers to modern method use in Madagascar had an impressive impact. Based on the 1997 Demographic and Health Survey (DHS) and the 2000 United Nation’s Children Fund (UNICEF) Multiple Indicator Cluster Survey, CMS con- tributed to improvements in the following areas: INCREASED CONTRACEPTIVE PREVALENCE. The prevalence rate for modern contraceptive methods increased from 7.3 percent in 1997 to 12 percent in 2000. INCREASED USE OF HORMONAL CONTRACEPTIVES. Use of OCs increased from 2.4 percent in 1997 to 3.3 per- cent in 2000, while the use of injectables increased from 4.7 percent to 6.7 percent. MORE COUPLE YEARS OF PROTECTION. While implement- ing the Madagascar program, CMS provided 160,618 couple years of protection (CYPs). Between 1999 and 2001, sales of Pilplan OCs increased 324 percent, sales of the injectable Confiance increased 680 percent, and sales of Protector condoms increased 55 percent (see Figure 2). IMPROVED KNOWLEDGE ABOUT STI/HIV/AIDS. Knowledge of STI/HIV/AIDS transmission and prevention improved dramatically. In 1997, 38 percent of women cited fidelity and 27 percent cited consistent condom use as the two main HIV prevention means. In 2000, 42.6 percent of women cited fidelity and 36 percent cited consistent condom use. SENEGAL: NGO-BASED SOCIAL MARKETING Senegal has experienced sustained economic growth since emerging from economic difficulties in the 1990s. Despite the encouraging growth rate, more than half of Senegalese families still live in poverty. Senegalese women bear an average of 5.2 children, and the annual population growth rate is 2.6 per- cent. Although contraceptive awareness is high, use of family planning remains low. In 1997, the contracep- tive prevalence rate was 12.9 percent (8.1 percent for modern methods). An estimated 33 percent of cou- ples who do not use contraceptives say they are inter- ested in family planning. Many factors limit the use of modern contraceptives, including frequent stock- outs, a shortage of urban providers, lack of informa- tion, strict regulations inhibiting promotion of health products, and religious and cultural barriers. The HIV prevalence rate is low in Senegal, due in part to high awareness of this infection and ways to prevent it. Awareness of other STIs, however, is low. Only 5 percent of men and 17 percent of women are aware of gonorrhea, the most common STI. CMS activities in Senegal included increasing access and expanding contraceptive choice, behavior change, and policy and advocacy. 17Final Report Figure 2. Protector, Pilplan, and Confiance CYPs (in thousands) 1997 1998 1999 2000 1st quarter 2001 0 2010 30 40 50 60 70 80 90 100 Protector condom Pilplan OC Confiance injectable CMS 18 Commercial Market Strategies Project SOCIAL MARKETING: INCREASING ACCESS AND EXPANDING CHOICE From 1999 to 2004, CMS implemented its activities in Senegal in partnership with the Agency for the Development of Social Marketing (ADEMAS), a local NGO with 14 years of experience in socially market- ing reproductive and other health products. To improve private-sector provision of family planning products and services, CMS provided technical assis- tance to ADEMAS in the areas of organizational development and financial sustainability. CMS/ADE- MAS promoted knowledge and use of condoms, with a focus on Protec (ADEMAS’s brand). To increase contraceptive choice, it also developed and intro- duced Securil, a low-cost OC. To improve consumer access, CMS/ADEMAS expanded Protec’s distribution beyond pharmacies (which are typically closed at night and on weekends) to non-traditional outlets such as nightclubs, gas sta- tions, and grocery stores. CMS/ADEMAS recruited and trained 10 Protec sales staff, who visited potential outlets and encouraged them to stock the product. The number of Protec outlets grew from 550 pharma- cies in 1999 to more than 3,000 outlets (pharmacies and non-traditional outlets) in 2003. Protec was originally launched as a family planning product, but CMS/ADEMAS positioned it also as an STI- and HIV-prevention product. CMS/ADEMAS launched a public relations campaign targeting wholesalers and retailers and trained more than 1,500 outlet staff on such topics as condom use, STIs and HIV, inventory management, interpersonal communication, and service quality. In addition, CMS/ADEMAS worked with the Union of Pharma- cists to update training manuals for pharmacists and counter clerks. Competitions and incentive programs further stimulated interest in the product. In April 2002, CMS/ADEMAS introduced Securil. At the time, only 3.3 percent of Senegalese women used oral contraceptives; and there were no low-cost OCs available through the private sector. The primary objective of the Securil program was to reduce Senegal’s high maternal mortality rate by providing women with a safe and reliable way to space births. To ensure that Securil would be affordable to the target audience (low- and middle-income women), CMS/ ADEMAS set the price based on an ability-to-pay analysis. CMS explored procuring the pills through a partnership with a pharmaceutical manufacturer, but the manufacturer could not reduce its prices suffi- ciently. CMS/ADEMAS then opted to use the USAID-donated pill Duofem as an affordable alterna- tive. Advertising and promotion for Securil highlight- ed the product’s proven safety record while address- ing public fears surrounding the pill. CMS/ADEMAS developed promotional and educational materials to build consumer confidence in oral contraceptives in general, and in Securil in particular. To minimize adverse reactions to the launch of Senegal’s first socially marketed oral contraceptive, ADEMAS held public relations events to inform partners and stake- holders about the campaign, including a press conference and a journalists’ workshop called “Contraception: A Factor of Well-Being.” The Securil campaign benefited from the resulting positive press coverage. Pharmacies in Dakar began stocking Securil two months before the official launch in early 2002. By that time, a CMS/ADEMAS team of five medical detailers and a product manager had already visited 90 percent of the city’s pharmacies and had begun visiting outlets in semi-urban areas to ensure broad geographic coverage. Over the course of the year, the team conducted 9,811 medical detailing visits, reach- ing OB/GYNs, general practitioners, midwives, nurses, and pharmacists. Detailers educated medical personnel about Securil and distributed materials (posters, pens, mobiles, prescription pads, and brochures) to promote high visibility for the product. The team reported enthusiastic responses from both pharmacists and providers. In addition, CMS/ADE- MAS introduced Securil to major medical organiza- tions, such as the Association of Gynecologists and Obstetricians and the Association of Midwives. BEHAVIOR CHANGE COMMUNICATIONS AND EDUCATION CAMPAIGN To promote awareness of Protec condoms, CMS/ ADEMAS created a comprehensive behavior change communications and education campaign. The campaign slogan was “Abstinence, Fidelite, sinon Protec” (“Abstinence, fidelity, if not Protec”). Youssou Ndour, a popular Senegalese singer, supported the campaign with a series of concerts in which he delivered AIDS- prevention messages highlighting the importance of condom use. He also appeared in Protec radio and Country Programs: Achievements and Results television ads and emphasized campaign messages in newspaper interviews. In addition, CMS/ADEMAS organized promotional campaigns for special events, such as the International Day against AIDS and the Soccer World Cup. In August 2001, CMS/ADEMAS partnered with Family Health International, Peace Corps, and the Sengalese Ministry of Health to produce a series of road shows around the theme “AIDS: I care…do you?” The shows, which reached more than 100,000 people nationwide, combined plays, skits, games, songs, and tassous (slogans repeated by the audience) to deliver HIV/AIDS-prevention messages. Heavy media coverage, radio shows, and 430 radio spots publicized the road shows and disseminated key messages. The campaign’s closing ceremony featured a 3,000- person march in Dakar. Following the march, local artists such as Youssou Ndour, Omar Péne, and Diarra Gueye addressed the audience and repeated the key messages of the campaign. National media covered the ceremony, and video footage was aired on the evening news. As a result of improved distribu- tion and the behavior change communications and educational campaign, Protec sales increased 66 per- cent between 1999 and 2003. POLICY AND ADVOCACY Senegal’s pharmaceutical sector is highly regulated — even changing the color of a product’s packaging can invalidate government certification. Also, it is illegal to advertise a specific prescription product. To guide the Securil campaign, CMS/ADEMAS conducted an in- depth assessment of the laws and precedents governing the prescribing, delivery, storage, and promotion of hormonal contraceptives. CMS/ADEMAS worked with the Ministry of Health (MOH) to create a technical committee of opinion leaders and public- and private- sector representatives to review the marketing strategy and support Securil’s launch. The committee carefully vetted all promotional materials and activities, ensur- ing that they were on target and culturally appropriate. PROGRAM RESULTS By focusing on improved product distribution, com- bined with a targeted brand and generic advertising and behavior change campaign, CMS/ADEMAS 19Final Report EDUCATING POTENTIAL SECURIL USERS The consumer brochure for Securil features an urban, middle-class family. The husband, a secondary target of the marketing campaign, says: “The pill for my family’s well-being.” The tag line reads: “A simple method for spacing births. For the good health of mother and child.” The brochure goes on to dispel common myths and rumors about oral contraceptives. 20 Commercial Market Strategies Project products and services. CMS worked toward this goal by socially marketing contraceptives and child health products and by providing training and support to private health care providers. The Moroccan MOH launched the country’s first contraceptive social marketing program in 1989. The goal of the program was to use the commercial sector to bring affordable contraceptives to low- and middle- income consumers. The program was established with USAID assistance, first through the SOMARC proj- ect and then through CMS. From 1998 to 2003, CMS managed and coordinated the Al Hilal family of contraceptive products, as well as Biosel, an oral rehy- dration solution. INCREASING THE MARKET FOR ORAL CONTRACEPTIVES The first socially marketed oral contraceptive was launched in 1992 under the name Kinat Al Hilal (Pill of the Moon), an umbrella brand for two moderately priced pills, Wyeth’s Minidril and Schering’s Microgynon. Although Moroccan law generally prohibits advertis- ing for branded pharmaceuticals, the Ministry of Health authorized the project to promote Kinat Al Hilal directly to consumers and even negotiated discounted commercial airtime with television and radio stations. In exchange for the promotional support, Wyeth and Schering agreed to lower the price of their oral con- traceptives by 20 percent. When CMS took over the project, it negotiated contributions from the two manufacturers in order to fund the production and airing of a new adver- tising campaign. Launched in April 2002, the cam- paign targeted women in rural areas, where unmet need is highest. It resulted in a 49 percent increase in sales of Kinat Al Hilal between 2001 and 2003 (see Figure 3). The social marketing of Kinat Al Hilal brands made a significant contribution to the development of a commercial market for oral contraceptives. Schering and Wyeth have expressed a commitment to keep social marketing prices low and to sustain advertising investments beyond the life of CMS. However, both companies believe that product sales will likely stag- nate if advertising does not continue. Because adver- tising of contraceptives by private companies is not permitted, CMS helped develop a partnership Country Programs: Achievements and Results succeeded in improving condom availability, sales, and use. It also succeeded in improving contraceptive options by introducing an affordable oral contracep- tive into the private-sector market. While significant increases in oral contraceptive use will take a long- term focused effort to overcome religious and cultur- al barriers and misinformation on hormonal contra- ceptives, the project was able to make an important first step in improving access, use, and choice: INCREASED CONDOM ACCESS. The Protec distribution network expanded from 690 outlets at the end of 1998 to 3,627 outlets at the end of June 2003. According to the nationally representative mid-term survey conducted by CMS/ADEMAS, 70 percent of male users said that they could access a Protec outlet within 15 minutes. LOCAL BRAND SUCCESSFULLY PROMOTED AS CONDOM OF CHOICE. Preliminary data indicate that 72.5 per- cent of men who usually use condoms use the Protec brand. Protec condom sales increased by 66 percent from 1998 to 2000 (2,351,410 sold in 1998; 3,909,900 in 2002). Moreover, compared to the 1997 DHS, condom use among men of reproductive age rose from 16.5 percent to 21 percent. INCREASED CONTRACEPTIVE CHOICE. Securil also increased the number of CYPs provided by CMS/ ADEMAS. During the first semester of 2003, CMS/ADEMAS contributed 21,250 CYPs, a 23 per- cent increase over the first semester of 2002. More than 21,700 cycles of Securil were sold in 2002, and 22,511 were sold during the first semester of 2003, making Securil one of the leading OC brands in the commercial market. MOROCCO: SOCIAL MARKETING THROUGH COMMERCIAL PARTNERSHIPS Morocco is a middle-income country with a popu- lation of nearly 30 million. The contraceptive prevalence rate rose from 19 percent in 1978 to 60 percent in 2000, with more than 60 percent of users opting for oral contraceptives. Although the public sector is the main provider of family plan- ning products and services, women are increasingly obtaining contraceptives from the private sector. CMS/Morocco’s objective was to increase the use of private-sector family planning and child health between the manufacturers and a local family plan- ning association, which supported social marketing activities after the end of the project. However, it is too early to know whether this model of sustainability will succeed without some measure of donor funding and implementation support. EXPANDING CONTRACEPTIVE CHOICE: INJECTABLES AND IUDS To expand couples’ choice of affordable methods of contraception, the Moroccan social marketing pro- gram introduced the Lawlab Al Hilal IUD and the Hoqnat Al Hilal injectable into the commercial market in 1997. CMS inherited both programs in 1999 and worked to increase the acceptability of these methods. Barriers to long-term contraceptive methods in Morocco included the high cost of IUD insertion at private facilities and strong resistance to injectables among both providers and the public. To address mispercep- tions among providers, CMS trained general practi- tioners in IUD insertion and in the management of side effects. Training sessions also included informa- tion on general reproductive health issues, the treat- ment of sexually transmitted diseases, and pregnancy management. CMS also published detailed articles in prominent medical magazines and held panel discus- sions at health events. To address user concerns, CMS aired radio and television advertisements and organized mahalla (community) meetings, which enabled women to discuss family planning methods with physicians. CMS reinforced the marketing of these products by developing agreements with the 21Final Report manufacturer of Hoqnat Al Hilal and the local distribu- tor of Lawlab Al Hilal that resulted in increased detail- ing of pharmacists and physicians in target areas. Despite substantial training and promotional efforts, demand for both IUDs and injectables remained disappointing. Sales of the injectable showed only a marginal increase from 2002 to 2003, and sales of the IUD peaked at 6,000 units in 1999, then dropped again. An assessment of the injectable and IUD social marketing program con- ducted in 2003 concluded that these products could not be graduated from donor support and would require continued investments in provider training and communication. CMS/Morocco demonstrated, however, that attitudes can change as a result of communication and training efforts, although efforts may have to be extensive and sustained. For example, an evaluation of CMS provider education sessions found that among those providers who participated in the sessions, only 55 percent expressed reluctance to recommend injecta- bles, compared with 69 percent in the control group. REDUCING INFANT MORTALITY THROUGH ORAL REHYDRATION Infant mortality is high in Morocco, and a leading cause of death is dehydration caused by diarrhea. To address this problem, Population Services Inter- national (PSI) introduced Biosel, a brand of oral rehydration salts (ORS), in 1990. This product was Figure 3. Morocco: Sales of Kinat Al Hilal oral contraceptives, 1992 to 2003 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 Cy cle s (in m ill io ns ) 1992 19941993 1995 1996 1997 1998 1999 2000 2001 2002 2003 Total OC Sales 22 Commercial Market Strategies Project originally developed with raw material donated by the United Nations Children’s fund (UNICEF), in part- nership with a local manufacturer, Cooper-Maroc. CMS took over the marketing of Biosel in 1998, airing new radio spots and creating a mobile video unit to promote Biosel and educate the public about diarrhea prevention and treatment. Between 1990 and 2000, the Biosel program helped reduce mortality among children under 5 from 112 per 1,000 to 53 per 1,000. This coincided with an increase in the use of ORS for children with diarrhea from 14 percent in 1992 to 19 percent in 2000. General awareness of ORS increased from 74 percent in 1994 to 87 per- cent in 2000. Together with its commercial partner, CMS explored strategies to ensure the financial sustainability of the brand. Large public-sector orders and growing con- sumer demand allowed for the creation of a return- to-project fund for Biosel. In August 2002, CMS and PSI signed a Biosel licensing agreement with Cooper- Maroc that transferred full management of the prod- uct to the company. The agreement guaranteed a yearly production of at least 360,000 packets, com- pliance with World Health Organization (WHO) quality standards, and a 2.75 percent yearly cap on price increases. Assistance from CMS helped strength- en local production capacity and re-launch Diarit, Cooper-Maroc’s own brand of commercial ORS. PROGRAM RESULTS The manufacturer’s model clearly succeeded in Morocco, though not all products fared equally well. Oral rehydration salts and oral contraceptives had considerable success, benefiting from favorable mar- ket conditions, which allowed them to become com- mercially sustainable. IUDs and injectables, on the other hand, faced cultural and economic barriers and proved to be in need of sustained donor funding. Moreover, because advertising of oral contraceptives is still not permitted by the for-profit sector, the program continues to face the challenge of relying on an intermediary to maintain promotional efforts. Whether this is viable without an external donor such as USAID brokering among the various manufactur- ers remains to be seen. Country Programs: Achievements and Results MAHALLAS: REACHING WOMEN THROUGH COMMUNITY EDUCATION In July 2001, CMS utilized the tradition of mahalla (communi- ty) meetings to help address misconceptions regarding con- traceptives — especially IUDs and injectables. At the meet- ings, women met with providers to discuss issues around family planning. Women were able to ask questions and voice their concerns about the methods and receive straightforward answers. CMS conducted a total of 74 such sessions in three target regions, bringing family planning information to more than 5,360 women. UGANDA: INTEGRATED PRIVATE- SECTOR PROGRAM Uganda’s contraceptive prevalence rate — 23 percent for all methods and 18 percent for modern methods — is high among African countries. Uganda has been cited as sub-Saharan Africa’s success story for its efforts to reduce HIV prevalence. Nonetheless, HIV/AIDS continues to be a major health problem, with an estimated infection rate of 5.1 percent in 2001. Overall health indicators in Uganda are poor. Life expectancy is low, and child, infant, and mater- nal mortality rates are high. Malaria kills between 70,000 and 100,000 people each year — the majori- ty children under 5. Even with added revenue from donor funds, the Ugandan government cannot satisfy its population’s health needs without help from the private sector, including for-profit and non-profit providers. CMS worked to improve the capacity of private providers to respond to the health needs of Ugandans, as well as to increase access to affordable, quality products and services. To achieve these objectives, CMS used three strategies: social marketing, including behavior change communications; support for private pro- viders; and identification and development of alter- native sources of health financing. SOCIAL MARKETING PROGRAMS Uganda is CMS’s largest and most diverse social mar- keting program. CMS began implementation of the Uganda program in late 1998 and continued through September 2003, when it was transitioned to the AIDSMark project. Products and activities fit under three broad categories: family planning, malaria pre- vention, and HIV/AIDS prevention. FAMILY PLANNING. CMS family planning activities were focused on expanding distribution of the con- dom Protector, the oral contraceptive Pilplan, and the injectable contraceptive Injectaplan. In 2000, CMS launched the My Choice campaign, promoting the Protector condom to sexually active youth, aged 15 to 25, as a means of preventing HIV/AIDS transmission. This campaign relied on intensive use of branded communications. A CMS 23Final Report A crowd in Morocco watches a video about diarrhea prevention and oral rehydration therapy on a specially equipped van with a large-screen television. Moroccan women attend an educational session about hygiene and childhood diarrhea. 24 Commercial Market Strategies Project survey conducted in 2002 found that the Protector condom campaign had achieved more than just brand recognition: CMS appeared to have significantly increased acceptance of condoms overall. More than 90 percent of users of other brands had been exposed to a Protector communication campaign. CMS/Uganda’s social marketing efforts emphasized accessibility and distribution — an approach that paid off: A distribution survey conducted in 2000 revealed that Protector condoms were available in 91 percent of pharmacies, 86 percent of drug shops, 76 percent of clinics, and 44 percent of general mer- chandise shops. The distribution strategy evolved from a traditional urban-based system to a segment- ed approach, based on specific program objectives. CMS promoted Pilplan and Injectaplan together, with marketing efforts focused on increasing consumer awareness, implementing a BCC campaign, improv- ing product accessibility, and improving provider knowledge. A national, branded radio campaign addressed prod- uct benefits, use, side effects, myths, and misconcep- tions. This campaign was complemented by behavior change efforts to educate couples about the benefits of using modern contraceptive methods. To improve provider knowledge and product accessibility, CMS detailing staff conducted site visits and outreach training. CMS also conducted monthly training ses- sions for midwives, in cooperation with the Uganda Private Midwives Association (UPMA). As of September 2003, over 1,000 providers were trained in the safe administration of Injectaplan, as well as in the proper management of side effects. In an effort to improve the safety of family planning clients and health workers, CMS revised the Injectaplan delivery system, replacing the standard syringe (which can be re-used) with a safer auto-disable syringe. MALARIA PREVENTION. In December 2000, CMS introduced a program to distribute an insecticide- treated bednet called SmartNet in six pilot districts to test market the product’s viability, as well as a new wash-resistant formulation called PermaNet. The pilot was successful, and in March 2001, the Ministry of Health approved a rapid national expansion. CMS quickly launched a brand awareness campaign and soon began distributing SmartNet in over 1,000 outlets throughout the country. Five months later — encouraged by SmartNet’s success, as well as govern- ment tax incentives — two private companies began marketing nets in Kampala (another two companies entered the market later). CMS shifted its focus to distributing SmartNet to low-income groups in Northern Uganda, limited its advertising, and worked to increase malaria risk awareness with IEC and BCC campaigns. The two commercial firms in Kampala continued their aggressive net advertising. The syner- gy created by these combined promotional efforts increased sales for all three brands. STI/HIV/AIDS PREVENTION. In December 1999, CMS launched a four-district pilot test of the Clear Seven STI treatment kit, a cost-effective all-in-one treat- ment for urethritis. Clear Seven is a pharmaceutical product whose advertising and distribution is limited by the Ugandan National Drug Authority. CMS’s ini- tial strategy used a low-key, interpersonal approach, focusing on provider training and BCC, as well as on provider sales and targeted institutional sales (male- only hostels and university dorms, the military, and police). CMS estimated that in its targeted institu- tional groups there were more than 130,000 highly mobile men who regularly engaged in casual sex with multiple partners. To ensure quality, CMS’s detailing team trained more than 1,500 health workers in the proper dis- pensing of Clear Seven and the syndromic management of urethritis. For the military and police, CMS devel- oped dramatic performances to promote awareness of STIs and emphasize the importance of early treat- ment. Activities were also held with university and college students. Based on Clear Seven evaluation data, the Ugandan National Drug Authority approved limited expansion in mid-2003. Going forward, Clear Seven will be dis- tributed through clinics and pharmacies in eight Ugandan districts, focusing on outlets located near groups at high risk of STIs, such as army barracks and tertiary educational establishments. In 2002, CMS implemented a pilot HIV/AIDS vol- untary counseling and testing (VCT) project in Uganda’s Mbarara and Kasese districts. The project linked a generic awareness campaign — targeting young couples and those planning to have a family — with referrals to a network of public-sector testing centers. CMS worked in close collaboration with the Ugandan MOH and the AIDS Information Centre. In addition to providing VCT services at their own Country Programs: Achievements and Results sites, the AIDS Information Centre provided train- ing, support, and quality assurance to MOH centers. CMS’s initial communications strategy focused on advocacy, increasing awareness about VCT, and pro- moting post-test clubs (PTCs) — support groups for people who have been tested for HIV (some HIV- positive and others HIV-negative). CMS developed a multi-pronged campaign to disseminate campaign messages. Radio spots featured real-life testimonials and highlighted the positive benefits of VCT. Posters, flyers, and numerous billboards used the same testi- monials as the radio spots. Outdoor media also included directional signs and smaller metal signs in suburban areas. To reach remote fishing villages, CMS linked community-based HIV/AIDS education organizations to the VCT sites. In addition, the project developed and implemented the communication campaign for a government- sponsored VCT pilot program in two districts. Initial assessments found that the campaign had high recall and helped increase client uptake in pilot VCT cen- ters by more than 50 percent. SUPPORTING PRIVATE PROVIDERS Uganda has approximately 800 private-provider midwives, roughly one-quarter of whom are active members of the UPMA. On a fee-for-service basis, the country’s private midwives provide antenatal and postnatal care, immunizations, and well-baby care; oversee deliveries; and provide family planning serv- ices and syndromic management of STIs, as well as HIV counseling and health education. In addition, they provide minor curative services. Midwives are motivated to provide quality services in order to sus- tain their livelihood and local reputation. (Unlike private doctors, who primarily work in urban areas, midwives are located in urban, peri-urban, and rural areas.) CMS worked closely with UPMA to improve and broaden its donor base and to expand its capacity to generate its own sources of income. CMS extended favorable pricing of its social marketing products to UPMA members, with a commission going to the UPMA. Similarly, CMS helped negotiate an agree- ment with a pharmaceutical company to offer preferred pricing to UMPA members. More signifi- cant, CMS helped to restructure the under-perform- ing UPMA-owned Kansanga Health Centre. CMS provided training in basic business skills to nearly 350 private providers (in 10 of the 11 UPMA branches). Special attention was paid to strategies for improving quality of care, including client – provider interactions, availability of drugs and supplies, hygiene and sanitation, patient confidentiality, and the affordability and accessibility of services. Follow- up visits demonstrated that providers improved their record-keeping skills and enhanced their ability to promote and expand their services. CMS also developed a micro-loan program for pri- vate health care providers through the Summa Foundation, after an assessment revealed that there was a significant demand for expanded credit and improved private-provider practices, as well as suffi- cient capacity to repay the loans. Potential loan recipients were identified through professional associations, such as the UPMA, the Uganda Medical Association, and the Uganda National Association of Nurses and Midwives. They were also recruited through direct marketing to private practices, espe- cially those whose providers participated in the busi- ness skills training program. Loans ranged from roughly $200 to more than $7,000; average loan size was $920. Loans were extended for 6 to 12 months, at a 3.5 percent monthly interest rate. Providers typically used the funds to buy drugs and equipment and to renovate and expand their clinics. Providers who successfully repaid their first loan could take out additional loans for larger amounts. As of January 2004, a total of 1,267 loans had been made, of which 733 were to repeat borrowers; some providers were on their third or fourth loan. The 97 percent repayment rate is excellent by micro- finance standards. With steady growth in the size of the loan portfolio and an increase in the number of participating bor- rowers, the loan program quickly achieved financial sustainability. CMS provided upfront funding for the effort (for capital requirements and staff support), and within two years, the micro-finance institution was able to meet all of its program operating costs and to generate a profit. 25Final Report 26 Commercial Market Strategies Project HEALTH FINANCING ACTIVIT IES Despite free services in the public health system, over 60 percent of Ugandans seek care from the private sector. However, paying for private health care can place a serious financial burden on lower-income families, who have no financial safety net in times of crisis. Community health insurance, which works by pooling community resources to help families share the risk of health care costs, can improve access to quality health care by reducing financial barriers and diminishing the economic burden of illness. Working in close collaboration with HealthPartners, a Minnesota-based managed care organization, CMS implemented health financing activities to improve access to affordable, quality health services. The Ugandan Health Cooperative (UHC), an initiative of HealthPartners, together with CMS, set up prepaid health care plans to help the rural poor access care. The plans were based on existing community groups, such as dairy and tea cooperatives. The individual plans contracted with private clinics, Mission clinics, and hospitals to provide care to the group. Several groups could contract with the same provider. One benefit of capitated, prepaid health insurance plans is that they increase incentives for providers to help maintain the health of the insured population and prevent disease. In Uganda, private providers traditionally have concentrated on curative care, with the government taking primary responsibility for prevention. In addition, members of community health plans do not usually seek preventive services — they want protection from the high costs of care when they fall sick. However, a few health plans have recog- nized the financial benefits of investing in preven- tion. Many have recognized that malaria is a major source of their costs. The Insurance-Net (In-Net) program, which promoted use of CMS’s SmartNet insecticide-treated mosquito net among members of UHC health plans, was a unique prevention activity integrating social marketing and health financing. CMS developed the In-Net program to improve the health of pregnant women and children under 5, two groups with high malaria mortality and morbidity. CMS and UHC also collaborated to improve mater- nal health outcomes and increase child survival in the war-torn Gulu district in northern Uganda and to improve the financial sustainability of St. Mary’s Hospital in Lacor. The Mothers Uplifting Children’s Health (MUCH) project had three components: an improved accounting and inventory management sys- tems at St. Mary’s Hospital, an upgraded hospital health information system, and a community-based health insurance plan. The health insurance plan was based at the hospital and covered some of the poorest people in the area (for example, a rock-breakers’ cooperative and a group of refugee widows); plan members were offered a heavily subsidized benefit package. CMS supplemented this with a direct subsidy to women, children, and the elderly to lower the cost of the premium for these vulnerable individuals. Premiums were further stratified according to ability to pay and the socioeconomic status of each health plan group. CMS also provided the hospital with protection against losses if premiums proved insufficient to cover fees for services used by plan members. In addition to improving health status and easing the burden of health care costs for low-income families, the project helped to cover a percentage of hospital expenditures through patient premiums, increasing the hospital’s sustainability. PROGRAM RESULTS CMS sought to improve a broad range of health out- comes in Uganda — including HIV/AIDS and malaria prevention, birth spacing, treatment of STIs, maternal and child health services — as well as to improve access to curative care through community health insurance plans. By taking a broad and integrated approach and working through the private sector where most Ugandans seek health care, CMS succeeded in having a significant impact on the health of Ugandans: INCREASED USE OF MODERN CONTRACEPTIVES. CMS/ Uganda provided more than 829,000 CYPs between 1998 and 2002 — contributing to improvements in contraceptive use and prevalence. Contraceptive prevalence for modern methods increased from 16.5 percent in 2001 to 18.2 percent in 2002, and use of injectables by married women increased from 6.4 percent to 13.1 percent. Research data indicate that CMS/Uganda also succeeded in growing the overall contraceptive market in Uganda. The percentage of women of reproductive age who use CMS contracep- tive brands grew from 5 to 9 percent between 2000 and 2002 while the combined market for condoms, pills, and injectables grew from 12 to 19 percent. Country Programs: Achievements and Results CREATION OF SUCCESSFUL PUBLIC-PRIVATE PARTNER- SHIP TO PROMOTE MOSQUITO NETS. CMS was instru- mental in stimulating demand for branded commer- cial mosquito nets, thereby building the market for insecticide-treated nets (ITNs) in Uganda. When CMS launched SmartNet in December 2000, com- mercially available nets were virtually non-existent — fewer than 40,000 were sold each year. But by 2002, ITN sales increased to more than 280,000, and almost 78,000 of these were SmartNets. In 2003, total net sales grew to 450,000, with SmartNet accounting for 30 percent of the market (see Figure 4). Moreover, while previously there were no firms in the commercial market, there were four companies selling ITNs in 2003: Quality Chemicals, A–Z , Syngenta, and Vestergaard Frandsen. EFFECTIVE ADVERTISING CAMPAIGNS. CMS/Uganda’s advertising campaigns stimulated demand for repro- ductive health and other essential health products. A CMS tracking study found that ITN use increased from 22 to 29 percent of households in the pilot dis- tricts in the first year of the SmartNet campaign. Similarly, a CMS household survey also showed that women of reproductive age who recall being exposed to CMS advertisements for oral contraceptives or injectables are more likely to use them. The same survey found that men of reproductive age who recall being exposed to a CMS advertisement for condoms are more likely to use condoms (see Figures 5a – c). INCREASE IN DUES-PAYING UPMA MEMBERSHIP. By adding valuable services, UPMA was able to increase the number of dues-paying members by 35 percent. 27Final Report Figure 4. Uganda: Sales of SmartNets, 2000 to 2003 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 N um be r o f S m ar tN et s so ld 2000 2001 2002 2003 Key services included a newsletter linking individual midwives, a database for comparing practice methods and performance, a member directory, training pro- grams, and income-generating activities. IMPROVED SERVICE QUALITY. Service quality improved among private providers who received Summa Foundation loans and training. Providers used Summa loans to buy drugs and equipment and to renovate and expand their clinics. Each loan recipi- ent received five days of business-skills training, including business planning and management, finan- cial record keeping, and loan management. The training included modules on the importance of good client – provider interaction and patient confi- dentiality; it emphasized that improving quality helps to attract more clients. An evaluation of the impact of Summa loans found that clients at intervention clin- ics were more likely to mention quality-related fac- tors, such as availability of drugs, privacy, fair charges, accessibility, agreeable surroundings, and range of services offered, as their reason for visiting the clinic than clients at these same clinics in the baseline survey or in the control clinics. Loyalty to intervention clinics also increased significantly; clients at intervention clinics were 1.8 times more likely to say that they always visited the same clinic compared to the baseline survey. EXPANDED MATERNAL AND CHILD HEALTH SERVICES. A rigorous evaluation of the impact of the loan fund on service expansion and quality found that intervention clinics had a significant increase (from 30 to 39 per- cent) in the proportion of clients who obtained pre- ventive MCH services. Clients at intervention clinics were slightly (1.6 times) more likely to report MCH services as the reason for their visit over baseline, while there was no change in this indicator at control clinics. INCREASED ACCESS TO CARE FOR LOW-INCOME POPULATIONS. Through its cooperation with HealthPartners/UHC, CMS increased access to afford- able health care for 14,000 low-income Ugandans, of whom 9,000 were school children benefiting from health care through school-based programs. Moreover, after obtaining insurance from St. Mary’s Hospital in Lacor, 33 percent of insured sought health care for an illness in the previous month, doubling from 15.5 per- cent in the same group before the insurance plan. 28 Commercial Market Strategies Project INCREASED BORROWER SAVINGS. The loan fund con- tributed to increasing savings — an important safety net for small businesses. Only 33 percent of borrowers reported savings of $168 or more at the time of the first loan application; by the time of the second loan application, that percentage had increased to 58 per- cent. By January 2004, a total of 1,267 borrowers had received loans — 534 were first-time borrowers; 733 were repeat borrowers. The majority of first-time bor- rowers used a portion of their loans to purchase drugs (73.9 percent), followed by equipment (34.2 percent), and clinic renovation and expansion (27.4 percent). FEWER PEOPLE FORCED TO SELL ASSETS OR BORROW MONEY. Before the insurance program began in Lacor, 42.8 percent of the patients who later enrolled and 48 percent of the patients in the com- parison group were forced to sell an asset to pay for health care. In addition, 11.5 percent in the inter- vention area and 8 percent in the control group had to borrow money. In the follow-up survey, only 15.5 percent of the insured who obtained care in the pre- vious month reported selling assets, while 48 percent in the uninsured comparison group had done so. Only 6.1 percent had to borrow money to pay for health care versus 8.9 percent in the control group. INDIA: INTEGRATED BEHAVIOR CHANGE CAMPAIGN CMS worked in India from 1998 to 2004 to improve reproductive health and child survival and increase HIV-prevention behaviors. It provided technical and management assistance to the USAID-funded Program for Advancement of Commercial Technology – Child and Reproductive Health (PACT–CRH) for three major efforts: a social mar- keting campaign to promote commercial low-dose oral contraceptives, a dual-protection condom campaign in cooperation with the private sector, and a campaign to increase use of World Health Organization (WHO)-approved ORS. CMS also provided assistance in private-sector development and social marketing to the State Innovations in Family Planning Services Agency (SIFPSA) and implemented a pilot project to market injectable contraceptives in three cities in Uttar Pradesh. Country Programs: Achievements and Results Did Not Recall CMS Ad Recalled CMS Ad Pe rc en t 50 40 30 20 10 0 Figure 5a–c. Uganda: Likelihood of using contraception, by whether respondent recalled CMS ad, 2002 1 7 Figure 5a. Women of reproductive age who currently use OCs, by exposure to CMS OC ad (percent) Figure 5b. Women of reproductive age who currently use injectables, by exposure to CMS injectables ad (percent) Figure 5c. Men of reproductive age who currently use condoms, by exposure to CMS condom ad (percent) Did Not Recall CMS Ad Recalled CMS Ad Pe rc en t 50 40 30 20 10 0 6 Did Not Recall CMS Ad Recalled CMS Ad Pe rc en t 50 40 30 20 10 0 16 15 34 CONTRACEPTIVE SOCIAL MARKETING In Uttar Pradesh, a key state in northern India that contains one-sixth of the country’s population, the total fertility rate is 4 births per woman. Use of tem- porary and spacing contraceptive methods — such as OCs, IUDs, and condoms — remains low, at 2 to 3 percent. Injectable use is negligible. To address this, CMS developed three social marketing programs based on close cooperation with the commercial and private sectors, targeting urban and rural areas in northern India. Although awareness of OCs is high in India, use in 1998 was low, at 2.1 percent among married women of reproductive age. Pre-campaign focus groups revealed that two primary barriers limit OC use: (1) fear of short-term side effects such as nausea, weight gain, and dizziness and (2) concerns about long-term side effects such as infertility. Research among doctors and chemists also showed high levels of concern about long-term OC use. Based on these findings, CMS launched a dynamic social marketing campaign in November 1998 designed to increase use of commercially available low-dose OCs. Goli ke Hamjoli (Hindi for “Friends of the Pill”) targeted urban women, aged 18 to 29, who intend to use family planning. Secondary audiences included doctors, chemists, opinion leaders, civic groups, and the media. The campaign aimed to promote the entire product category of low-dose pills, rather than focusing on one specific brand, and targeted urban areas of eight states in northern India that are home to almost half of India’s population. The pill was positioned as a friend to young women and couples. Advertising and public relations messages reassured potential users that side effects are minimal and temporary, while providing detailed information about safety, correct use, and benefits. Goli ke Hamjoli used an integrated approach, combin- ing advertising, public relations, and large-scale provider training and detailing, to address barriers to OC use and expand the market. The program was based on partnerships with pharmaceutical manufac- turers Wyeth Lederle and Organon, who linked their brands to the campaign by “overbranding” their promotional materials with the Goli ke Hamjoli logo. As part of the partnership agreement, these firms intensified the distribution and promotion of their respective brands (OCs are available over the count- er in India). The low-dose OC market also included several subsidized social marketing brands, including one promoted by the government of India. Because Goli ke Hamjoli promoted the entire category, these lower-priced products benefited from the campaign. Joint promotion of commercial and social marketing products improved the availability of a wide range of affordable OC brands — thus offering something suitable for almost all socioeconomic groups. Ogilvy & Mather was contracted to develop the adver- tising, public relations, and other communications components of the campaign. Mass media advertise- ments addressed fears and raised awareness about the new generation of low-dose pills. Some featured celebrities talking about how side effects are tempo- rary or how the method is reversible, while others discussed benefits, spacing, joint decision making, or what to do if one forgets to take a pill. Advertisements were broadcast over major Indian tel- evision channels and augmented with billboards and posters. The mass media campaign was highly success- ful: In 2002, 80 percent of women in the target audience were able to recall key messages. To complement the mass media campaign, public relations and training activities reached consumers, opinion leaders, and providers. For example, CMS trained beauticians to work as peer educators, since beauty shops are popular spots for young women to exchange information. Using this same interperson- al approach, the Hamjoli Batcheet (Happy User) pro- gram linked interested non-users to women who use the pill so that they could discuss experiences and concerns. Briefings for civic groups, such as the Rotary Club, and provider groups, such as the Indian Medical Association, plus training and con- ferences for physicians helped dispel deeply rooted myths about hormonal contraceptives. CMS created and managed a medical detailing staff of more than 100 promoters who visited doctors and chemists with information about OCs and educated providers about the advantages and differences between the newer generation of low-dose pills and the older, high-dose formulations. CMS’s detailing activities dovetailed with manufacturers’ increased marketing efforts, which improved their own brand equity. As of September 2003, CMS had trained 34,012 chemists, 28,360 traditional doctors (who practice non-allopathic forms of medicine), and 6,707 beauticians. Fifty-five thousand providers were revisited on a bi-monthly basis with materials and 29Final Report 30 Commercial Market Strategies Project detailing messages, and mailers and technical updates were regularly sent to 27,000 doctors. By the end of 2003, the program had detailing teams in 34 cities, and more than 480 physicians were offering free counseling to women interested in OCs. To complement efforts to address substantial biases against hormonal contraceptives among providers in India, CMS worked with the Federation of Obstetricians and Gynecologists of India (FOGSI) to develop official statements that endorse low-dose oral contraceptives and injectables within the WHO guide- lines. As a result, in January 2004, the annual meet- ing of FOGSI released a consensus statement that low- dose oral contraceptives and the injectable DPMA are safe and effective methods of contraception. The statement advised FOGSI members to use these meth- ods within the WHO guidelines. India’s example shows that improving the environment goes beyond making a product legal. The attitudinal barriers of providers and clients also shape the decision of whether to offer or accept different methods and thus constrain method choice and a client’s ability to use the method best suited to her needs. PRIVATE-SECTOR APPROACHES CMS provided technical assistance with private-sector and social marketing initiatives to SIFPSA, the parastatal agency that implements the Innovations in Family Planning Services (IFPS) project, a joint effort of the Indian government and USAID. IFPS works in Uttar Pradesh to implement social market- ing programs for pills, condoms, and other maternal and child health products such as ORS, iron folate tablets, and disposable delivery kits. Program activi- ties are implemented by local organizations under performance-based contracts that CMS helped to develop, award, monitor, and evaluate. In 2000, CMS helped SIFPSA award a contract to Hindustan Latex Limited for the social marketing of condoms and pills throughout Uttar Pradesh. To guide the program, CMS conducted a survey of rural retail outlets and a willingness-to-pay study for con- doms and pills among rural consumers. Before the contract was awarded, CMS helped establish contract performance targets and evaluate proposals. This approach, in contrast to relying on internal sales reports, helped focus marketing efforts on priority products, regions, and populations. Based on the impact of the Hindustan Latex rural marketing con- tract, SIFPSA issued three more contracts. The first was a statewide contract to market the government’s social marketing brand of condoms and OCs — both products soon showed sales increases. (In fact, Uttar Pradesh is the only state in India with growing rural condom sales.) The other two contracts were regional and promoted a basket of reproductive health and child health products, including OCs, condoms, ORS, clean-delivery kits, and iron folate tablets. EXPANDING SOCIAL MARKETING TO ORS Based on Goli ke Hamjoli’s success in expanding the oral contraceptive market, CMS was asked to develop a campaign to improve awareness and the correct use of World Health Organization-approved oral rehydra- tion salts (WHO – ORS) in northern India. Diarrhea kills almost 600,000 children under age 5 every year in India. Most of these deaths can be prevented with the correct use of ORS. CMS designed an integrated communications cam- paign that addressed the two main barriers to effec- tive ORS use: (1) a lack of awareness, by parents and physicians, that dehydration from diarrhea can be fatal and (2) incorrect use. Launched in April 2002 in partnership with six Indian ORS manufacturers, the campaign combined mass media advertising, pub- lic relations and community outreach activities, and provider training and detailing similar to the Goli ke Hamjoli campaign. Partner manufacturers used their field teams to promote WHO – ORS to pediatricians, general practitioners, and chemists. In 2003, these teams covered 9,000 providers each, demonstrating correct preparation and distributing generic and branded campaign point-of-sale materials, leaflets, and samples. The manufacturers also produced and distributed generic and brand materials at their own expense. Five out of the six incorporated the cam- paign logo on their product packs, making it easier for consumers to identify and purchase a WHO- recommended brand. Media placements and public relations activities coincided with the diarrhea season (April to September). Messages emphasized the importance of administering ORS as soon as diarrhea begins and again after every stool; correct mixing, frequency, and duration of ORS therapy; the need to stock ORS at home; and the value of WHO – ORS versus other Country Programs: Achievements and Results brands and home-made remedies. India’s most pop- ular soap opera, Kyunki Saas Bhi Kabhi Bahu Thi, integrat- ed WHO – ORS messages into one of its episodes, which was viewed by millions in the target audience. The day after the episode aired, a survey of 291 women revealed that 71 percent correctly recalled the campaign messages. Other campaign partners included McCann Healthcare, the health care communication division of McCann Erickson, which developed and managed the advertising and public relations components (with technical direction from CMS), and the Indian Academy of Pediatrics, which provided med- ical guidance, endorsed advertisements, encouraged doctors to prescribe WHO – ORS brands, and par- ticipated in outreach activities. CMS convinced the Delhi Transport Corporation, a public company, to advertise on about 2,000 of its buses. By negotiat- ing similar agreements with local businesses throughout northern India, CMS engaged and leveraged the private sector. At the end of 2003, more than 400 articles repeat- ing intended messages had run in leading Indian newspapers and magazines, and broadcast media had covered events and interviewed key spokespeople. CMS/India field teams delivered campaign messages to over 55,000 providers every two months. The ORS campaign featured a strong community out- reach program, including house visits by health pro- moters to mothers with children under age 3. By the end of 2003, promoters had visited 77,000 house- holds in key cities and handed out over 150,000 samples. Another program, Gift A Life, encouraged traditional doctors to prescribe WHO – ORS brands by providing them with prescription pads. PROGRAM RESULTS INCREASED USE OF ORAL CONTRACEPTIVES. Goli ke Hamjoli tracking surveys show that use of oral contra- ceptives increased from 4 to 11 percent of the target audience (young urban women) between 1999 and 2003. Sales of all commercially available brands increased by 42 percent, and 15 percent more- chemists stocked OCs. Surveys also showed positive changes in attitude and knowledge among both providers and consumers. INCREASED CONDOM USE. Between 1999 and 2003, the rural condom market increased by 108 percent — going from 52 million to 110 million condoms sold annually. The number of villages in which condoms were available more than doubled — from 12,000 to 26,000 villages. The percentage of villages in which both condoms and OCs were available increased from 18.5 percent to 48 percent. INCREASED AWARENESS, USE, SALES, AND AVAILABILITY OF ORS. In the first year of the campaign (2002), mothers reporting use of ORS increased from 26 to 36 percent, and by the end of 2003, half of all mothers surveyed reported using ORS. During the first year of the campaign, sales of WHO brands rose by 45 percent, and the total market increased by 17 percent. After the 2003 campaign, sales of WHO brands increased by another 20 percent, and the total market increased by 9 percent. Share of the WHO – ORS market segment grew to 26 percent at the end of 2003, up from 19 percent before the campaign. Over the same time frame, WHO-recom- mended brands, only available at 23 percent of phar- macies before the campaign, were found at 62 per- cent of target-area pharmacies. PUBLIC RELATIONS EFFORTS EFFECTIVE. More than 420 articles on Goli ke Hamjoli and OCs were published in national and northern Indian newspapers and maga- zines during the course of the 1999–2003 program. Goli ke Hamjoli was named the Healthcare Campaign of the Year at the 1999 Asian Public Relations Awards and won India’s Abby Award from the Bombay Ad Club for the Best Social Concern Campaign. In September 2004, the campaign was nominated as one of the finalists for the Asian Brand Marketing Effectiveness Awards. NEPAL: PROVIDER NETWORKS Nepal is one of the poorest nations in the world, and many of its health and social indicators are among the lowest in South Asia. The majority of the population lives in rural areas without access to basic infrastruc- ture or services. Nepal’s infant and maternal mortality rates are among the highest in the world. Its annual population growth rate is 2.1 percent, and women have an average of 4.1 children. The total contracep- tive prevalence rate is 39 percent, and the modern con- traceptive prevalence rate is 35 percent. Sterilization is the most popular form of contraception, followed by 31Final Report 32 Commercial Market Strategies Project injectables. The unmet need for family planning in Nepal is estimated at 31 percent: 14 percent for spac- ing methods and 17 percent for limiting births. There is, therefore, considerable potential for mod- ern temporary methods. CMS initially took over responsibility for working with the already-established Parivar Swasthya Sewa Network (PSSN) from the SOMARC project. PSSN was a physician network in Kathmandu created to expand and improve the quality of private-sector family plan- ning services. CMS used local advertising agencies to implement an integrated marketing campaign. After several years of working with PSSN, however, CMS realized that its exclusive reliance on urban- based doctors (who tend to focus on the provision of gynecological services) was limiting the growth of the network as well as its ability to serve lower-income clients. Therefore, CMS proposed developing and testing an alternate model that would build on the PSSN experience, but utilize nurses and paramedics, formally trained clinician groups who serve mostly poor, rural clients. In May 2001, CMS launched the Sewa pilot network in Nepal’s Rupandehi district, an area with a lower socioeconomic profile and fewer doctors than Kathmandu. Sewa means service in Nepali. The main objective of the pilot was to test whether a nurse and paramedic network could increase the use of family planning and reproductive health services. Inter- mediate goals included improving service quality at Sewa clinics and increasing awareness of Sewa at the district level. Rupandehi district has a population of 708,419, a literacy rate of 42 percent, and annual per capita income of $125. CMS designed the Sewa network using a fractional franchise model, where a package of services is added to an existing practice (or business) and offered in accordance with a specific set of guidelines estab- lished by the franchiser and outlined in a contract. The franchise network model offered several advan- tages. First, even though working with individual providers can mean significant variability in the qual- ity of services, the franchise model facilitated ongoing quality monitoring, thus improving and standardiz- ing quality. Second, providing training and promo- tion for a network, rather than individual providers, offered significant economies of scale. Third, brand- ing the network with a logo created a symbol of high- quality services that in turn attracted new clients to network clinics. Finally, nurses and paramedics were interested in being affiliated with a larger provider community and linked with fellow providers. KEY PROJECT COMPONENTS The Sewa network included the following key elements: • Provider recruitment. Sewa recruited 64 of the 150 nurses and paramedics with private clinics in the Rupandehi district to join the network. Selection criteria included the presence of a physical facility and a reasonable client volume, level of interest in joining the network, clinic location, existing service mix, and willingness to comply with the clinic monitoring protocols. • Membership contract. The membership contract spec- ifies the roles and responsibilities of the franchis- er, Nepal Fertility Care Center (NFCC), and the franchisees, the individual nurse and paramedic providers. The franchiser is responsible for pro- viding training, quality monitoring, and market- ing support and for establishing a referral system. In return, the franchisee agrees to pay member- ship fees, offer family planning and reproductive health services, follow quality protocols, adhere to an agreed upon fee schedule, and maintain serv- ice statistics. • Training. Network members received a seven-day, reproductive health training and a two-day ses- sion on services marketing. A subset of female nurses and midwives also received 21-day IUD training. The reproductive health training, which included an overview of the service quality proto- cols outlined in the franchise contract, covered topics such as infection prevention, use of essen- tial supplies, family planning, reproductive health (e.g., antenatal and postnatal care, gynecological problems), and STIs/HIV/AIDS. The services marketing session used role-playing, lectures, and group exercises to emphasize the importance of service quality and interactive marketing (the use of interpersonal techniques to build relationships and ensure a positive client – provider interac- tion) in retaining existing clients and attracting Country Programs: Achievements and Results new clients. The session also outlined the net- work’s external marketing activities (mass media; outreach; and information, education, and com- munication, or IEC) and encouraged provider participation. • Marketing and promotion. CMS supported network members with a broad range of marketing activi- ties. The Sewa name and logo figured prominently on the clinic signboards and white coats given to each provider. Activities aimed at creating aware- ness for the network services ranged from mass media (radio and print advertisements, bill- boards, brochures, leaflets) to interpersonal (a door-to-door campaign, clinic open houses, and promotional booths in local farmers’ markets). In addition, CMS developed a monthly newsletter that reinforced the value of Sewa membership and kept providers informed of network activities. • Referrals. CMS established internal and external referral systems to ensure that the clients had access to an integrated package of services. The internal system allowed network nurses and paramedics to refer a client to a trained female provider for IUD services. For more complicated health problems, the external system provided a link to private physi- cians and government health facilities. • Quality monitoring. Each month, the franchiser sent a field coordinator to all network clinics to moni- tor quality of care and ensure that service proto- cols were followed. The field coordinator checked clinic service statistics, observed service delivery, and administered a detailed checklist to assess technical quality. Checklist categories included infection prevention, availability of essential sup- plies and equipment, and client – provider inter- action. The field coordinator also reinforced services marketing techniques, stressing the importance of good client – provider interaction. To fully assess provider compliance with service protocols, the coordinator also spoke with clients. Upon completing the monitoring visit, the coor- dinator shared the monitoring results with the service provider and, if necessary, suggested ways to improve weak areas. The Sewa franchise, now managed by Population Services International, was consolidated into a new, expanded network, Sun Quality Health, which oper- ates in rural and peri-urban areas, including the Kathmandu, Bhaktapur, and Lalitpur districts in the Kathmandu Valley. Although the Sun Quality Health network includes doctors, it is a paramedic-focused franchise, drawing heavily on the Sewa fractional fran- chise model. This new network offers a full range of family planning products and services, including long-term and permanent methods, as well as mater- nal and child health care, STI diagnosis and treat- ment, and HIV/AIDS prevention. PROGRAM RESULTS The program was evaluated by using program monitor- ing data, including evaluation visits by a quality coordi- nator, mystery client surveys, and clinic service statis- tics. In addition, an impact evaluation was conducted using a quasi-experimental design. Three instruments used were (1) client exit interviews, (2) provider inter- views, and (3) household interviews. The interviews were conducted at two points in time. Baseline surveys were conducted during April and May 2001, and fol- low-up surveys were conducted during December 2002 and January 2003. Among the findings: INCREASED REPRODUCTIVE HEALTH SERVICE UTILIZA- TION AT SEWA CLINICS. Service statistics showed an increase in average monthly family planning and reproductive health visits at Sewa providers from 28 to 50 clients per month. There was also an increase in total number of clients at Sewa clinics (average daily client visits increased from 12.7 to 14.2). An opposite trend was observed in the control group clinics (see Figure 6). IMPROVED QUALITY AT SEWA CLINICS. In addition to the initial training, the franchiser sent a field coordi- nator to all network clinics each month to monitor quality of care and ensure that service protocols were followed. Upon completing the monitoring visit, the coordinator shared the monitoring results with the service provider and, if necessary, suggested ways to improve weak areas. As a result of this approach, observed technical quality improved on 23 out of 24 indicators. All network clinics improved their average scores for infection prevention, availability of essential supplies, record keeping, and the provision of family planning services. Client satisfaction with Sewa clinic services also improved from 58 to 75 percent, while at control group clinics, client satisfaction remained unchanged. Moreover, clients saw Sewa providers as “caring” and “reliable,” characteristics that CMS 33Final Report 34 Commercial Market Strategies Project baseline research had identified as important deter- minants of provider choice and that had subsequently been incorporated into the training and advertising. The proportion of clients citing “caring provider” as a reason for choosing the clinic increased from 34 to 41 percent at Sewa clinics. Similarly, the proportion of clients citing “reliable provider” as a reason for choosing the clinic increased from 35 to 52 percent. An opposite trend was observed in the control group clinics. Similarly, repeat visits were most frequent among satisfied clients and clients reporting caring and reliable providers. LOW AWARENESS OF SEWA BRAND. CMS’s marketing efforts did not build sufficient recognition for the Sewa brand. Evaluation data show that awareness of the Sewa network was very low: 24 percent of respon- dents at Sewa clinics and only 15 percent of married women of reproductive age in the pilot district had ever heard of the franchise. Although baseline research findings were used to develop mass media messages, the limited marketing budget did not allow for extensive formative research or for monitoring the effectiveness of media activities. Radio messages included quality cues (such as friendly, caring providers of reproductive health services), but per- haps fell short of reinforcing the overall Sewa brand. Short-term technical assistance to improve the design and implementation of the mass media campaign may have helped, but CMS did not have sufficient funds to send qualified marketing experts. Political unrest and the associated implementation delays may have hampered CMS’s efforts: Network promotion (including mass media and outreach) began only two weeks prior to the second-round survey. NICARAGUA: INTEGRATED CLINIC NETWORK CMS worked in Nicaragua to build the private sec- tor’s capacity to offer high-quality and affordable health services. In pursuit of this goal, CMS estab- lished a network of clinics in areas affected by Hurricane Mitch, which hit Central America in October 1998, causing massive flooding and mud- slides that left 10,000 dead and hundreds of thou- sands homeless. In Nicaragua alone, the storm caused an estimated $1.5 billion in damage to crops, homes, and infrastructure, including the public health sys- tem. CMS proposed a private provider network as a sustainable solution for meeting the health needs of those affected by the hurricane. One of the goals of the clinic network project was to strengthen private-sector delivery of essential health services. The project replicated a self-sustaining model developed by PROSALUD, a Bolivian NGO with a private clinic network that provides affordable primary care services to a large population while maintaining high levels of sustainability and patient satisfaction. CMS selected Profamilia, a local NGO, as a project partner. As one of the largest non-profit providers in Nicaragua, Profamilia had a reputation for high-quality services. To the 10 existing Profamilia clinics, CMS added 6 new clinics in areas affected by Hurricane Mitch, in the towns of Tipitapa, Sebaco, Esteli, Jalapa, Somoto, and Rio Blanco. The 6 clinics provided free preventive care, including immunizations, for both adults and children; curative and reproductive health care were provided at locally affordable fees. The clinics in the more-populous municipalities of Tipitapa, Esteli, and Sebaco offered expanded servic- es, including specialized pediatric and OB/GYN care, X-rays, and basic surgical procedures. These expand- ed clinics acted as referral centers for the basic clin- ics. Together, the 16 clinics constituted a combined NGO network offering the basic package of health services introduced by CMS in addition to the family planning services historically offered in the Profamilia clinics (see Figure 7). The development of the private clinic network involved five elements: clinic construction, manage- ment, quality of care, marketing, and sustainability. Country Programs: Achievements and Results Baseline Endline Sewa Control Av er ag e da ily c lie nt v isi ts 15 10 5 0 12.7 14.2 12.9 10.9 Figure 6. Nepal: Average daily client flow CLINIC CONSTRUCTION To identify appropriate sites for the six new clinics, CMS assessed 14 geographic areas for competition, consumer demand, and residents’ ability to pay for services. Within the selected locations, consumers expressed a need for high-quality, low-cost health care, which they said they were not receiving from the overstrained public sector or the expensive private sector. In addition, people indicated they did not feel that their current health care providers treated them with respect. The overwhelming majority of potential clients said they were looking for “one-stop shopping” in health care. In the selected sites, the local municipalities agreed to donate the necessary land. However, in certain cases the municipalities failed to follow through, and in others, the plots offered were inappropriate for a clinic; for example, they were in areas lacking elec- tricity or running water. Ultimately, CMS had to buy the land for each of the sites, a process complicated by the fact that some of the titles were encumbered with unanticipated conditions or liens. MANAGEMENT A month prior to each clinic’s opening, CMS began recruiting and training staff. Candidates were invited to a workshop in which CMS personnel could assess their communication, team building, conflict resolu- tion, and leadership skills. CMS then trained the new managers in general administrative skills, supervi- sion, quality of care, and how to care for HIV/AIDS patients. CMS codified these skills in management manuals and installed an information system that tracks service utilization and costs. QUALITY OF CARE High standards and superior quality were of central importance to the clinic network project. CMS’s objective was to provide effective and efficient inte- grated health service based on rigorous norms and procedures. At the inception of the project, CMS developed a manual that highlighted components of quality of care: staff recruitment and selection, training, service delivery, customer service, policies and procedures, and monitoring tools and systems. CMS’s operating plans for each of the clinics included quality of care indicators, which were mon- itored by supervisors who paid the clinics monthly visits, gathered data, and made recommendations as necessary. CMS trained administrative and medical staff in serv- ice delivery, patient care, supervision, human rela- tions, and sales. A “Quality Team” was created in each clinic, and each staff member was made respon- sible for monitoring a particular aspect of the quality control plan and reporting results on a monthly basis. To assess patient satisfaction, CMS conducted 35Final Report PROFAMILIA Clinic Network 10 Clinics Figure 7. Nicaragua: Clinic Network Structure Services Offered Family planning Basic health services Services Offered Charge · General medical · Maternal and child health · Family planning · Dental care · Pharmacy · Ultrasound · Laboratory Services Offered Integrated services, including all CMS and PROFAMILIA services > > > CMS Clinic Network 6 Clinics NGO Network 16 Clinics Exempt · Vaccinations · Oral rehydration therapy · Prenatal and postnatal care · Malaria · Health education + = 36 Commercial Market Strategies Project exit interviews and informal household surveys. In addition, each clinic was outfitted with a suggestion box. Because clinic norms were developed in accor- dance with Ministry of Health guidelines, by the time CMS ended its involvement, all six of the clinics had been accredited. MARKETING CMS helped build awareness of the new clinics through several interlinked marketing strategies, including a media campaign, interpersonal communications, clin- ic-based marketing, and promotions. CMS positioned the clinics as a one-stop shop for low-cost, quality health care services for the whole family. Associating the Profamilia name and logo with the clinics was a sig- nificant element of the marketing strategy. CMS research indicated that radio campaigns, flyers, loudspeakers, and street announcements were the most effective means of increasing popular awareness of the new clinics. Radio advertisements aired one week prior to each clinic opening. The openings themselves were key promotional activities, designed to be festive events that included national and local health authorities. To promote the events, banners were hung over the towns’ main streets, announce- ments were made from a loudspeaker car, and flyers were distributed door-to-door. Each clinic had at least one promotora, or health promot- er, who travels door-to-door to inform the community of clinic locations, hours, and services. The promotoras also provided basic preventive health education and ensured that patients comply with treatment regimens. SUSTAINABIL ITY CMS emphasized the clinics’ sustainability from the start. Strategies included • market assessments to set prices and identify needed services, • business plans with monthly targets for each clinic, • cost recovery as an integral part of clinic culture, • use of mass media to raise awareness of the clinics, • high-quality services to maintain client loyalty, • health care packages to attract new clients, and • curative and ancillary services to cross-subsidize preventive services. CMS set prices at a level that balanced cost recovery and affordability. In order to make Profamilia’s serv- ices attractive and ensure adequate client flow, the fees were set lower than at other private providers — yet higher than at public facilities — to ensure cost recov- ery. In addition, physicians were paid on a per-patient basis, rather than at a fixed salary. This innovative, business-oriented payment system helped to cut costs and encourage an entrepreneurial approach. It is a variant of a payment system developed by PROSALUD in which doctors are paid a percentage of each patient’s fee. Similarly, CMS developed a service mix that took into account the broad spectrum of health needs. The original Profamilia clinics, because of their focus on reproductive health, primarily served and attracted women. CMS developed services that would also draw men and children to the new clinics, thereby increasing the type and number of clients who would use them. PROGRAM RESULTS To monitor and evaluate the new clinic network, CMS used service statistics, financial records, and other data, as well as an impact evaluation. Surveys conducted in mid-2001 (baseline) and spring 2003 (endline) were matched against an equal number of households in four control municipalities. Among the findings: NEARLY 250,000 PEOPLE IN HURRICANE MITCH- AFFECTED AREAS WERE PROVIDED WITH ACCESS TO HIGH-QUALITY, AFFORDABLE HEALTH CARE. As of early 2003, 25 percent of women in the clinic treatment areas reported that they or a family member had used one of the CMS/Profamilia clinics in the previous 6 months, which is especially noteworthy in light of the fact that the clinics had at that point only been oper- ational for 14 to 24 months. Clients were most likely to report coming to the clinics for curative care (66 percent). They also reported receiving reproductive health services (32 percent) and lab tests (24 per- cent). Ten percent of clients were men. Country Programs: Achievements and Results HIGH SERVICE UTILIZATION. During the first three months of 2002, the enhanced clinics received about 4,500 client visits, and the basic clinics about 2,500. By 2003, that number had increased by 34 percent for the enhanced clinics (to 6,000) and by 24 per- cent for the basic clinics (to 4,200). CMS/PROFAMILIA CLINICS USED BY CLIENTS WHO PREVIOUSLY USED THE PUBLIC SECTOR. CMS surveys showed that 51 percent of network clients had previ- ously received health services from the public sector. Of those clients, 87 percent reported that the quality of services in the Profamilia clinics was superior to that of the public sector. HIGH SATISFACTION LEVELS. Three-quarters of clients reported that the quality of care they received was good or excellent, and more than 90 percent said they plan to return to a Profamilia clinic in the future. Nearly three-quarters of clients reported that the fees were reasonable or inexpensive. Almost 90 percent said the care they received was well worth the money they spent. Incomes of clients fell between those of other private-sector clients and those of public-sector clients, suggesting that the Profamilia clinics filled a niche between the public and private sectors — one of the goals of the net- work initiative. INCREASED SUSTAINABILITY FOR PROFAMILIA. By adding primary health services to their clinics and by improving their marketing and quality of care, reducing the number of staff, and adding a cost- sharing agreement with doctors, the Profamilia clinic network increased its cost recovery rate from 68 per- cent in 2001 to 84 percent by the end of 2003, indi- cating an improvement in financial sustainability from the adoption of the CMS model. GHANA: NGO AND CORPORATE PROGRAMS In Ghana, CMS worked to improve family health by helping ensure long-term access to reproductive health products and services and developing corporate HIV/AIDS programs. In particular, CMS/Ghana focused on improving the long-term sustainability of GSMF International (previously known as the Ghana Social Marketing Foundation), one of Ghana’s largest contraceptive providers, and improving and developing workplace HIV/AIDS awareness and prevention programs and an anti- retroviral (ARV) therapy initiative. NGO SUSTAINABIL ITY GSMF International is Ghana’s leading social mar- keting NGO, providing approximately 43 percent of the country’s contraceptives. Founded with help from USAID in 1993, GSMF had 60 employees and a nationwide product-distribution and sales network by 2003. GSMF promotes and distributes 11 socially marketed products, including oral and injectable contraceptives as well as male and female condoms; it targets mainly low- and middle-income populations. Since 1999, GSMF has steadily increased the share of contraceptives it provides in Ghana. In 2000, CMS began providing technical assistance to GSMF to strengthen its financial sustainability. CMS helped GSMF improve its planning and orga- nizational structures, increase revenues, and diver- sify sources of funding. With assistance from CMS, GSMF developed a detailed, short-term sustain- ability plan for the period 2002 to 2004. The plan estimated upcoming costs and potential revenues and set out expectations for reduced dependence on USAID funding. CMS also helped GSMF improve organizational systems — for example, by introducing timesheet use and modifying the cost accounting system. In May 2000, CMS arranged feasibility studies for five potentially profitable products that GSMF could market through the commercial sector. The studies indicated that GSMF could generate revenue by offering a line of innovative, trendy condoms target- ed to upper-income consumers. GSMF proceeded quickly with the condom initiative, moving from the CMS-supported evaluation of the initiative’s feasibil- ity study in the spring of 2000 to the launch of a luxury condom brand in the fall of 2001. The Aganzi condom line surpassed expectations. In 2002, Aganzi sales generated almost $100,000 and represented 13.6 percent of total annual GSMF product sales. In 2003, Aganzi not only generated a profit for GSMF, but also cross-subsidized the organization’s socially marketed products and increased the overall cost- efficiency of programs. 37Final Report 38 Commercial Market Strategies Project To help GSMF recover the costs of its socially mar- keted contraceptives, CMS conducted a study to determine whether people would pay more for these products. The study found that prices could be raised on subsidized family planning products without los- ing sales. For almost all products, more than 75 per- cent of clients said they were willing to pay at least 50 percent more than they currently paid. Fewer than 10 percent of current family planning clients said they would stop using contraception if prices were raised too high for them to afford — instead, they would switch methods, switch sources for their method, or use a new brand. Based on the study’s findings, GSMF successfully increased the price of its Champion condom brand. HIV/AIDS PREVENTION AND TREATMENT The HIV infection rate in Ghana is low, estimated at 3 percent at the end of 2001. The Ghanaian govern- ment is attempting to contain the epidemic through behavior change communications that target high- risk groups. This approach, however, is limited by a lack of resources and capacity. Recognizing the role that the commercial sector can play in containing and reducing HIV/AIDS, CMS collaborated with private clinics, employers, and NGOs to implement HIV/AIDS prevention and treatment programs through the workplace. CMS’s first HIV/AIDS workplace intervention in Ghana was with Unilever, a major multinational company. Unilever had an HIV/AIDS education pro- gram for its employees, but it did not include many recognized best practices. CMS contracted with GSMF to implement an improved workplace program at Unilever. The Life Check program, implemented by GSMF with CMS funding, sought to increase knowl- edge about HIV/AIDS and to reduce transmission among employees and in their communities. GSMF conducted advocacy for the program with Unilever management, held four major sensitization sessions for workers and their communities, trained 94 peer educators, produced and distributed promotional and informational materials, and distributed 8,000 condoms. The program was conducted at Unilever’s headquarters in Tema and at two palm plantation sites; it reached 2,100 Unilever employees and approximately 100,000 people in the surrounding communities. The Unilever program showcased an HIV/AIDS awareness and prevention program to the Ghanaian business community and was a catalyst in getting companies interested in responding to HIV/AIDS. After that initial success, CMS worked with industry associations to cost-effectively scale-up HIV/AIDS workplace programs in high-risk sectors, such as mines, timber, hotels and tourism, manufacturing, and ports and harbors. Anecdotal evidence of the relatively high HIV-prevalence rate among miners and the fact that Ashanti Goldfields Company (the largest mining company in Ghana) already had initi- ated a well-publicized AIDS awareness program for its employees made the mining sector an obvious candidate for developing CMS’s first sector-wide workplace program. A CMS assessment of the Chamber of Mine’s membership revealed that although many mining companies had some form of HIV/AIDS prevention program, most fell short of best practices, which should include • development of an HIV/AIDS workplace policy, • advocacy and education at all levels in the company, • peer education, • condom promotion and distribution, • voluntary counseling and testing, • treatment of sexually transmitted infections, • community outreach, and • monitoring and evaluation. CMS developed HIV/AIDS policy guidelines for the Chamber and assisted member companies in adapting the guidelines for their own purposes. CMS also linked the Chamber of Mines with GSMF International, to help each of the member companies develop and implement a program tailored to its needs and resources. The expectation is that individual mining companies will pay GSMF to implement best practice programs for their employees. The program targeted the Chamber’s 18,000 at-risk miners and 200,000 community members. Country Programs: Achievements and Results 39Final Report In addition, CMS undertook efforts to • Create commercial-sector demand. Because HIV/AIDS prevalence rates are low, CMS/Ghana had to con- vince companies that workplace HIV/AIDS pro- grams are worth undertaking. To demonstrate the potential financial benefit of prevention programs in a tangible manner, CMS developed an advocacy tool — a simple model that estimates the costs ver- sus the benefits of investing in HIV/AIDS preven- tion and treatment programs. CMS and the firm that developed the model taught local HIV/AIDS organizations how to use it to advocate for work- place HIV/AIDS programs. • Build the capacity of private providers to offer HIV/AIDS work- place services. CMS provided financial support and training in family planning and HIV-related serv- ices to C&J Medicare, a commercial health service provider for the 11,000 employees and depend- ents of 54 Ghanaian and multinational compa- nies. To receive a $200,000 loan from the Summa Foundation for a new hospital with expanded inpatient and outpatient capacity, C&J Medicare was required by Summa to promote fam- ily planning and voluntary counseling and testing for HIV and other STIs. The loan was used to open a new hospital with expanded inpatient and outpa- tient capacity and two consultation rooms dedicat- ed to family planning and VCT. To support C&J Medicare in meeting the loan criteria, CMS trained C&J Medicare staff in family planning and HIV-related services and procedures. • Provide HIV/AIDS treatment through the private sector. In collaboration with PharmAccess International (PAI), a Netherlands-based NGO, CMS devel- oped three private treatment sites that offer VCT, ARV therapy, and treatment of associated infec- tions. The initiative used ARV drugs available in Ghana at a moderate price. Because the clinics already offered a broad range of medical services, individuals seeking treatment there could be identified as AIDS patients. CMS trained staff members to administer VTC, and PAI provided training in ARV treatment. PAI also provided technical assistance to a laboratory (MedLab) in procuring equipment and in the procedures for monitoring viral loads and performing CD4 T-cell counts to support the treatment sites. Peer education is a key element of best practice HIV/AIDS workplace programs. Emmanuel is the head peer educator at Unilever’s Twifo palm plantation. 40 Commercial Market Strategies Project Country Programs: Achievements and Results CMS also helped Ghanaian health insurance firms develop an ARV rider (an optional supplement to their standard benefits package that would cover AIDS treatment). At the end of the CMS project in March 2004, PAI continued supporting existing sites and expanded the program with a two-year grant from the Royal Netherlands Embassy in Ghana. PROGRAM RESULTS PROGRESS TOWARD GSMF SUSTAINABILITY. Even with an expanded budget resulting from increased external funding, GSMF’s cost-recovery rate increased from 23 to 37 percent between 2000 and 2003. This increase was especially notable because higher levels of donor funding usually depress cost-recovery rates. GSMF’s cost-recovery rate of nearly 40 percent at year-end 2003 was much higher than that of compa- rable programs in Africa, typically between 8 and 10 percent. In addition, the improvements GSMF made in income generation and efficiency did not come at the cost of its social mission. Since 2001, GSMF- supplied CYPs increased by an average of 15 percent annually. GSMF’s social marketing activities may also have contributed to increased condom use across Ghana. For example, a reproductive health study conducted by GSMF found that condom use, as reported by men, increased from 9 to 19 percent between 1998 and 2001. IMPROVED WORKER KNOWLEDGE OF HIV/AIDS. A survey to evaluate the knowledge, attitudes, and behaviors of Unilever employees conducted before and after implementation of the enhanced program revealed an increased proportion of respondents who had accurate knowledge of HIV/AIDS prevention and transmission measures. For instance, 52 percent knew that absti- nence could prevent AIDS transmission, compared with 32 percent at baseline. Furthermore, 87 percent knew where to obtain condoms, compared with 80 percent at baseline, and 66 percent knew that con- dom use could prevent AIDS transmission, compared with 63 percent at baseline. This knowledge will result in reduced HIV-transmission among Unilever employees and in their communities. INVESTMENT IN HIV/AIDS WORKPLACE PROGRAMS DESPITE LOW HIV PREVALENCE. Despite the challenge of working in a low-HIV-prevalence country, CMS mobilized companies to invest in HIV/AIDS workplace programs. For instance, Unilever contributed about 32 TARGETING INDUSTRY SECTORS FOR HIV/AIDS PREVENTION: HOTELS AND TOURISM, PORTS AND HARBORS In collaboration with the Ministry of Tourism and the Ghana AIDS Commission, CMS conducted five workshops in areas with high concentrations of hotels to create awareness about HIV/AIDS and its impact on the hotel and tourism sector, obtain commitments from hotels to implement HIV/AIDS programs, and determine roles and levels of intervention for hotels. More than 300 hotel owners and managers participated in the workshops, and most agreed to explore workplace programs further. To follow up the successful workshops, CMS conducted a qualitative study to understand the role of hotels in the trans- mission of HIV/AIDS. CMS organized a national-level meeting to disseminate the results; link hotels with resources for condom procurement, educational materials, and training; and determine the next steps to implementing HIV/AIDS awareness and prevention programs. The program targeted about 200 hotels and should reach 6,000 workers. GSMF International is implementing an HIV/AIDS workplace program for the ports and harbors sector. CMS assisted the program by identifying high-risk groups in this sector and determining knowledge, attitudes, and practices related to HIV/AIDS. The findings were presented to key stakeholders, such as the Ghana Ports and Harbors Authority, and will guide the design of GSMF’s ports and harbors program. Workers in ports and harbors are at moderate to high risk of HIV/AIDS. GSMF is conducting a program that aims to prevent the spread of the infection. 41Final Report percent of the funding for its workplace program. Using CMS’s costing model, C&J convinced two firms to initiate HIV/AIDS workplace programs and its long- term client, Coca-Cola, to enhance its existing pro- gram and add a VCT center. After an actuarial study to price the addition of highly active antiretroviral therapy (HAART) to an existing commercial insurance policy, the insurer (covering 10,000 lives) agreed to add the benefit beginning in 2004. THE PHILIPPINES: CONTRACEPTIVE SECURITY AND PRIVATE-SECTOR STRATEGIES In 2003, there were 81.6 million people living in the Philippines. At the current annual growth rate of 2.2 percent, the country’s population will double in less than 30 years. Already, roughly 40 percent of the population lives at or below the poverty level. Total contraceptive use among married women was 49 percent in 2003–35 percent for modern methods — and has been increasing. The Philippines has a very young population: Women aged 15 to 19 outnumber women aged 45 to 49 by a ratio of more than 2:1. In addition, millions of women who report wanting to space or limit births did not using family planning. The total fertility rate was 3.5, but in the 2000 DHS, desired family size was reported at 2.7. In a national survey, 90 percent of all respondents said that it is important for Filipinos to be able to plan their families by controlling their fertility. As a result, demand for contraception will likely increase in the coming years. Through its public-sector clinics and hospitals, the government of the Philippines provides family plan- ning to 72 percent of all users in the country. Family planning products and services are offered regardless of clients’ income or ability to pay. But many women who use the public sector have the means to pay for private services. Nearly 70 percent of women in the upper-middle quintile obtain their contraceptives from the public sector, as do almost half of all women in the wealthiest quintile. The vast majority of these women indicate that they are willing to pay for family planning services. Segments of the population who live in poverty or reside in rural areas do not have access to family planning other than through public-sector clinics. For more than 35 years, most public-sector contra- ceptives provided in the Philippines were donated by USAID. In 2002, USAID announced plans to phase down contraceptive donations and redirect its resources toward more sustainable programs (that is, programs that promote a transition to contraceptive self-reliance). Accordingly, USAID has encouraged the Philippine government to take responsibility for purchasing contraceptives. Despite a budget alloca- tion for contraceptive procurement, however, the national government as of 2003 had not procured contraceptives for its public-sector program. (In fall 2003, the Arroyo government supported a family planning effort that focused on natural methods.) Local governments, which have responsibility for local health care provision, had begun contraceptive procurement in an inconsistent manner. Failure by the Philippine government to respond to this situation could lead to stock-outs in the public sector. A significant segment of public-sector clients who are too poor or too rural to have access to private providers could be adversely affected, potentially switching to less-effective traditional contraceptive methods or giving up contraception altogether. To prevent this outcome, USAID is supporting efforts to strengthen private-sector provision of fam- ily planning. The underlying strategy is to encourage or require clients with the ability to pay to obtain their contraceptives from the private sector, so that limited government resources can be targeted to clients with the greatest need. Since most family planning users — of all income levels — have sought care from government clinics for the last three decades, private providers’ knowledge and attitudes of modern contraceptive methods is sometimes dated. Early in 2002, CMS began working with physicians, midwives, and pharmacy sales staff to improve their family planning knowledge and counseling skills — critical steps in preparing these providers to play a larger role in meeting the country’s reproductive health needs. In addition, CMS facilitated the involvement of the Filipino business community in what the community refers to as the “population management” debate. Along with other social leaders, the commercial sector is concerned that the country’s economic growth will be outpaced by population growth, making it difficult to reduce poverty and improve quality of life. Business leaders thus are 42 Commercial Market Strategies Project considering providing family planning information and services to their employees and encouraging the government to expand its role as well. Two broad strategies defined CMS’s work in the Philippines: (1) training to increase the comfort level and skill of private providers in offering family plan- ning and (2) support for the business sector to expand provision of family planning information and services to employees and to transform its growing population management concerns into an effective public policy voice. Both strategies stemmed from CMS’s country assessment, as well as a market seg- mentation analysis that estimated the potential growth of the private sector if it were to respond to the country’s increasing contraceptive demand (cou- pled with the programmatic interventions required to achieve that potential). IMPROVING PROVIDERS’ KNOWLEDGE OF FAMILY PLANNING CMS conducted a qualitative study of private providers’ knowledge and attitudes toward family planning. Based on its findings, CMS determined that a multifaceted approach involving formal train- ing, targeted communications, and medical detailing would be the best way to improve private providers’ contraceptive knowledge and counseling skills (par- ticularly among pharmacy sales staff). CMS estab- lished two teams of experienced private-provider specialists — six regionally based field specialists and 40 medical detailers — and launched an evidence- based medicine communications campaign. In April 2003, CMS, with the help of its field spe- cialists, began developing partnerships with private- provider associations. CMS organized a variety of reproductive health training sessions, including workshops that provide participants with continuing medical education credits and technical sessions attached to association conferences. Between April 2003 and July 2004, an average of 20 training events were held each month — a total of 323 training events with over 14,000 providers in attendance. Private physicians, midwives, and pharmacy sales staff learned about recent findings in contraceptive tech- nology, discussed within the context of evidence- based medicine and best practices. To help private-sector providers become effective and confident sources of family planning services, CMS supplemented the professional training sessions with medical detailing visits. A team of 31 medical detail- ers visited providers on a bi-monthly basis, reiterat- ing and reinforcing critical information related to contraceptive counseling and use. To further reinforce training and detailing efforts, CMS undertook an evidence-based medicine com- munications campaign. (Evidence-based medicine integrates individual clinical expertise with the best available external clinical evidence from systematic research.) The campaign focused on placing repro- ductive health articles, technical updates, and medical guides in familiar and respected provider publica- tions, such as professional journals. PARTNERSHIPS WITH BUSINESS LEADERS AND INSURANCE COMPANIES Philippine business leaders are concerned that the country’s high population growth rate is threatening national economic gains. Over the next few decades, they doubt that economic growth will be high enough to generate sufficient numbers of jobs. And they are increasingly concerned about the government’s ability to provide adequate education and health and social services for the rapidly growing population. CMS worked with business leaders and organizations to raise awareness in the business community about the impact of rapid population growth on the business sector. In turn, an increasing number of business leaders spoke out to insist that the government take a more responsive course of action. By providing technical assistance and organizational support, CMS helped to raise the public policy pro- file of Filipino business leaders’ population con- cerns. For example, CMS used the electronic network that links geographically dispersed business associa- tion members (the Philippines is made up of 7,000 islands) to distribute BizPop, CMS’s bi-monthly e- newsletter that increases business owners’ awareness of population issues. BizPop highlighted the unique role that the business sector can play in population management, thereby helping build consensus for taking a public stance on the issue. It also educated businesses on the benefits of offering family planning services directly to employees. Country Programs: Achievements and Results CMS worked with the largest and most influential business associations in the Philippines to promote population awareness and implement population- related activities among the association’s members. These associations included the Philippine Chamber of Commerce and Industry (PCCI), the Employer’s Confederation of the Philippines (ECOP), the Philippine Exporter’s Confederation (PhilExport), the Personnel Management Association of the Philippines (PMAP), and Philippines, Inc. CMS conducted a series of dialogues with these groups in order to share important population management and program information needed to increase advoca- cy, awareness-raising, and interest-generation efforts among the associations and its members. These dia- logues provided a venue for firms that were already providing FP/RH services to share their best practices with the rest of the participants. Together with these associations, CMS proposed the formulation of a national business agenda for pro- ductivity and global competitiveness, which has as its objective, incorporating FP/RH services provision in the workplace as part of an overall strategy to increase productivity and global competitiveness. CMS linked up with, and tapped the resources of, other existing local FP/RH partners and cooperating agencies, including Responsible Parenthood and Maternal and Child Health Association of the Philippines (RPM- CHAP), Friendly Care Foundation, Inc. (FCFI), John Snow, Inc. – Well Family Clinic (JSI – WFC), DKT, and the Family Planning Organization of the Philippines (FPOP). As of August 2004, a total of 79 workshops and con- ferences had been held all over the country, with over 12,000 participants in attendance. Advocacy efforts to promote FP in the workplace were received favor- ably by the business community nationwide and resulted in the following specific accomplishments: • PCCI’s business conferences for each regional area, which were attended by the member cham- bers of commerce and industry associations for each region (i.e., National Capital Region, North Luzon, South Luzon, Visayas, and Mindanao), resulted in the passage of separate resolutions that urge the government to support private-sector population activities and encourage members to provide FP/RH services to employees. These area conferences culminated in the annual Philippine Business Conference (PBC), where members submit to the President of the Philippines a set of policy recommendations culled from these regional business conferences. • PCCI reorganized its organizational structures, assigned officers, and identified activities to strengthen population management advocacy campaigns in order to jumpstart and sustain efforts at the local or regional level. Among the changes to its organizational structure is the cre- ation of the PCCI National Population Committee. • ECOP committed to the formation of the Population Management Action Center (PMAC), which aims to bring FP/RH programs to the firm level. • PMAP conducted sessions where members shared best practices in the provision of FP/RH services. • PCCI and Philippines, Inc., formulated and pre- sented a list of 10 priority business issues (includ- ing population management) to the president and local candidates during the political parties forum held prior to the May 2004 elections. PROGRAM RESULTS The Philippines program has been effective in mobi- lizing commercial-sector organizations and industry associations to address population issues and in pro- viding up-to-date training and access to information to a large number of private providers about contra- ceptive technologies. Outcomes from these efforts were not measured in a systematic manner because of the relatively short duration of the program. Nonetheless, they provided USAID in the Philippines with a solid base of evidence that the corporate sector can be a valuable and dependable ally in expanding access to family planning through employer-based activities and provider-targeted initiatives. Both of these components will continue under a USAID- funded project that will follow on the footsteps of CMS, beginning in October 2004. 43Final Report Technical Assistance Projects 3 Technical Assistance Projects 46 Commercial Market Strategies Project Technical Assistance Projects TECHNICAL ASSISTANCE PROJECTS In addition to implementing large-scale, multi-year country programs, CMS also provided USAID Missions and local organizations with focused technical assistance (TA) to expand private-sector involvement in family planning and to improve the enabling envi- ronment for commercial-sector strategies. The TA provided was fairly broad in nature and included TA for social marketing organizations, TA on NGO sus- tainability, contraceptive security assessments, market segmentation analyses, and feasibility studies of private-sector HIV/AIDS treatment programs. These efforts were complemented by core-funded initia- tives to advance the state of the art in private-sector family planning. The initiatives included diagnostic studies, country assessments, pilot projects, and Summa Foundation loans. They were undertaken as a way to stimulate Mission interest in promising projects and to test the potential for private-sector involvement and desired health outcomes. Technical assistance activities and core-funded initia- tives were generally not undertaken in isolation but in various combinations, depending upon the partic- ular context. Discussed below are selected examples — in selected settings — of these activities. Although more limited in scope and duration than country programs, they provided valuable knowledge and pointed to potential new areas of activity in future USAID programs. TECHNICAL ASSISTANCE TO NGOS Between 1998 and 2004, CMS provided sustainabili- ty assistance to NGOs in 12 countries and held regional sustainability workshops in Africa, Latin America, and the Arab world. As a leader in private- sector approaches to reproductive health, CMS brought a rigorous, integrated approach to NGO sustainability programs. In illustrating CMS strategies, results, and lessons learned, this section draws on three examples, in addition to the NGO strengthening activities for Ghana and Nicaragua described in Chapter 2. Discussed here are activities in Dominican Republic, Brazil, and Bangladesh. DOMINICAN REPUBLIC: TECHNICAL ASSISTANCE TO ADOPLAFAM The NGO Asociación Dominicana de Planificación Familiar (ADOPLAFAM) was established in 1987 to offer reproductive health products and services to low-income populations. ADOPLAFAM has affili- ated clinics and a distribution network of commu- nity health workers, which grew from an initial 235 volunteers to over 1,500 in 2003. In 2001, it opened a diagnostic center to provide health servic- es to low-income consumers in an underserved part of Santo Domingo. CMS began working with ADOPLAFAM to improve its sustainability in 1999, when the NGO’s largest donor (USAID/Dominican Republic) began to reduce its funding for population programs. Among other activities, CMS worked with the diag- nostic center to increase the number of paying clients; by improving center efficiency, the center was able to increase monthly income from an aver- age of $2,937 in 2001, to $5,085 in 2002, and to $5,710 in 2003. CMS helped ADOPLAFAM devise an ambitious plan to improve its institutional structure and to strategi- cally diversify its portfolio of services and products. ADOPLAFAM has maintained and protected its social mission, providing for the poorest of the poor via a voucher system, while expanding profitable serv- ices that will be used to cross-subsidize other pro- grams. By carefully devising a long-term strategic plan, being responsive to the needs of the surround- ing community through the addition of new labora- tory services, and adopting good business practices, ADOPLAFAM is now more sustainable and self-suf- ficient. Between 2000 and 2003, ADOPLAFAM’s cost-recovery rate jumped from 26 percent to 52 percent, and the USAID proportion of funding declined by more than half. However, during that time, couple years of protection decreased, as ADO- PLAFAM shifted its service delivery focus and USAID population funding decreased. This tendency has been observed in other settings as well (e.g., Cambodia), as NGOs diversify their services from family planning into mother and child health or HIV/AIDS. 47Final Report 1999 2000 2001 2002 2003 Cost recovery rate – 26 35 39 52 USAID funding 54 24 22 23 20 as % of budget CYPs generated – 15,906 31,738 28,510 22,389 BRAZIL : TECHNICAL ASSISTANCE TO BEMFAM BEMFAM, the Brazilian International Planned Parenthood Federation (IPPF) affiliate, was founded in 1965 as a non-profit NGO with a mission to defend the right of men, women, and teenagers to receive reproductive and sexual health assistance, as well as to uphold their right to informed and free choice on family planning. It provides reproductive health services through a nationwide network of clinics and, over four decades, has become the most significant non-profit family planning organization in Brazil. BEMFAM works in 16 states and conducts more than 3 million consultations each year, mainly with low-income clients. BEMFAM has contracts with over 1,000 municipalities to support sexual and reproductive health activities. When CMS began working with BEMFAM in 1999, it had an annual operating budget of US$8 million. Of that amount, 63 percent was locally generated revenue and 37 percent came from international donors. With USAID funding scheduled to phase out after 1999, USAID/Brazil asked CMS to help increase BEMFAM’s sustainability. CMS provided targeted assistance to strengthen the NGO’s commercial division, which had been created under a previous project to generate revenue. CMS hired an external consultant to conduct an assessment of which areas could become more profitable. Based on the assessment, CMS helped BEMFAM increase the price of its PROSEX condoms and to expand mar- keting and distribution for the brand. During January and February 1999, BEMFAM ran a televi- sion advertising campaign for PROSEX, created with technical assistance from CMS. The commercial ran 83 times in four targeted regions. In addition to raising awareness, the television campaign increased condom sales in three of the four regions by 91 per- cent, compared to 44 percent in the country overall. Revenues from PROSEX sales increased from $105,000 per month to $140,000 between January and December 1999. CMS also helped BEMFAM improve the financial profile of its laboratories. Originally, BEMFAM’s laboratories served its own clinics and were not intended to generate a profit. CMS’s financial assess- ment determined that by offering their services to other medical providers in the community, the labo- ratories could become profitable by the end of 1999. With technical guidance from CMS, BEMFAM made several changes to the labs. For example, the sales strategy for the laboratory in Recife was adapted to better suit the characteristics of the local market. While the Recife lab’s initial marketing efforts target- ed HMOs, the health insurance market was weak in this economically depressed area of Brazil. Therefore, BEMFAM changed the primary target for laboratory services to private doctors. By May 1999, Recife’s laboratory had signed agreements with 68 doctors and two mid-sized hospitals to refer patients to BEMFAM’s labs. The NGO also explored performing hormonal clinical analysis via a partnership with an independent lab technician and adopting software used by the lab to keep track of commissions for doc- tors and sales representatives. By the time CMS completed its work with BEMFAM, the NGO was on track to becoming 90 percent financially self-sufficient. Beyond the improvements facilitated by CMS, progress toward sustainability was also supported by BEMFAM’s involvement in new areas (such as HIV/AIDS), which the organization had pursued on its own. BEMFAM’s creative and broad-minded approach to increasing revenue through service and product diversification was a sig- nificant factor in improving its self-sufficiency. With technical assistance from CMS to help structure its efforts, the NGO demonstrated that building on an established reputation in new ways could yield tangi- ble sustainability results. BANGLADESH: TECHNICAL ASSISTANCE TO SMC Bangladesh is one of the most densely populated countries in the world, with an estimated 120 million people. The country has undergone a remarkable demographic transition over the past three decades. The average life expectancy at birth increased from 46 years in 1974 to over 60 years in 2000. Over the 48 Commercial Market Strategies Project Technical Assistance Projects same period, the total fertility rate declined from 6.3 children per woman to 3.3, and total contraceptive prevalence increased from 8 percent to 54 percent. Although Bangladesh has been successful at meeting population goals, new challenges to contraceptive security are emerging. Historically, the country has been dependent on donated commodities to meet its family planning needs. Donations are declining, however, and are expected to fall short of future demand as the population grows and more couples use contraception. Two players dominate the family planning market in Bangladesh: the public health system and the Social Marketing Company (SMC) — one of the largest social marketing NGOs in the world. The public sector serves 64 percent of modern-method users; SMC provides 71 percent of all condoms and 29 percent of pills. Most of SMC’s contraceptive supplies are donated, and the organization traditionally has sold its products for less than cost. As donors are reducing the quantity of con- traceptive supplies, SMC must generate new income and improve its long-term sustainability. To improve SMC’s operational efficiency and long- term sustainability, CMS provided technical assis- tance in several areas, including organizational restructuring, strategic pricing, commercial part- nership development, and public relations and advocacy. ORGANIZATIONAL RESTRUCTURING. CMS’s organiza- tional assessment found that SMC could benefit from a more entrepreneurial organizational structure. Specific issues and recommendations included empowering mid-level managers and their staff to handle routine tasks, thereby freeing senior staff to focus on strategic challenges; revising the perform- ance appraisal system, so that individual staff output can be measured against pre-defined goals and indi- cators and that staff development (training) can be systematic and aligned with tasks and desired results; realigning the staffing structure with existing and anticipated marketing plans; and ensuring that posts are filled by qualified individuals. CMS’s reorganization plan was approved by the SMC board of directors. CMS also helped SMC recruit top managers, revise the SMC administrative manual, and finalize a new compensation package. The imme- diate outcomes of the restructuring program includ- ed a flatter, streamlined organizational structure, supported by revised administrative policies and a company-wide commitment to performance-based staff development. STRATEGIC PRICING. SMC sells pills and condoms pri- marily through private-sector outlets and distributes injectable contraceptives through the Blue Star pro- gram — a network of more than 2,100 providers, including general practitioners, gynecologists, and indigenous providers. To help, CMS conducted sur- veys to determine demand and willingness to pay increased prices and helped SMC develop a strategic, long-term approach to product pricing. COMMERCIAL PARTNERSHIPS. CMS helped SMC nego- tiate a five-year agreement with the pharmaceutical manufacturer Wyeth for the joint marketing of Nordette oral contraceptive pills. CMS assistance was also instrumental in initiating discussions with Ansell India for the marketing of a premium condom brand and with Wyeth for the marketing of the premium pill brand Loette. PUBLIC RELATIONS AND ADVOCACY. Although SMC had been successful in social marketing, it lacked a coherent public relations strategy. To help strengthen SMC’s relationships with stakeholders in the public and private sectors, CMS conducted interviews about communications issues with internal and external audiences. CMS found that new generations of gov- ernment officials did not have a clear understanding of social marketing, SMC’s history, or its valuable contribution to national family planning goals. To address this issue, CMS and SMC developed a com- munication and advocacy strategy, which included • forming an advocacy team for communication with the government; • creating a series of presentations, including a video documentary, aimed at improving SMC’s image; • expanding media-relations efforts, using infor- mational media kits, user testimonials, and regu- lar calls to the media; • conducting reputation surveys among various stakeholders to identify trouble areas; and • introducing an internal communications plan for better staff engagement. 49Final Report The new public relations/advocacy strategy was designed to improve SMC’s image in the eyes of the government, donors, and other audiences and to create an appreciation for the organization’s signifi- cant contribution to Bangladesh’s family planning program. NGO SUSTAINABIL ITY WORKSHOPS Between 2001 and 2003, CMS sponsored five multi- ple-day NGO sustainability workshops. These work- shops enabled NGOs to learn planning, financial, and business skills from CMS facilitators and to share their experiences with each other. Two of the work- shops — one in Africa and one in Latin America — were held in conjunction with Frontiers, a Population Council program. CMS also conducted a workshop for IPPF affiliates in the Arab region and two for affiliates of the African Alliance of the Young Men’s Christian Association. The workshops were rigorous and business focused, with a specific emphasis on planning, marketing, and financial strengthening through income-gener- ating activities. They offered skills and tools for business planning through lectures, group discus- sion, exercises, case studies, lessons learned and best practice presentations, and breakout sessions. At the end of the conference, participants presented an idea for a new service/product to generate income locally. In some cases, participants were given train- ing material and templates of planning documents on CDs to take back. “South-to-South” sharing of experiences was a constructive, cost-effective way to maximize donor investment in technical assistance. Exposure to other experiences, lessons learned, pit- falls, and success stories benefited NGOs at all stages of development. CONTRACEPTIVE SECURITY ASSESSMENTS CMS was a key player in USAID’s efforts to address issues of contraceptive security, both in assessing indi- vidual country environments and providing recom- mendations (Bangladesh, Armenia, Dominican Republic, El Salvador, Honduras, and Nicaragua) and in providing technical leadership for defining the private sector’s role in contraceptive security matters. BANGLADESH In Bangladesh, a market segmentation analysis was conducted to inform the policy dialogue among stakeholders and to help identify the most appropri- ate target markets for the public, private, and NGO sectors. Market segmentation analysis can highlight duplicated efforts or unproductive competition. Segmentation techniques can be used to meet the family planning needs of an entire population by identifying complementary roles (and target markets) for the public, NGO, and commercial sectors. For example, if upper-income groups can be shifted to the private sector and middle-income groups can be encouraged to use the subsidized (NGO) social marketing programs, then limited public-sector resources can be targeted to meet the needs of the lowest-income groups. CMS worked with the DELIVER Project (which helps developing countries establish effective supply chains for public health and family planning programs) to facilitate a participatory market segmentation approach to family planning policymaking. CMS and DELIVER produced a market segmentation report that was shared with stakeholders from the public, commercial, and NGO sectors. The analysis found that the Bangladesh market is somewhat seg- mented, but that there are opportunities for greater efficiency. Overall, the public sector meets between 75 and 90 percent of the contraceptive needs of the poorest quintiles and caters to the bulk of family planning clients in rural areas. NGOs are concen- trated in urban areas where they cater mainly to the poor, serving 18 percent in the poorest quintile and 7 percent in the wealthiest. The commercial sector meets the contraceptive needs of more than 49 per- cent of the richest quintile. Given these findings, a second phase of market segmentation analysis was undertaken to further examine the issues surround- ing discontinuation of specific contraceptive methods and opportunities for expanding household financ- ing of contraceptives through government fees or private-sector sales. A stakeholder conference provided useful feedback that helped tailor the analysis to address various stakeholders’ needs and to elaborate on opportunities for each sector. During a second conference, CMS presented tailored analyses to each of the stakehold- ers, who were then able to identify and discuss appro- priate roles for each sector. Participants agreed that 50 Commercial Market Strategies Project Technical Assistance Projects the core objective of improving resource allocation could not be achieved without a coordinated strategy involving the public, commercial, and NGO sectors. ARMENIA In Armenia, there is heavy reliance on abortion, and misconceptions about hormonal contraceptives result in low levels of modern contraceptive use. Yet fertility has declined significantly since independence. Low fertility combined with emigration has resulted in a population decline. Despite the potential hardships the nation faces as a result of falling population, at the individual level, Armenians express a strong desire to limit family size. During the 1990s, a network of family planning cabi- nets was developed with support from UNFPA and housed in public health clinics and hospitals. Supplies for these cabinets — condoms, oral contra- ceptives, and IUDs — were provided by UNFPA in 1998. In 2002, these supplies were expected to be exhausted or to expire within 12 to 18 months. Because the government was not likely to step in and procure contraceptives, USAID/Armenia asked CMS to undertake an analysis to examine the following questions: • What proportion of the population relies on the public sector for provision of family planning methods and, therefore, is at risk for losing access to its method? • Might social marketing be a cost-effective approach to meeting the needs of family planning users and intenders? • What is the likely projected demand for modern contraceptive methods in the short term? The CMS segmentation analysis showed that only 20 percent of ever-married women in Armenia used modern contraception. More women relied on tradi- tional contraceptive methods, while an even higher number used no method at all. Abortions were com- mon, and although the procedure was presumed to be free of charge, women overwhelmingly reported that the cost of abortions was a problem. Although government service providers dominated the market for clinical and long-term methods, condoms were heavily served by the commercial sector. As many as 90 percent of the condoms used by wealthier Armenians were purchased in pharmacies. Even the poor used private-sector sources, although to a lesser extent. A portion of contraceptive users relied on the public sector for their methods, however, and would be vulnerable if donated supplies disappeared. Based on these findings, CMS recommended that any contraceptive security strategy focus on the needs of the group that relies on public contraceptive sources. Specifically, CMS recommended that IUDs be made available to public-sector clinics for all who sought them and that donated condoms and pills be targeted to clinics that serve the rural and urban poor or women eligible for income assistance. Experience showed that most other Armenians could buy re- supply methods in the market. The creation of a social marketing program in Armenia was seen to be cost-prohibitive and to cut into the existing commer- cial market. In addition, given its pro-natalist ten- dencies, the Armenian government was not likely to support a visible social marketing campaign. To fur- ther strengthen and expand the existing private mar- ket, however, CMS recommended that a targeted effort be undertaken to work with existing private- sector distributors to improve patient education. LATIN AMERICA: A MULTI-COUNTRY STUDY In 2004, CMS completed a core-funded contracep- tive security study of four countries in the Latin American and Caribbean (LAC) region, assessing demand and supply patterns in Dominican Republic, El Salvador, Honduras, and Nicaragua. The study was conducted in response to USAID missions in the LAC region, which are beginning to phase out com- modity donations, causing recipient governments and organizations to face the challenge of ensuring con- tinued access to affordable, high-quality contracep- tives for those who need them. The study outlined strategies for accessing private-sector suppliers of oral and injectable contraceptives to meet the growing family planning needs of consumers in the region. It examined the ability and willingness of private sup- pliers to meet the needs of NGOs, governments, and the populations they serve. The study found that most female users in the four countries studied obtain contraceptives from the public sector or NGOs. Commercial pharmacies rep- resent less than 10 percent of the total volume of 51Final Report contraceptives distributed in the region and tend to focus on a high-income clientele. Trends showed users’ increasing reliance on subsidized products, underscoring the need to identify alternatives sources of supply for governments and NGO programs. The LAC study identified procurement options for public and social marketing programs, including • Negotiating for large-volume discounts directly with manufacturers’ upper management, rather than a local representative who may not be able or authorized to extend special prices; • Issuing tenders with local and regional manufac- turers of low-cost brands, who may offer a con- venient and low-cost alternative for governments; • Using the services provided by UNFPA’s central- ized contraceptive procurement office, which offers some of the lowest prices in the world. UNFPA services are accessible to both govern- ments and NGOs together with procurement training, local testing, and inspection; and • Partnering with IPPF, which is gearing up to be a major provider of low-cost contraceptives in the region to its affiliates, as well as to other NGOs and some governments. INVOLVING THE PRIVATE SECTOR IN CONTRACEPTIVE SECURITY As part of its core-funded technical leadership, CMS collaborated with many other USAID projects and partners and contributed to the development of guidelines and best practices. • CMS was one of the primary authors, with the DELIVER and POLICY projects, of the Strategic Pathways for Reproductive Health Commodity Security (SPARHCS) documenta- tion on conducting contraceptive security assess- ments, including the framework, approach, and guide to data collection. CMS participation ensured that the private-sector role in contra- ceptive security was understood and incorporat- ed throughout the materials. In this endeavor, CMS participated in a field test of the diagnostic tool in Nigeria. • CMS collaborated with the POLICY project, which hosted a workshop in Jordan in June 2002 on “Developing a Common Understanding of Contraceptive Security,” where CMS presented its work on the private sector and demand creation. • For USAID’s Contraceptive Security Working Group, CMS was the primary author on two of six lessons on contraceptive security. CMS wrote lessons on defining a role for the private sector through market segmentation and targeting, with input from the POLICY and PHRPlus projects, and on using demand-side interventions of social marketing and communication, with JHUCCP. SUMMA LOANS TO PRIVATE PROVIDERS Summa Foundation loans to private providers, both commercial clinics and hospitals, and to health sector NGOs (such as GSMF in Ghana) constituted an important vehicle for expanding the supply of quality health services in the private sector. Summa loans in Peru, Ghana, and Cambodia, summarized here, illustrate the technical approaches and health out- comes that CMS collaboration with Summa achieved. PERU: SAN PABLO HOSPITAL In 2001, the Summa Foundation designed an inter- vention in partnership with the San Pablo Hospital Complex (SPHC), the largest commercial health care provider in Lima, to increase access to care for the underserved. SPHC, which operates five medical facilities and a medical training school in Lima, is an ideal partner for several reasons. First, it was inter- ested in expanding its operations into lower-income areas. Second, the owner recognized the importance of MCH and was willing to work with the Summa Foundation to promote it. Third, SPHC was seeing high rates of STIs and cervical/vaginal disease at its clinics and agreed that there was a demonstrated need for an integrated health program that includes volun- tary family planning, STI prevention, and education. SPHC received a $1 million loan from the Summa Foundation to construct and equip a new MCH clinic in the San Miguel district, a lower-middle-income neighborhood in Lima where health care is dominat- ed by the public sector. SPHC’s San Miguel Clinic is 52 Commercial Market Strategies Project Technical Assistance Projects the first large, commercial health care provider in the district. In exchange for the financing for this expan- sion, SPHC agreed to promote an integrated repro- ductive health program at all of its facilities. The loan to SPHC had two primary objectives: (1) to shift middle-lower income users in the San Miguel area from the public sector to the private sector, alle- viating some of the demands on the district’s public health system, and (2) to improve and expand the commercial delivery of voluntary family planning, reproductive health, and other primary care services in an underserved area of Lima. The clinic opened in January 2003. During the first three quarters of the year, family planning visits increased across all methods. Family planning and reproductive health visits also increased throughout San Pablo’s other facilities, reaching 33,000 through September 2003, an increase of about 30 percent over 2002. The Summa Foundation estimates that the new clinic will benefit directly more than 276,000 residents of San Miguel and neighboring districts, including 49,000 children and 62,000 women of reproductive age. During the term of the loan, SPHC expects to see over 46,000 family planning clients. GHANA: C&J MEDICARE In May 2002, the Summa Foundation extended a $200,000 loan to C&J Medicare, a commercial health service provider in Ghana, in order to expand reproductive, pediatric, and other health services. C&J used the loan to complete construction and to equip and refinance a new health facility. The loan enabled C&J to add a surgical theater; increase inpa- tient and outpatient capacity; improve diagnostic ability; open a stand-alone pharmacy; and promote family planning, voluntary counseling and testing, and maternal and child health. The new facility opened in January 2003. It offered family planning services, including long-term meth- ods; promoted family planning more widely among clients; promoted and distributed contraceptive products; and dedicated two of its new consultation rooms for family planning and voluntary counseling and testing. C&J clinical staff received VCT training in March 2003 and family planning training in the summer and fall of 2003. Client visits and revenue increased significantly right away; VCT and family planning visits were initially relatively slow, but serv- ice statistics in all areas are expected to increase. CAMBODIA: REPRODUCTIVE HEALTH ASSOCIATION OF CAMBODIA The Summa Foundation provided a $150,000 loan to the Reproductive Health Association of Cambodia (RHAC) in July 2001 to purchase its main clinic and headquarters in Phnom Penh. The objective of the loan is to increase RHAC’s sustainability by no longer having to pay rent on the Phnom Pen property. The loan also allowed the clinic to construct three addi- tional consultation rooms, expanding its capacity by 45 clients per day. Summa also provided technical assistance to RHAC in 2002, promoting sustainabili- ty through proper investment of cash reserves. RHAC is Cambodia’s largest private reproductive health provider, offering clinical reproductive health care, health outreach, adolescent and workplace- based programs, and training. RHAC has established itself as a leader in family planning, dual protection, HIV/AIDS counseling, STI prevention, and antenatal and postnatal care. RHAC, known for high-quality care at affordable prices, operates six reproductive health clinics and health outreach programs in five provinces of Cambodia. Summa is monitoring RHAC to determine whether there is a positive change in revenue during the loan period. As of June 2003, there was a 26 percent increase in revenue compared to the baseline. Clinical care generated the most revenue, followed by pharmacy sales, laboratory fees, and sales of family planning products. By no longer paying rent on the clinic, RHAC had a total cost savings of $21,348 by September 30, 2003. In terms of service delivery, the loan was also contributing to RHAC’s mission: com- pared to the first six months of 2001, the baseline period, there was a 34 percent increase in total client visits for all RHAC clinics and programs. In addition, there was a 24 percent increase in voluntary family planning acceptors and a 16 percent increase in cou- ple years of protection. Nonetheless, RHAC has experienced a 36 percent decrease in family planning clients, as a broader service delivery mix has been introduced, including child survival and HIV/AIDS. 53Final Report HEALTH FINANCING Providing access to affordable products and services through health financing mechanisms, including insurance and third-party payments, was an impor- tant component of the CMS core-funded technical leadership mandate. CMS addressed this issue through a Technical Advisory Group meeting, which served to frame the key opportunities and constraints for expanding family planning and reproductive health through financing mechanisms. In parallel, CMS provided inputs into the health care financing programs in Uganda and Ghana, and undertook a core-funded initiative in Nicaragua to address key factors impacting utilization of family planning serv- ices under an innovative health insurance model involving private providers. TECHNICAL ADVISORY GROUP In 2000, CMS convened a one-day Technical Advisory Group (TAG) meeting in Washington, DC, for USAID and the cooperating agency community, for technical experts and corporate representatives in the health insurance field to explore options for uti- lizing health financing mechanisms to expand family planning service provision in developing countries. The TAG meeting determined the following: • Geographically, the greatest potential for utilizing health financing lies in Africa and Asia. Although per capita health care spending is low in Africa, the government is usually a weak service provider, and a well-run insurance plan can provide better service at an acceptable cost. In Asia, existing pri- vate health care spending, already larger than in Africa, must be structured into health insurance mechanisms. Such mechanisms must move beyond conventional indemnity insurance to use of innovative payment and quality control meth- ods. One strategy would be to move existing insurers “down market” to lower-paid employees in large industrial enterprises, offering group enrollment in a limited benefit policy that includes primary and preventive care. Where social security systems are strong, as in much of Latin America, the market for private health insurance schemes will be limited. In Latin American countries without strong social security systems, there may be some market for “mutuelle- type” plans if government services are absent or of poor quality. To prosper, any such plan must be based on a strong pre-existing community group or private provider. • Support for health insurance mechanisms is, at best, an indirect way of increasing contraceptive prevalence or shifting users from government services. While primary care and reproductive health services can be included in an affordable benefit package, contraceptive usage patterns will not soon change as a result. Improving primary care is a better reason to support health insurance mechanisms. Enlightened managers and most beneficiaries see the advantage of including pre- ventive services. Insurance can lower the barriers to primary care, particularly where competing government services are weak. Support for health insurance mechanisms should be based on achiev- ing broader health system goals, not on a desire to directly impact contraceptive use. NICARAGUA: PRIVATE PROVIDERS INIT IATIVE In collaboration with the Summa Foundation, CMS undertook a number of initiatives to increase repro- ductive health care delivery through private-sector providers. These included a public-private partner- ship to expand the family planning services of two private providers that are under contract to the Nicaraguan Social Security Institute (INSS). In 2001, CMS and Summa entered into a partner- ship with the INSS, which contracts out service deliv- ery to private providers under a broad program of decentralization and health care reform. In 1994, the INSS had introduced a new health care financing and service delivery model under which INSS collects contributions from employers and employees and makes monthly per capita payments to public- and private-sector providers for a basic package of health services. The contracted providers, known as Empresas Medicas Previsionales (EMPs), include for-profit firms, Ministry of Health facilities, and NGOs. By 2002, the INSS model covered about 13 percent of the pop- ulation, with 214,000 enrollees and about 466,000 spouses and children. The INSS package covers a wide range of preventive and curative services, including reproductive health care; maternal and child health care; prenatal care; 54 Commercial Market Strategies Project Technical Assistance Projects family planning counseling; and temporary, long- term, and permanent methods of contraception. The model is ideal for private delivery of reproductive health and family planning services and for shifting users from public-sector to private-sector sources. To help INSS improve the quality of and capacity for reproductive and maternal health services, CMS and the Summa Foundation also partnered directly with Salud Integral and SuMedico, two of the leading private-sector EMPs working with the INSS. To determine the two EMPs’ needs for technical assis- tance, CMS and Summa surveyed more than 1,00

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