How Social Marketing and NGOs are Expanding Access to Emergency Contraception

Publication date: 2012

To learn about about how this sector is expanding access to EC and what additional steps could be taken, we conducted a survey of four international social marketing organizations (DKT International, Marie Stopes International, Population Services International, and ProSalud Interamericana) and the International Planned Parenthood Federation. We investigated a variety of indicators to assess how successful each program is and why; we also explored barriers to providing EC in programs that have not incorporated EC into their method mixes or have not done so successfully. Our four main findings are: 1. There is potential for great success with EC in the social marketing sector. 2. The majority of social marketing family planning programs do not include EC. 3. A variety of barriers exist that prevent programs from providing EC. 4. We need to learn more about the interaction between social marketing organizations and the commercial sector. Great Potential There are at least ten social marketing programs that have been very successful with EC provision as demonstrated by high volume sales. The driving forces behind these achievements range from government support to advertising and public education to other more general factors that affect contraceptive uptake and preference for EC. Country program examples with factors theorized to be driving these successes include: • IndIa (MSI): a) Government approval of OTC sales; b) mass media advertising; c) large urban population; and d) introduction of a single pill product. How Social Marketing and NGOs are Expanding Access to Emergency Contraception EC a nd S oc ia l M ar ke tin g The term “social marketing” has a host of meanings, but here we refer to the selling of EC products by a non-profit/NGO organization. The sale of the EC products can take a number of forms, such as: • A commercial partner distributes the product through commercial outlets while the NGO provides support such as advocacy with policy makers, advertising, training of providers, and outreach to women. • An NGO registers, imports and distributes the product either through commercial outlets or through branded or “franchised” clinics, pharmacies, or drug sellers. Social marketing programs successfully provide reproductive health products and services around the world. They work through existing commercial channels, normalize these products by placing them on the shelf along with other health and household related items, and innovate in their branding, advertising and marketing. Social marketing agencies bring experience in reproductive health and a passion for social good to commercial partners and products. With a special focus on the poor, social marketing programs sometimes subsidize a product in order to provide it at an affordable price. The private, non-profit sector, which includes NGOs and social marketing organizations, has a unique role to play in making EC and other family planning methods available to women in developing countries. February 2012 2 • VIetnaM (dKt): a) Women like the price and convenience of EC; b) competitive pricing; and c) government support for EC and social marketing programs as part of its population policy. • Venezuela (ProSalud): a) Word of mouth; b) widespread high purchasing power; c) high use of oral contraceptives and low use of other contraceptive methods, especially long-acting methods; and d) high rates of unprotected sex. • ethIoPIa (dKt): DKT’s EC sales in Ethiopia were substantially higher than projected, for reasons that are unclear. Possible contributing factors include: a) rapid urbanization; b) low use of regular methods of contraception coupled with a desire to avoid pregnancy; and c) convenience and discretion of private sector marketing. • PaKIStan – GreenStar (PSI): a) Continuous promotion among providers in social franchise clinic network; and b) promotion within the commercial market. There are two other products available besides ecp® (Greenstar’s product): emkit® (a local product) & Postinor.® Greenstar estimates having 85% of the EC market. In addition, some countries have not had very high EC sales but are showing growth and potential for continued improvement. Programs that appear to be growing include: • IndoneSIa (dKt): a) Wider availability of the product in pharmacies due to improved distribution; and b) greater awareness by shop owners, shop staff and customers. • eGyPt (dKt): a) “Rebranding” of EC as a responsible choice for couples; b) direct-to-consumer educational campaigns and promotional activities; and c) doctor/pharmacist education. eC is still not inCluded in Majority of ProGraMs Only 33% of social marketing family planning programs have substantial EC programs: • dKt: 39% (7/18) of family planning programs include EC. • MSI: 74% (28/38) of family planning programs include EC but if we only include programs that sold at least 1,000 EC packs in 2010, the percentage drops to 37% (14/38). • PSI: 18% (7/39) of family planning programs include EC. • ProSalud: 100% (5/5) of family planning programs include EC. MultiPle Barriers to eC Provision There are multiple reasons for why social marketing country programs have not included EC in their method mixes, ranging from lack of prioritization at the organizational level to limited program scope to political/legislative barriers. Other programs are in the process of registering an EC product and hopefully will be adding EC soon. Finally, there are many country programs that have included EC in their family planning programs, but with very minimal success. Barriers to successful EC provision (with country examples) include: Policy Barriers • PhIlIPPIneS (dKt): EC delisted by the Philippines Food and Drug Authority. DKT Philippines will not pursue EC unless FDA reverses their position. Main barriers are thus a) regulatory environment; and b) the Catholic Church. • Peru (ProSalud): (Program with minimal success.) Court decision declaring EC an aborti- facient and prohibiting public sector distribution has had a dampening effect in the private sector. • ChIle (ProSalud): (Program with minimal success.) Prescription requirement plus taboo history make it hard to successfully promote EC. Funding Barriers • MalawI (PSI): EC not yet introduced due to lack of funding. (The public sector already has EC; generally accepted but very few efforts to market or promote, resulting in very low uptake.) • MultIPle CountrIeS: Lack of donor funding to socially market EC is limiting the ability of some social marketing organizations to promote EC in more countries. The Funders’ Network, which analyzes RH spending by US private foundations, estimated that grants supporting EC made up 0.2% of all population-related funding in 2007 (the last year for which such data is available). Institutional Barriers • MalaySIa (dKt): Condom-only program • MultIPle CountrIeS: Some major social marketing organizations do not see EC as a priority (they are focused on other family planning and/or abortion services) and thus have not included EC in many of their country programs. Knowledge Barriers • CaMbodIa (MSI): (Program with minimal success.) There is very little demand for EC in Cambodia. A key barrier is lack of client knowledge that EC is an option. It’s also possible that some clients are getting EC direct from pharmacies. Multiple Barriers • MadaGaSCar (MSI): Barriers are a) the authorization process as it can take a very long time; b) the cost for potential clients who are mostly young; and c) lack of EC knowledge among the population. EC in the Pipeline • brazIl (dKt): In the process of registering EC (which is widely accepted in Brazil). • CaMbodIa (PSI): In the process of introducing EC by using PSI program income as a revolving fund; hoping product will arrive June 2012. soCial MarketinG and the CoMMerCial seCtor In some countries, EC access may be fairly widespread through the commercial sector, making it harder (and also less necessary) for social marketing agencies to provide the product. Three examples: • MexICo (dKt): In 2010, pharmaceutical companies decided to distribute directly in the retail market, ending their relationship with most distributors at that time (including DKT). On the other hand, EC, in particular Postinor-2, is apparently widely available and successfully offered via the commercial sector. • IndIa (PSI): Decline in social marketing sales is mainly due to the fact that there are more than 10 commercial companies promoting EC in a highly competitive commercial market. Additionally, free supply is provided through the public health system. Overall, EC sales are growing in India; however, PSI does not currently have any donor funding to socially market EC. • CaMbodIa (MSI): It’s possible that some clients are getting EC direct from pharmacies. 3 international Planned Parenthood federation IPPF was an innovator in providing EC through its clinic networks in a number of countries early in EC’s history. As EC has moved to over-the-counter status and the commercial sector has become more interested in supplying EC, the role of these networks has changed. Over 75 of IPPF’s country programs now include EC provision. The majority of these programs are clinic networks that provide direct healthcare services. Within these systems, there is a wide range of EC provision. High Volume Programs • SrI lanKa: This affiliate was among the very first providers of EC worldwide and has a mature program. It introduced EC through its clinic networks but realized very early that women prefer to access EC through pharmacies and so established a distribution system of Postinor-2 to private pharmacies. In this way, the Sri Lankan affiliate is acting much as a commercial distributor. Factors behind the success of this program include: a) EC has been available without a prescription/over the counter since introduction; b) island-wide distribution by more than 3,000 pharmacies; c) the government family planning program includes EC, indicating high-level support; and d) numerous promotional activities, especially at the time of EC introduction (dedicated hotline, jingle on Postinor-2, dealer incentives, promotion with pharmacists and doctors). Low Volume Programs • nIGerIa: IPPF-affiliated FP programs focus on provision of long-acting contraceptive methods. Barriers to provision of EC: a) Lack of funding for EC programs; and b) stock-out. At the same time, PSI has highly successful social marketing programs that provide EC widely at pharmacies and drug-sellers, so access is still assured for Nigerian women. • botSwana: Uptake of EC has been low due to lack of public knowledge on the availability of this service. In addition, the previous President of Botswana ordered EC’s status changed from an over-the-counter to a prescription drug; this has negatively impacted access. • Ghana: The gradual increase in EC provision can be attributed to the educational programs and campaigns done during the inception of their EC project. In addition, information on EC has been integrated into family planning (and other) counseling. EC (and another hormonal product, not EC but used post-coitally by Ghanaian women) is widely available through pharmacies. • Kenya: Private sector pharmacies dominate EC provision. Overall country success attributed to: a) role of private sector distribution; b) public education; and c) open market. disCussion As EC has become more available and accepted, the commercial sector has become increasingly involved in selling EC in some countries. In some cases this reduces the “share” of the EC market for social marketing and NGO programs. However, there are still many countries with inadequate access to EC and in these settings, the NGO/social marketing sector can play an important role in expanding access. A number of barriers to incorporating EC into NGO/ social marketing programs have been identified, but the majority of these can be addressed. We hope to see additional EC programs in this sector in the coming years. 4

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