Private Sector Contribution to Improving Health Outcomes in Fragile States: The Case of the Afghan Social Marketing Organization

Publication date: 2019

Private Sector Contribution to Improving Health Outcomes in Fragile States: The Case of the Afghan Social Marketing Organization ASMO has implemented USAID-supported social marketing programs for over a decade, and is now Afghanistan’s leading social marketing organization and largest private sector provider of many critical health products. Weakened by decades of conflict, Afghanistan is now rebuilding its public health systems. ASMO is complementing the government’s efforts by marketing six affordably priced and high quality health products: Asodagi condoms, Khoshi combined oral contraceptive pills, Khoshi injectable contraceptives, Shefa oral rehydration solution (ORS), Abpakon household water treatment solution, and Taqwia Khon iron-folic acid tablets. ASMO distributes these health products through a network of over 4,000 wholesalers, pharmacies, and general stores to ensure that products are easily accessible by men and women across Afghanistan. The Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project analyzed data from the 2015 Afghanistan Demographic Health Survey (DHS) and used established modeling tools to more fully understand ASMO’s contribution to health outcomes in Afghanistan. The Afghan Social Marketing Organization (ASMO) is a critical contributor to maternal and child health and family planning outcomes in Afghanistan. A substantial proportion of people residing in both urban and rural areas use ASMO’s products, as do people from both lower and higher socioeconomic strata. ASMO’s contributions demonstrate how social marketing programs complement the public sector in fragile states. • ASMO contributes nearly one-quarter of Afghanistan’s modern contraceptive prevalence rate (mCPR) through sales of its socially marketed family planning products. • ASMO contributes 16 percent of total household water treatment use, 11 percent of ORS use, and 5 percent of iron-folic acid use through sales of its socially marketed maternal and child health products. • Though a greater proportion of urban and wealthier users rely on ASMO’s brands, ASMO also meets the needs for a substantial proportion of rural and poorer users. This is possibly due to their extensive availability and affordable price throughout the country. Key Findings P h o to : N ai m at R aw an Methods Method 1—ASMO’s brand share using DHS For condoms and combined oral contraceptive pills, DHS specifically asks users which brand they are using. This allowed SHOPS Plus to calculate ASMO’s share of users for those products. Since men are more likely to recall the brand of condom they use, SHOPS Plus used Afghanistan DHS data from the men’s survey to determine ASMO’s contribution to condom use for family planning. For oral contraceptive pills, SHOPS Plus used Afghanistan DHS data from the women’s survey. For each product, SHOPS Plus analyzed the proportion of product users who reported that they (a) used ASMO’s brand of the product and (b) obtained it from a private source and not from a public facility. Method 2—modeled share using ASMO’s sales For products other than condoms and oral contraceptive pills, DHS does not ask users which brand they are using. SHOPS Plus used a combination of DHS and sales data to estimate ASMO’s brand share for their remaining products. First, SHOPS Plus translated Afghanistan DHS data on the percentage of people who reported using each product into estimates of the number of units of each product that must have been distributed to reach those users. To do this, SHOPS Plus used the methodology developed for the OneHealth Tool,1 the FamPlan,2 and the Lives Saved Tool (LiST)3 model. SHOPS Plus then used sales data from each of ASMO’s brands to estimate its contribution to total use of the product. Findings Nearly a quarter of modern contraceptive users rely on an ASMO product Figure 1 presents ASMO’s contribution to national use of condoms, oral contraceptive pills, and injectable contraceptives. The public and private sectors are both important sources of oral contraceptive pills and injectable contraceptives, with ASMO being the leading provider in the private sector. Nearly one-half of oral contraceptive pills users rely on an ASMO brand with the other half using public sector supplies. Similarly, one-third of women who use injectable contraceptives rely on ASMO’s brand and most others use public sector supplies. ASMO’s contribution to condom use for family planning is relatively low and supplemented by significant contributions from other social marketing organizations, the commercial sector, and the public sector. The public sector is the dominant source of long-acting reversible methods and permanent methods, and ASMO does not currently provide these products and services. 1 The OneHealth Tool, developed by Avenir Health, is a model used for supporting national strategic health planning in low- and middle-income countries. The tool facilitates an assessment of resource needs associated with key strategic activities and their associated costs. 2 FamPlan, developed by Avenir Health, projects family planning requirements needed to reach national goals for addressing unmet need or achieving desired fertility. The program uses assumptions about the proximate determinants of fertility and the characteristics of the family planning program (method mix, source mix, discontinuation rates) to calculate the cost and the number of users and acceptors of different methods by source. 3 LiST, developed by the Institute for International Programs at Johns Hopkins Bloomberg School of Public Health, is a model that estimates the impact of scaling up health and nutrition interventions on maternal, newborn, and child health, and stillbirths. Figure 1. Among condom, oral contraceptive pill, and injectable contraceptive users, percent using ASMO brands Asodagi condoms Khoshi oral contraceptive pills Khoshi injectable contraceptives 14% 46% 32% To obtain ASMO’s total contribution to national use of modern family planning methods, SHOPS Plus weighted estimates of ASMO’s share of users for each method by the total use of each method (including methods that ASMO does not socially market) among ever-married users in Afghanistan. Through this, SHOPS Plus estimated that ASMO’s annual sales of condoms, oral contraceptive pills, and injectable contraceptives contribute to 22 percent of Afghanistan’s total mCPR. Between 5 and 16 percent of users use ASMO’s brands for iron-folic acid, ORS, and household water treatment ASMO contributes 16 percent of total household water treatment use, 11 percent of ORS use, and 5 percent of iron-folic acid use through its socially marketed maternal and child health products. SHOPS Plus estimated ASMO’s contribution to national use of these products based on the number of units that ASMO sold to retail outlets. Estimates of contributions by the public sector and other actors is not available for these products. Nearly 1 in 4 modern contraceptive users use an ASMO product Contraceptive users across all geographies and wealth quintiles rely on ASMO products To examine the extent to which ASMO’s social marketing activities are serving remote and vulnerable populations, SHOPS Plus disaggregated the proportion of women who report using ASMO’s brands of condoms and oral contraceptive pills by their residence and wealth status as presented in Figure 2. Expectedly, ASMO’s brands are used by a larger proportion of women from the upper three wealth quintiles and those residing in urban areas. However, a significant proportion of poorer users and users residing in rural areas also use an ASMO brand. Figure 2. Among condom and pill users, percent using ASMO brands by residence and wealth status Urban/Rural Residence 18% 25% Urban Rural Upper 3 wealth quintiles Lower 2 wealth quintiles Wealth status 12% 57% 41% 10% 60% 40% Asodagi condoms Khoshi oral contraceptive pills Asodagi condoms Khoshi oral contraceptive pills ASMO’s contribution to use of maternal and child health products 16% contribution to household water treatment use 5% contribution to iron-folic acid use 11% contribution to ORS use Implications Decades of conflict have severely affected Afghanistan’s public health system. Despite significant gains in recent years, public sector products and services do not reach all population segments consistently. By socially marketing essential health products at low prices and through private sector distribution networks, ASMO has rapidly scaled up the population’s access to these products. As a result, nearly a fourth of all modern contraceptive users rely on ASMO’s products, and between 5 and 16 percent of essential maternal and child health product users rely on ASMO’s brands. ASMO’s contribution underscores the complementary role that social marketing plays in fragile states—they provide an alternate source of products for users who prefer the convenience of the private sector, and for those living in areas where public sector services are not available or experience stockouts. P h o to : N ai m at R aw an Sustaining Health Outcomes through the Private Sector (SHOPS) Plus is a five-year cooperative agreement (AID-OAA-A-15-00067) funded by the United States Agency for International Development (USAID). The project strategically engages the private sector to improve health outcomes in family planning, HIV, maternal and child health, and other health areas. Abt Associates implements SHOPS Plus in collaboration with the American College of Nurse-Midwives, Avenir Health, Broad Branch Associates, Banyan Global, Insight Health Advisors, Iris Group, Population Services International, and the William Davidson Institute at the University of Michigan. This brief is made possible by the generous support of the American people through USAID. The contents are the responsibility of Abt Associates and do not necessarily reflect the views of USAID or the United States government. July 2019 Find Us SHOPSPlusProject.org

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