So Marc Library

Submitted to:

A.I.D.I Office of Population Family Planning Services Division Rosslyn, Virginia

SOMARC YEAR IV-V WORKPLAN

July 1996

SO MARC LIBRARY

The Futures Group, Inc.

Prepared by:

SOMARCfThe Futures Group 10S0 17th Street, NW, #1000 Washington, DC 20036

Under Contract No. A.I.D.lCCP-30S1-C-00-2016-00 CONTENTS

INTRODUCTION 1

KEY OBJECTIVES 3

Increase Modern Method Prevalence Rates 3 Improve Cost-Recovery and Access 4 Maximize Use of Alternative Commodities 4 Increase Correct, Effective Use of Contraceptives 6 Develop Innovative Advertising and Promotion Techniques 6 Enhance Institutionalization of Local Skills 7 Information Dissemination 7 Research and Evaluation 8 Management Information Systems 8 Resource Issues 9

REGIONAL OVERVIEW 11

Asia/Near East 11 Newly Independent States 25 North Africa and Middle East 49 Sub-Saharan Africa 67 Latin America and Caribbean 77 INTRODUCTION

The Social Marketing for Change (SOMARC III) project is currently in its fourth year of implementation. This WORKPLAN provides a comprehensive overview of SO MARC's proposed activities for the remaining six months of 1996 through September 1997. Included in the workplan is an overview of the key objectives of the SOMARC III project and how they relate to the United States Agency for International Development (USAID) and particularly the Global Bureau's Population, Health, and Nutrition (G/PHN) Center's new strategic plan. The submission of the workplan is delayed due to the recent congressional mandates regarding fiscal year funding for 1996 (FY96) which also prohibited expenditure of these funds before July 1, 1996.

Included within this workplan are individual country plans, offering a comprehensive overview for each country, providing important background information, and including accomplishments for Years I through III. The individual country plans also describe the current challenges facing each social marketing initiative and describe the planned activities for 1996 and 1997 and their quantitative outputs. In addition, each country plan also presents a second scenario which describes SO MARC's expected activities and outputs if the project is extended to 1998. Within the resources section, there is also an overview of the financial information and additional resources required.

The activities described herein are funded through a combination of core, field support, and buy-in monies. SOMARC's core monies will be used to fund new initiatives, research and evaluation, and technical leadership activities. Field support and buy-in funds are designed to cover country-specific activities. KEY OBJECTIVES

Increase Modern Method Prevalence Rates usage through SOMARC III has contributed significantly to increased contraceptive methods. This commercial channels, and particularly with the promotion of long-term Population, Health, key objective for SOMARC is directly related to the Global Bureau's use by women and and Nutrition (G/PHN) Center's Strategic Objective #1 of increased Because it is difficult, if men of voluntary practices that contribute to reduced fertility. of any discrete not impossible, to measure the impact on contraceptive prevalence indicator through the family planning initiative, SOMARC monitors its contribution to this be attributed directly to tracking of sales and couple years of protection (CYP) that can its social marketing efforts. and CYPs have Since the beginning of SOMARC III in September 1992, sales a total cumulative increased approximately 9 percent from 1992 to 1995 with increase reflects an contribution of 15,402,165 CYPs as of December 1995. This historical increases, by approximate 3 percent increase annually. Based upon these cumulative CYPs. September 1997 SOMARC III will have contributed to over 26 million contribution to 43 Should this trend continue, SOMARC estimates a total cumulative .. the expected CYP outputs for million CYPs by September 1998. Table 1 summarizes 1996-1997 as well as for 1998 should the SOMARC project be extended.

Table 1. SO MARC CYP Summary

1992 1993 1994 1995 1996 to 1996 to 1997 1998 CYPs PRODUCT CYPs CYPs CYPs CYPs CYPs CONDOMS 515.092 437.123 632.305 919.704 2.013.390 3.391.299 VFTS 48,143 65,737 58,204 51,871 95,178 148,055 ORALS 1,276,419 1,373,673 1,354,410 1,363,052 3,956,813 6,561,233 INJECTABL 821,557 1,447,196 ES 610,430 496,238 391,367 394,507 IUDS 1,210,198 542,908 2,306,113 1,084,648 3,386,604 5,523,884 IMPLANTS - 670 75,920 193,435 348,111 541,506

SHORT- 6,065,381 10,100,587 TERM 1,839,655 1,876,533 2,044,919 2,334,627 LONG- 4,556,272 7,512,586 TERM 1,820,628 1,039,815 2,773,400 1,672,589 TOTAL 3,660,283 2,916,348 4,818,319 4,007,216 10,621,65 17,613,173 4

PREVIOUS PAGE BLANK 3 - ... Improve Cost-Recovery and Access

All of SOMARC programs are designed to pursue and the dual objectives of cost recovery maximized access. This key SOMARC objective is directly related Result 1.3 of enhanced capacity to G/PHN's for private, non-governmental organizations and community-based organizations (NGOs), to design, implement, and evaluate family planning programs. SOMARC sustainable is working with all of these types in its social marketing programs of organizations to expand access, but also ..... recovery and sustainability. to address increased cost In Latin America, for example, currently with NGOs, much of SOMARC's work is assisting them to improve the programs. cost-recovery potential of their This technical leadership is provided USAID's in a regional environment strategy is to phase out donor where assistance to these agencies. SOMARC's helps to improve the NGO's cost-recovery work access at the same time as ensure to quality, affordable family continued .... planning products and services. summarizes SOMARC's current Table 2 projections by product of cost-recovery sufficiency for each of its social and self marketing projects, and the expected should SOMARC be extended. status in 1998 - Maximize Use of Alternative Commodities

SOMARC continues to emphasize the use of locally commodities available or commercially purchased to eliminate reliance on USAID-sourced Throughout commodities as a key objective. the Asian, Middle East, Newly Independent States, and Latin American regions, the large majority of social marketing projects are using commercially or locally available products. purchased For those countries that started with there has been an increased donated products, effort to move these programs to key objective of commercial products. This the SOMARC III project is also directly enhanced related to G/PHN's Result 1.3 of capacity for private, NGO, and community-based ... implement, organizations to design, and evaluate sustainable family alternative planning programs. The emphasis sourcing of commodities helps on to ensure that programs are cost-effective sustainable and that they leverage and private sector resources where feasible. illustrates the current commodity Table 3 sourcing under SOMARC III representing a cumulative for all country programs, cost savings to USAID of over US$21 commercially sourced million for all of its ... products. Table 3 also depicts transition what additional products would to commercial purchase by 1998. ....

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1995.

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Project Products received funding Products funding

limited sector. sufficient

Condom

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Not USA/O USAIO Prod~~tlsubSidY

Graduated No fundin Continuinq

AU Continued

25 40 25 70

0 NA 0 NA 0 100 60 NA 100 NA 60 65 0

55 100

100 100 42 NA 42 100 42 42 NA

100

30 19 90 95

60 0 0 0 0 0 0

NA NA NA NA NA NA NA NA 50 100 100 100 NA NA 100 100 100 100 100 100 100 NA NA 100 100 NA 50 NA NA 50 NA NA NA 0 0 50

100 ;";,~~nCY/R.A;! 100 37

37 100 37 100 37 NA NA

100 100

100 100 100

0 0 0 0 0 0 0 0 0 0 0 0 19 19 19 0 30 30 40 0

40 0 0 I, 0 0 0 4

100 25 0 25 0 0 0 0 0 0

25 10

100

22 22 22

eurre~,mPI.

65 95 60 90 90 90

100 100 85 85 100 35 35 60 35 60

100 100 100 199. 42 100 100 42 42 42 50 100 100

50-100 I 50-100 50-100

50 57 90 85 85 85

100 100 100 75 75 50 100 25 100 100 100 100 25 50 100 100 25

100 37 37 37 37 50 50 NA NA 50 NA NA 100 100 100 100 100

100 100

50-100 50-100

50-100

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

35 0 0 0 0 25 35 0

80 0 0 0 75 0 0 0 0 0 0 0 25 0

0 0 0 0 0 0 0 0 0 0 6

100 100 20 20 100 100

100 17 100 100 100 100 100 100 22 100 100 22 22 20 20 20

e,,,,.ntdve,~~;omo

55 90

100

100 100 100 100 100 100 100 60 60 100 100 60 100 100 100 1998 100 28 100 100 45 100 42 NA 42 42 42 NA

100

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(

46 90 46

100 100 NA NA

100 100 100 100 100 100 100 100 100 50 100 100 100 100 100 50 100 100 50 100 100 100 39 100 100 100 22 100 100 100 37 100 37 100 37 NA 37 100 100 NA

100 100 100

100 100 100 100 100 100

Sal~~q:~rce

Distributionl

0 0 0 0 0 0

46 46 46 40 40 I

100 100 100 100 100 100 100 100 100 100 20 100 20 100 NA 20 NA NA 100 100 100 25 18 100 100 100 23 22 100 22 22 100 22 NA 100

100

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Current

0 0 0

100 100 NA 0 100 100 100 100

100 100 100 100 100 100 100 80

100 .99. 100 100 NA

NA NA

100 100 100 100 100

100 100 100 100 NA 0 100 100 100 100 100 100 100 100 100 100 100 100 100 100

100 100 100 100 100 100 80 100 100 100 100 100 100 100 100 NA 100 100 100 100 100 100 NA

100 100 100 100 100

100 100 100

eo~~,~dity

Status

,n'

0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 100 100 0 0 0 100 0 0 0 100 0 0 0 100 100 0 100 100 0 0 0 100

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100 NA

100 100 100 100 100 100 100 100 100 100

100 100

Test

.j"

Pills Pills Pills

Pills

NSV Pills Pills

IUDs PiUs

IUDs IUDs Pills

Pills

IUDs Pills Pills

DMPA Pills DMPA Pills

DMPA

DMPA DMPA

VFTs DMPA

Donated

OMPA Product! DMPA

Condoms

Condom Services Condoms

Condoms Preg. Condoms Services

Services

Services Condoms Products Condoms

Condoms Condoms Condoms

Condoms Condoms Commercial Condoms Condoms Condoms

Self-Sufficiency

II.

Ecuador Guatemala Haiti Jamaica Pe, Egypt

Jordan

CA.R.

Morocco Turkey

I'!iger Mali

Sene Swaziland Uganda To Zimbabwe

India Philippines Indonesia Nepal

Table

II -

Table 3. Commodity Sourcing

REGION! SOURCE COUNTRY PROQUCT 1996 1997 1993 AMERICAS BRAZIL IUDS e e e COLOMBIA CONDOM 0 e e JNJECTABLES e e e IMPLANT 0 0 0 IUDS 0 0 0 ORALS DC DC DC VFTS 0 0 0 ECUADOR CONDOM 0 0 0 INJE.CTASLES 0 e e IUDS 0 0 0 ORALS e e e VFTS e e e EL SALVADOR CONDOM DC DC DC .... ORALS DC DC DC GUATEMALA CONDOM DC DC DC INJECT ABLES 0 DC DC ORALS DC DC DC VFTS e e e HAITI ORALs e e e HONDURAS CONDOM 0 0 0 ORALS 0 0 0 JAMAICA INJECTABlES e e e ORALS e e e MEXICO CONDOM e e e .... IMPLANT e e e ORALS e e e PERU CONDOM e e e INJECTA8LES e e e ORALS e e e VFTS e e e ... ASWNEAR EAST INDIA CONDOM e c e ORALS e e e INDONESIA CONDOM e e e INJECTABLES e e e ,uos e e e ORALS e e e KAZAKISTAN INJECTA8LES e e e ORALS e e e NEPAL CONDOM 0 0 0 INJECTABLeS 0 0 0 ORALS 0 0 0 VFTS 0 0 0 PHILIPPINES CONDOM e e e INJECT ABLES e e e ORALS e e e PAPUA N. GUINEA CONDOM 0 e e ORALS e e e TURKEY CONDOM e e e ORALS e e e UZBEKISTAN INJECTA8LES e e e ORALS e e e NWAFRICA EGYPT CONDOM 0 e e INJECTABLES 0 e e IUDS DC e e ORALS 0 e e GHANA CONDOM 0 0 0 INJECTABLES 0 0 0 IUDS 0 e e ORALS 0 0 0 VFTS 0 0 0 JORDAN INJECTABLES e e e ORALS e e e CONDOM 0 0 0 "'" ORALS 0 0 0 MOROCCO CONDOM e e e ORALS e e e It4JECTASLE I I e e NIGER CONDOM 0 0 0 SENEGAL CONOOM 0 0 e ORALS 0 0 SEAFRICA UGANDA CONOOM 0 0 0 ORALS 0 0 0 INJECTABLE. 0 0 0 ZIMBABWE CONDOM e e e TOTAL COMMERCIAL PRODUCTS 42 TOTAL DONATED PRODUCTS 29" "28 TOTAL PRODUCTS "78 " "

6 Increase Correct and Effective Use of Contraceptives

SOMARC has incorporated a significant number of activities designed to increase correct and effective use of contraceptives. The key to ensuring correct and effective use is to plan and implement programs that integrate key concepts of quality of care - i.e. informed choice, mechanisms to ensure continuity, and interpersonal relations. This key SOMARC objective is related to G/PHN's Result 1.4 of increased access to, quality of, cost effectiveness of and motivation for use of family planning, breastfeeding, and selected reproductive health information and services. In Turkey, for example, SOMARC is introducing a number of "new acceptor" leaflets for consumers who have just started a new method. These materials are designed to provide detailed information to new users on correct use, management of side effects, follow up visits, and any special signs or symptoms requiring physician follow up. These materials are being made available in both pharmacies and private healthcare facilities.

More recently, SOMARC has been proactive in participating in the meetings of the Maximizing Access and Quality (MAQ) working group. Since many Collaborating Agencies (CAs) are unaware of all that SOMARC currently does in terms of quality improvement, SOMARC's participation in these working groups has been critical to increasing awareness of the broad range of activities that social marketing currently uses as well as to allow SOMARC to benefit and adapt where appropriate the new techniques being used by other agencies.

Develop Innovative Advertising and Promotion Techniques

SOMARC has long been committed to developing innovative promotion and advertising techniques. This key objective is directly related to G/PHN's Result 1.4 of increased access to, quality of, cost effectiveness of and motivation for use of family planning, breastfeeding, and selected reproductive health information and services. SO MARC monitors the impact of these initiatives by tracking increased sales and increased awareness and recall of key messages. Currently, SOMARC is developing plans to do mass media advertising for no-scalpel vasectomy services. To date, little mass media communication has been used for this method, and SO MARC is pursuing with AVSC International ways to link an innovative global campaign to some of their no-scalpel vasectomy programs. SO MARC is also aggressively pursuing new forms of media coverage which will also have significant impact. For example, unlike in the U.S., consumers in many developing countries still have very little access to health information. In some countries, the media is just beginning to respond to this demand for information, and the little information that is supplied is extremely well received. To take advantage of this important vehicle, SOMARC is creating and tapping into health programs and health news to discuss reproductive health. This type of non-paid media can also be extremely cost-effective. For example, in Jamaica, SOMARC is pursuing co-sponsorship of a highly viewed "Healthwatch," a program that is currently funded by BlueCross BlueShield of Jamaica to provide more information on contraceptive products.

7 Enhance Institutionalization of Local Skills

Under the terms of the project for both short and long-term assistance, SOMARC is required to provide training for local service providers and project personnel in areas of contraceptive technology, strategic marketing, marketing research, cost-recovery, integrated marketing communication, and services marketing. This key activity is also related to G/PHN's Result 1.3 of enhanced capacity for public, private, NGO and community-based organizations to design, implement, evaluate and finance sustainable family planning programs. SOMARC's training activities have helped further the institutionalization of local capabilities in these various types of organizations. In Mexico, for example, SOMARC will provide services marketing training to MEXFAM and FEMAP, two local NGOs, to help them diversify and strengthen their services, including internal and external marketing and management.

Information Dissemination

Another major component of SOMARC's global leadership initiatives is its responsibility to disseminate information and lessons learned on social marketing programs worldwide. As part of this activity, SO MARC will disseminate lessons learned in communications, public relations, distribution, research, long-term methods, services marketing and other new initiatives to the broad domestic and international agencies involved in reproductive health programs. This worldwide information dissemination will continue to be published through Highlights, occasional papers, journal articles, the new SOMARC Reports, a semi-annual report that spotlights on lessons learned from SOMARC's areas of expertise, and SOMARC's Practical Guide Series. ....

The newsletter Highlights will continue to report the current new social marketing programs and techniques. Upcoming editions will detail the launch of the Jordan Birth ... Spacing Project and a new look at the MEXFAM program. An upcoming edition will up date the Red Apple program in Uzbekistan and another will take an in-depth look at SOMARC's unique media training. There will 10 editions of the publication during the life of the project.

SOMARC Practical Guide Series on public relations has been very well received. In its ... second printing, more than 1000 have been sent throughout the world to more than 60 different countries, including Cuba, Syria, Iraq, Iran and Vietnam as well as many USAIO/missions. The next series installment will focus on Practical Marketing and Practical Communications. Eight new publications will be published during the remainder of the contract. The Practical Marketing editions are: Basics of Social Marketing, Marketing Plan Design, Basic Market Research, How to Plan for Self Sufficiency, Financial Management, How to Monitor a Research Agency, How to Monitor an Ad Agency and Distribution. Practical Communications will include Integrated Media Innovations and a final Practical Public Relations on Monitoring a Public Relations Firm.

SOMARC Reports is a new publication scheduled to appear in mid-summer 1996. It will serve as the official account of lessons learned from several of the most important SOMARC initiatives. The four editions will document sustainability, communications, 8 introduction of DMPA and services marketing. Occasional papers and journal articles will be written as technical presentations of SOMARC's efforts in certain areas, such as long-term methods and services networks.

Research and Evaluation

Research and evaluation is another very important area that will be funded through core monies. SOMARC will focus its research and evaluation activities on impact monitoring and cross-country studies designed to identify impact and key lessons learned. Currently, four special studies have been designed and are in progress under SOMARC III. These are: (1) Price Elasticity of Demand, (2) Monitoring the Market Impact of Graduated Products, (3) Lifestyle Differences Between Product Users and Nonusers, and (4) Impact of Services Marketing.

In addition, SOMARC is planning to conduct individual "impact monitoring" studies in countries such as Morocco, Turkey, Indonesia, Mexico and Jamaica. These activities will evaluate the short-term impact of social marketing as a private sector intervention and will document specific results of project activities.

Management Information Systems

SOMARC's management information systems are designed primarily to manage sales and financial information. In addition, the MIS staff is capable of producing ad-hoc reports in a wide variety of areas, based on the needs of other project staff. The systems are PC-based and located in the Washington, DC SOMARC office. Both the sales and the financial MIS are Paradox-based systems that allow reasonably sophisticated manipulation of data through menu-driven applications which users with limited relational database skills can input and access information. MIS are managed by the MIS director and assistant who are also able to create and provide reports and other information not included in the standard applications.

The sales system operates from the bottom-up, with local staff providing monthly and quarterly sales information which is input into the primary database. Twice each year a massive report is produced which provides quarterly and year-to-date sales data by product for all SO MARC countries. In addition, the reports include data from non- SO MARC social marketing projects run by PSI and DKT. The reports are disseminated to all SOMARC offices, USAID and other cooperating agencies.

The financial MIS takes automated accounting files (DEL TEK) and manipulates the information in these files through a Paradox application to provide detailed monthly financial information to each country manager. After subcontractor invoices, regional office vouchers, travel expenses and the like are processed by the TFGI accounting office in Connecticut, the information is forwarded to Washington where it is reorganized into a user-friendly format by the Paradox database. Once reorganized, it can be manipulated to produce reports at varying levels of detail.

As a whole, the MIS provides sufficient information in both the sales and financial areas. However, the reports produced by both systems could be improved to provide 9 relevant information more clearly. The monthly financial reports have undergone several changes over the past year and continue to be changed to adapt to new budgeting requirements. The accounting department is contemplating the purchase of ... new software which would eliminate the need for the Paradox MIS system, thus allowing direct access to accounting files, and virtually unlimited ability to manipulate ... data into both standard and ad-hoc reports.

After review by the Project Director and the MIS staff, it has been determined that the sales report does not provide information in a format that is as useful as is necessary. Over the next few months, all sales data in the current database will be checked against source documents to ensure accuracy, before a decision is made regarding upgrading of the system into a Windows-based product.

Resource Issues ...

Funding and LOE levels for the Core contract were initially adequate to meet the requirements of the contract. However, there are three issues which have impacted on the ability of LOE and funding levels to adequately meet current and future requirements: delays in the delivery order process, the projected elimination of buyins, .... and changes in the USAID budgeting process. It is anticipated that current LOE and financial ceilings imposed by the Core contract will be insufficient to meet requirements.

Deliverv Order Process LOE distortions caused by delays in the delivery order process already have a negative impact on the project. Consultant, short-term technical assistance and marketinglfield positions LOE is overextended and is insufficient to meet future project requirements. Given the structure of Core and Requirements contracts, when delivery orders are delayed in execution, staff that has been hired and placed must be charged against .... Core LOE. The result has been that Core LOE, particularly for the three personnel categories listed above, has been exhausted at a faster rate than originally anticipated.

Elimination of Buyins Although buyins have been structured to cover field and local staff such as resident advisors, they were also originally projected to cover approximately 15% of full-time program staffs time over the life of the CSM III project. Now that the budgeting system has changed and Missions will be doing fewer buyins, LOE that would normally have been covered by buyins will come into the Core contract. Current LOE ceilings are too low to absorb this additional LOE.

The adequacy of funding levels is tied to both LOE issues above. Because the Core - contract is expected to absorb greater levels of LOE than anticipated, it must also absorb greater levels of expenditures for labor, overhead and related costs. With the elimination of buyins, it is also expected that Mission requested support will need to be funded by the Core contract. This will add to the burden on LOE and funds already created by delays in the buyin process. This means that not only will labor and overhead line items be insufficient to meet future requirements, but also subcontractor, other direct costs, equipment, and other line items will be insufficient to support requested in-country activities. FUTURES expects that without an increase in both 10 - ... LOE and funding ceilings, current resources will be insufficient to meet the projected levels of LOE and financial expenditures.

Budgeting Process Changes Changes in the USAID budgeting process will have a smaller, but nonetheless important, effect on SOMARC's ability to meet project requirements. The old budgeting process allowed the flexibility of responding to requests for limited technical assistance through Core central activities funds. Without this flexibility in Core funds, SOMARC will be unable to respond to requests for limited assistance, and unable to "cover" activities while waiting for delivery order approval on any outstanding buyins.

An additional strain on LOE expenditure has been that of project support staff. By including support staff in the LOE requirement, the projected LOE needs through the end of the project are higher than they need or should be. They also do not track with the funding of support staff, putting FUTURES in the position of initially having sufficient salary and overhead funds to hire the necessary support staff to efficiently administer and manage the project, but without the accompanying LOE allocation. To remedy this situation, FUTURES originally requested that support staff be removed from the LOE allocations. This strategy has been changed with our request to increase the LOE ceiling in the Core contract.

Funding and LOE levels for individual delivery orders under the Requirements contract have been sufficient to meet project requirements. FUTURES has designed LOE and expense budgets for each delivery order based on a specific scope of work, and the budget reflects the requirements of the delivery order.

II REGIONAL OVERVIEW

Asia/Near East ...

.....

12 India

In 1991, India's population had reached 865 million. The present annual growth rate is 2.1 percent. It took 65 years to double the 1901 population, but in the short span of last 20 years it has increased by a further 60 percent. In general, except for 1911 - 1921, the population has been steadily increasing. The population of India is young, with nearly 40 percent consisting of children below 15 years. The progressive increase in the 15-59 age group poses a threat to the Indian economy. The overall gender ratio has been increasing with more males per 1000 females. The male to female ratio in 1991 was 1076:1000. India's population grow1h is largely influenced by fertility and mortality trends. The average fertility continues to be as high as 4.8.

Uttar Pradesh (U.P.) is SOMARC's area of operation. U.P. has the largest population of any state in India. If independent, it would be the 7th most populous country in the world. Uttar Pradesh is estimated to have an overall population of 142 million, 20 percent of which resides in urban areas. Males outnumber females (917 females per 1000 males). Literacy rates for women are low (78 percent illiterate), and 89 percent of women do not work.

According to the U.P. National Family Health Survey (NFHS) 1992-93, the total fertility rate is 4.8 and the average desired family size is 3.4 children, reflecting a considerable gap between actual and desired fertility. According to this survey, 31 percent of women do not want any more children and another 26 percent want to wait at least two years before the birth of the next child. The knowledge of modern methods is less than universal among currently married women in U.P., with 65 percent knowing pills, 56 percent IUDs, 25 percent injectables, 67 percent condoms, 93 percent female sterilization, 88 percent male sterilization. Knowledge of sources for the contraceptive methods is far less. This survey further confirms that only 23 percent of married women of reproductive age have tried a contraceptive method, and only 19 percent are currently contracepting.

USAID Objectives The Government of India (GOI) and the U.S. Agency for International Development (USAID) embarked on a ten-year program to increase contraceptive prevalence in Uttar Pradesh (UP). The Innovations in Family Planning Services Project (IFPS) was created to achieve this objective. To achieve this purpose, IFPS project has three objectives:

• Increase access to family planning services.

• Improve the quality of family planning services.

• Promote family planning among couples.

• Develop a high profile and positive image for products that enable family planning, reproductive health and the prevention of HIV/AIDS

• Reduce barriers that would obstruct the acceptance of these products.

• Provide education and training to the people actually providing services or selling products.

SOMARC Objectives In 1994, SOMARC subcontracted two functional Indian organizations [Population Services International (PSI) and Parivar Seva Sanstha (PSS)] which were already engaged in contraceptive social marketing in the urban and peri-urban areas of U.P .. SOMARC's objectives are to: • Use commercial networks to make family planning, reproductive health, and HIV/AIDS prevention products and services more affordable and available to low income families.

14 PREVIOUS PAGE BLANK • Achieve some level of cost recovery.

Year I Accomplishments (1993) During 1993, SOMARC had not yet initiated its program in India.

Year II Accomplishments (1994) In 1994, SO MARC completed a secondary research review for U.P. which included review and analysis of the contraceptive market, potential sources of CSM products, and attitudes of consumers to temporary and long-term family planning methods. A preliminary market research plan was developed and RFPs for baseline survey were issued. To map consumer and provider perceptions, a KAP study and consumer focus group discussions were arranged to explore attitudes toward currently available spacing methods, brand perceptions and barriers. SO MARC chose a research agency to conduct a retail store audit of urban and rural markets. A public relations agency was also short listed to launch PR campaign for low dose oral contraceptives. .. • Finalized subcontracts with PSS and PSI in November-December 1994. • Achieved sale of 2,769,000 pieces condoms and 16,200 oral contraceptive cycles in November ,ioo;j December 1994.

Year'" Accomplishments (1995) In the second year of operations, SOMARC assisted PSI and PSS in selecting of advertising agencies and in developing brand-specific campaigns. SO MARC hired a research agency for conducting a baseline study for brand imaging/mapping and market segmentation. With the help of available research, advertising agencies of PSS I PSI were assisted in developing communication plans and media strategies. A shift in GOl's procurement policy, disrupted availability of condoms and OCPs.

• Achieved sales of 18,605,000 condoms and 216,887 oral contraceptive cycles without much media or communication support.

Challenges for the Future The prime challenges for SOMARC's India project are to involve private sector manufacturers in market expansion for condoms and pills, neutralize negative image of Family Planning and dilute strong social preference for male children, start Public Relations effort to counter feminist groups working against the introduction of DMPA as a component of family planning program, ensure uninterrupted availability of condoms and pills for ongoing marketing operations of PSS and PSI.

Scenario I: Year IV - V (1996-97) During 1996-97, SOMARC will respond to the growing demand and opportunities for private sector ventures, particularly in marketing commercial contraceptives and services. These products and services are needed to ensure expansion of family planning efforts and prevention of STD / HIV & AIDS. SO MARC will develop a comprehensive approach to stimulate increased private sector involvement to expand the commercial market for a broad range of contraceptive products including condoms, pills, IUDs and injectables.

• Assist USAID in preparing a plan of action for freeing up bilateral funds earmarked for the social marketing activities.

• Achieve sales targets of 26.24 million pieces condoms and 753 thousand cycles of pills.

• Implement PR activities in collaboration with SOMARC PR Director and PR ConSUltant.

, ' 15 • Continue implementation of marketing and advertising plans by PSS and PSI.

• Develop and implement training modules for Indigenous System of Medical Practitioners for expanded acceptance and availability of modern reversible contraceptives.

• Develop and implement delivery systems modules for CSM products in rural areas.

• Initiate market research activities that will help to identify new target audiences, develop appropriate delivery/distribution systems, and define new promotional strategies.

Scenario II: Year IV -VI (1996-98) An additional year of support will enable SO MARC to develop and implement strategies for countering feminist groups engaged in high pitch propaganda against the availability of DMPA as an additional method of contraception. This additional support will also help SOMARC in opening distribution outlets in all the 251 towns (with population of 10,000 and above) and networking tie-ups with the distributors who reach the smallest villages in the U.P.

• Assist PSS and PSI to have stockists and distribution tie-ups in 251 directly covered towns. ....

• Achieve the sale of 33.214 million pieces condoms and 1 million cycles of pills.

• Identify and contract manufacturers willing to participate in market expansion activities for condoms.

• Select private sector organizations for brand promotion and/or distribution of pills for social marketing.

• Intensify the efforts of adding DMPA and the IUD to the CSM method mix.

• Begin working with private practitioners and clinics on a services marketing scheme that would emphasize the delivery of longer term methods (IUD, and DMPA) and related reproductive health services.

Resources

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support" $1,038,056 $800,000 $1,838,056 $1,098,287 $739,769 $1,000,000 $2,000,000 OYB Transfer 0 0 Buyin 600,000 200,000 800,000 175,092 624,908 346,755 600,000 Total $1,638.056 $1,000.000 $2.638.056 $1,273.379 $1,364.677 $1.346.755 $2,600,000 .....

16 Nepal

While Nepal has shown some encouraging signs of progress towards reaching the government's health policy goals for the year 2000, continued strong support for family planning and maternal child health programs is still necessary. There remains a very large unmet need for family planning; a great number of gaps in family planning and maternal-child service delivery; and a large number of high-risk births.

Data from the 1991/92 Nepal Fertility, Family Planning and Health Survey suggest a strong and growing demand for quality family planning services. Mean desired family size has declined from 4.0 to 3.2 children since 1976, and the unmet demand for family planning is high. The survey estimated that approximately 1.1 million married women of reproductive age want to limit (51 percent) or space (49 percent) their next birth.

Currently contraceptive prevalence is 24 percent of MWRA, with sterilization accounting for the majority (21 percent), with temporary methods making up the difference. With the strong demand for spacing methods, there is tremendous potential for modern temporary methods. Research has indicated that the recently introduced injectable is fast approaching sterilization as women's method of choice, though access has and continues to be a problem. To serve an expanding consumer market, Nepal is covered by a vast array of retail outlets, including over 12,000 pharmacies and many more general shops, of various types. Many pharmacies have trained staff who provide for basic health care needs, including injections, so the potential to increase availability of the injectable contraceptives is promiSing. Although private physicians are few, the service quality is perceived to be higher than in the public sector and the potential for increased provision of family planning services through this channel is also quite promising.

USAID Objective • Increase the availability and use of quality voluntary family planning and reproductive health services in Nepal.

SOMARC Objectives • Enhance commercial distribution of condoms through aggressive marketing, distribution and promotion through all retail outlets, expanding beyond the traditional (pharmacy) network.

• Consolidate the current three pill brands to two by phasing out the current standard dose pill.

• Expand the current Sangini (DMPA) pharmacy program throughout Nepal, supported by national media promotion, quality of care training and monitoring of all Sangini retail outlets.

• Establish a sustainable Family Planning Services Marketing network that provides a range of affordable, quality reproductive health services through the private sector.

Year I Accomplishments (1993) SO MARC worked with its local implementing agency, Nepal CRS Company to develop more aggressive marketing and distribution strategies combined with organizational development to achieve more effective and cost efficient marketing of condoms and pills. SOMARC also developed a comprehensive marketing plan for the planned launch of DMPA, locally branded as Sangini in the Kathmandu Valley through a small, well trained and monitored, network of 50 pharmacies.

• Achieved sales of 5.7 million units of condoms.

• Achieved sales of 300,000 units of low-dose oral contraceptives.

17 .... • Achieved overall CYPs of 87,344, the highest sales in the history of the Nepal CRS Company.

Year II Accomplishments (1994) SOMARC continued its efforts to develop Nepal CRS Company as a cost effective marketing and distribution company, by providing training and technical assistance in financial cost-recovery, MIS, communications and research. Advertising and marketing efforts for condoms and pills was intensified, with new advertising for both methods. Through an agreement with USAID's AIDSCAP project condom distribution and promotional activities for the prevention and control of HIV/AIDS in Nepal were initiated. In the fall of 1994, SO MARC and its partner agencies - Nepal CRS Company and NFCC, launched DMPA through a pharmacy network pilot program in the Kathmandu Valley. Though sales were modest, the effort proved highly successful and plans were made for expansion.

• Achieved 7.2 million units of condom sales, an increase of 27 percent. ...

• Achieved sales of 400,000 oral contraceptives, an overall increase of 32 percent, with low dose orals achieving an impressive 59 percent increase over the previous year, through more focused promotional efforts.

• For the first time in its history, Nepal CRS Company surpassed 100,000 CYP achievement, with an overall increase of 26 percent over 1993 to 110,270 CYPs.

• CRS self-generated revenues also achieved a record high 5.7 million Rupees, a 90 percent increase over 1993.

Year //I Accomplishments (1995) During 1995, SOMARC expanded the successful Sangini pilot project to approximately 300 pharmacies, while also expanding the training and monitoring activities to ensure a high quality of care. "Mystery client" and user studies showed good counseling and high quality service provision and very high client satisfaction. Discussions were also initiated with AVSC and NFCC to expand family planning service provision through private physicians.

• Achieved sales of 8.6 million units of condoms.

• Achieved sales of 383,300 units of oral contraceptives, with low dose pills accounting for 43 percent .... share of pill sales, up from 36 percent share the previous year.

• Sangini (DMPA) program expanded to over 300 pharmacies, with sales of 11,221 vials.

• Total CYP achievement of 121,232.

Challenges for the Future SOMARC's major challenge for Nepal is to expand consumer access to quality family planning methods as well as information and counseling. The wide accessibility of pharmacies throughout the country makes them an ideal conduit for both products and information.

The current constraints for consumers are access and information. Women, especially, are poorly informed about available products and services, even though awareness of methods, per se, is quite high. - In fact, for all too many women, contraception means completing their families, then being sterilized. Spacing methods are poorly understood and husbands lack motivation to provide assistance in the choice of spacing methods. ...

AIDS prevalence is projected to increase rapidly in Nepal as a result of families torn for economic reasons. Nepali girls are "trafficked" to India, laborers leave their homes to earn needed cash to

llilii supplement insufficient farm income, and, as everywhere, transport workers and other businessmen find themselves away from their homes and families for extended periods of time. All of these factors create ripe conditions for the spread of the HIV virus through casual, unprotected sex. The challenge can be met, at least in part by greater availability and easier accessibility of condoms, combined with education/information

Scenario I Year IV-V (1996-1997) During 1996-1997, SOMARC will expand the private practitioner program to at least 75 physicians, expand condom distribution especially through non-pharmacy outlets, increase distribution of condoms and pills through multiple distribution channels, in addition to Nepal CRS Company, and increase the number of trained Sangini retailers to 500 .

... • Achieve graduated sales of 10 million units of condoms.

• Achieve graduated sales of 400,000 units of low-dose oral contraceptives.

• Achieve sales of 30,000 vials of Sangini and 1800 units of IUDs.

• Expand Services Marketing pilot network to include 75 facilities.

Scenario II Year IV-VI (1996-1998) To date, SO MARC activities have been implemented by a sole distributor, Nepal CRS Company. To assist CRS in cost effective social marketing, SOMARC has provided technical assistance to improve the organizational capabilities of CRS in sales, marketing, communications, distribution, and most recently integrating quality of care activities into functions with the introduction and launch of DMPA. Since 1994, CRS has expanded its product line with the introduction and launch of the injectable, DMPA, marketed locally as Sangini, and the inclusion of Virex, a disinfectant bleaching powder distributed to health facilities, and Safe Home Delivery Kits into its product line. Additional program activities now include condom promotion and distribution for the AIDSCAP project, including retailer training and video van operations. In 1995 discussions were initiated with KfIN to market a low dose pill under the Gulaf name to replace the USAID commodity as well as Jeevan Jal oral rehydration solution in cooperation with Royal Drugs. CRS has, also been successful in achieving cost recovery goals, and in 1995 covered 25 percent of its operational costs through self generated revenue funds. To meet its future cost recovery goals, CRS has developed a "Future Vision" plan which would enable it to cover 100 percent of operating costs, exclusive of commodities, by the year 2000. The implementation of these aggressive cost recovery goals would entail the re-design of CRS as a fully commercial business, with a social marketing commitment and mission, but include additional health products in its product line to expand its consumer offerings, and at the same time increase self-generated revenues.

In February of this year, the CRS management team determined to put in place an essential component of becoming more commercial- the elimination of redundant staff positions accumulated after years of operations as a protected social marketing monopoly. This plan, though conceived and put forward by the management team, was met with fierce resistance from within the organization, as well as dissension within the management team itself, creating a leadership impasse. In April, despite USAID's objection, CRS's Board of Directors stepped in and accepted the resignation of the entire management team, including not only the general manager and financial/administrative director, but also the deputy general manager/marketing director - the principal architect and gUiding force behind CRS's "Vision 2000". In addition, the resignations of 17 staff members and contract employees have also been accepted. At present, the organization is in a management transition crisis, and is seeking a new general manager/marketing director as well as a finance/administrative director.

SO MARC has recommended to USAID that this situation be viewed in the larger context of social marketing in Nepal. While CRS has been an able organization over the past 18 years, current demands by HMG and the donor community and market opportunities suggest that more effective and efficient social marketing results could be achieved by looking towards more commercial models of social

19 marketing, utilizing private sector distribution capabilities. With its current corporate culture, strongly influenced by years of enjoying a virtual market monopoly, the CRS organization has inherent difficulties in re-tooling itself. In order to develop a more commercial model of social marketing operations in Nepal, - SOMARC has recommended that market distribution activities be expanded to include the private sector, which has the distribution capability and has shown a keen interest in taking on social marketing operations. The CRS organization will have the opportunity to participate in this more competitive social marketing environment, and in the process, it is envisioned that the overall market can expand more effectively than with the current monopoly situation.

SO MARC feels that an additional year of support would allow SOMARC to facilitate the tnansition ... to a more commercial model of social marketing in Nepal, with one or more commercial social marketing distribution entities. The establishment of such capabilities will provide a valuable resource for all donors and HMG in distribution and marketing of all social marketing products in Nepal.

With an additional year of support, SO MARC would identify additional commercial distributors capable and interested in providing marketing and distribution of USAID commodities, issue RFP(s) for commodity distribution and implement this commercial social marketing project. SOMARC would also continue support of the Nepal CRS Company, during its management transition process. Establishing a more commercial distribution model is expected to increase the total market share of socially marketed condoms and pills to over 50 percent. SOMARC would also expand the Services Marketing approach to reach additional urban areas of Nepal. The network approach would have been fully tested and documented, highlighting the major strengths and weaknesses of the strategy for other private sector projects. The additional year of support would also allow the network to become fully sustainable - with day-to-day management of the network being taken over by a local implementing agency, NFCC. The approach would also have a strong "halo" effect on other private facilities, stimulating them to increase quality of services, lower prices, and in general, better respond to client needs.

The additional year of support would also allow SOMARC to work in partnership with the German donor, KfW, to transition the oral contraceptive, Gulaf, from a standard dose to a low dose. KfW's role will ease the financial burden on USAID, provide the consumer with a high quality low dose product under a familiar brand name, and build on USAID's successful investment in developing and maintaining brand equity. KfW also plans significant inputs into expanding steady and consistent supply of Jeevan Jal ORS packets. Though market potential is high, estimated to be over 10,000,000 packets per annum, a variety of (mostly supply-side) problems have hampered consistent product availability and distribution. SO MARC plans for the country manager to work closely with KfW to ensure adequate supply through the major producer, Royal Drugs Ltd. and to ensure effective distribution and promotion of the product, targeted to the consumer, trade, and medical authorities.

• Achieve sales of 15 million units of condoms in 1998.

• Achieve sales of 500,000 units of low-dose oral contraceptives in 1998 (including KfW supported commodities).

• Achieve sales of 45,000 Sangini vials in 1998 and 5,500 units of IUDs.

• Achieve approximately 240,000 total CYPs - 100 percent increase over 1995 - with longer-term methods accounting for approximately 25 percent of the total (up from 4 percent in 1995).

• Expand Services Marketing network to 4 additional urban areas beyond Kathmandu, including more than 100 facilities. In coordination with AVSC and NFCC, provide training and promotional support to all Sangini retailers and private physicians to deliver high quality family planning counseling and service delivery.

• With KfW funding, distribute 2,500,000 million sachets of ORS, supported by promotional campaign.

20 Resources To support ongoing activities, for both scenarios these estimates include maintaining a local Country Manager along with in-country consultant support. In 1998, 50 percent of the country manager's time will be supported through KfW funding, making USAID's investment extremely cost efficient. Technical assistance and project oversight will continue to be provided by SOMARC/Asia Regional office.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support" 656,000 350,000 1,006,000 1,089,748 (83,748) 350,000 700,000 OYB Transfer 0 a Buyin a a Total $656,000 $350,000 $1,006,000 $1,089,748 ($83,748) $350,000 $700,000

21 ... Philippines

Fertility in the Philippines continues its gradual decline. Based on the 1993 National Demographic - Health Survey, Filipino women will give birth on average to 4.1 children during their reproductive years, 0.2 children less than that recorded in 1988. However, total fertility remains high compared to the levels ... achieved in neighboring Southeast Asian countries. Virtually all women know of a family planning method; the pill, female sterilization, IUD and condoms are known to over 90 percent women. Contraceptive use is highest in the urban areas and among women with higher than secondary education. Four in 10 married .... women are currently using contraception. Contraceptive prevalence rate for modern methods is 25 percent. The majority of contraceptive users obtain their methods from a public sector provider (70 percent).

Half of married women say they want no more children, and 12 percent have been sterilized. An additional 19 percent want to wait 2 years before having another child. Almost two-thirds of the women express a preference for having 3 or less children. Results from the survey indicate that if all unwanted births were avoided, the total fertility rate would be 2.9 children, which is almost 30 percent less than the observed rate. If the potential demand for family planning is satisfied, the contraceptive prevalence rate could increase to 69 percent.

The private sector offers a huge potential in satisfying this unmet need through the availability of high quality and affordable contraceptives. This potential of the private sector in providing products and services is enhanced by the existence of over 6,000 pharmacies, 1200 private hospitals/clinics, 2000 Ob/Gyns, 14,000 GPs and about 20,000 practicing private midwives. To support this further, the government has resolved to increase private sector family planning provision through policy reforms and support of family planning programs working with the commercial sector, NGOs and industry-based clinics.

USAID Objective To reduce the population growth rate and improve maternal and child health through:

• Increased public sector provision of FP/MCH services.

• Strengthening of national systems to promote and support the FP/MCH program.

• Increased private sector provision of contraceptives and FP/MCH services.

SOMARC Objectives The overall project objective is to increase sales of SOMARC contraceptives by 150 percent from December 1995 through September 1997, and

• Expand the existing CSM line to include lower priced pills, and an IUD.

• Increase the role of private sector providers in providing quality counseling and in prescribing CSM products.

• Stimulate trial and continued correct use of CSM products through a combination of mass media and grass roots communications.

• Improve the quality and magnitude of distribution and detailing efforts undertaken by partiCipating manufacturers and their agents.

22 Year I Accomplishments (1993) At the beginning of the fiscal year, SOMARC launched a condom primarily positioned for AIDS prevention. The Couple's Choice Program was launched in June, 1993 with three brands of low-dose oral contraceptives. Both the pill and the condom were supported with radio advertising and aggressive marketing in three major urban areas. In 1993, the Philippine economy dipped as a result of a series of major natural calamities that struck the country during the previous 2 years. This situation greatly affected all industries including pharmaceuticals. The total hormonal contraceptive commercial market declined by 17 percent. There were only four brands that registered real growth; three of these brands are those under the SOMARC Project, while the other is the heavily promoted Logynon of Schering. SO MARC believes that the marketing support it extended to the three brands reversed an otherwise imminent market decline.

• Achieved sales of 1.1 million condom units, equivalent to 78 percent growth over 1992.

• Achieved annual sales of 252,000 units of low-dose contraceptives, representing a growth of 4 percent.

Year II Accomplishments (1994) In March 1994, SO MARC added the contraceptive injectable, Depo-Provera, to the Couple's Choice Program. As in the pill and condom launch, the injectable was supported by radio advertising and promotion. In June 1994, SOMARC launched the first ever nation-wide television commercial for private sector pills, an effort that resulted in the high consumer awareness level that the program continues to enjoy. Support for the condoms were focused on improving distribution levels.

• Achieved sales of 1.6 million condom units, 50 percent over 1993.

• Achieved annual sales of 291 ,700 units of low-dose contraceptives, a growth of 16 percent over previous year.

• Achieved sales of 23,000 vials for Depo Provera.

Year III Accomplishments' (1995) In August 1995, SOMARC launched the first condom TV commercial that positioned the product as a lifestyle product. In response to the results of the consumer tracking study, the manufacturer redesigned the product packaging to make it look more high-quality modern, and gender-sensitive. It was also during this year that the project undertook research among private providers to explore the feasibility of developing and promoting a private provider network. Sales of Depo-Provera declined due to the decision of local Upjohn management not to take an aggressive stance on product promotion with doctors because of a call to boycott Upjohn products by the groups within the Catholic Church.

• Achieved sales of 1.1 million units of condoms.

• Achieved sales of 390,282 units of low-dose contraceptives.

• Achieved sales of 18,000 vials of Depo-Provera.

Challenges for the Future SOMARC's major challenge for the Philippines is to continue to identify ways to expand the private sector's role in offering a wide range of family planning products and services. The current major constraints in expanding sales of SOMARC products are: relatively high prices; consumer fear of side effects; and the lack of participation among private providers.

Scenario I Year IV-V /1996-1997)

23 In 1996, SOMARC will graduate the condom (AIDS prevention component) and will create a new product line that will result in a program that is more focused on family planning. SO MARC will attempt to achieve better price differentiation between Couple's Choice products and other commercial .... contraceptives. It will address the issues related to side effects through media advertising, as well as traditional and grass roots public relations efforts. SOMARC will begin merchandising the Couple's Choice signage in provider clinics and include promotion of these service points in method-specific media advertisements. By the end of 1997, SOMARC will have met its objectives in increasing private sector participation, contributing significantly to the achievement of the government goals for the year 2000. .... • Achieve sales of 975,000 units of low-dose oral contraceptives, 150 percent over the 1995 sales level.

• Achieve sales of 45,000 units of the injectable, 150 percent over the 1995 sales level.

• Merchandise the Couple's Choice logo in at least 100 private clinics in Manila, Cebu and Davao.

Scenario 1/ Year IV-VI !1996-1998\ With an additional year of support, SOMARC would launch an IUD in 1997 to continue to expand the availability of affordable methods in the private sector. The introduction and promotion of this method would not be feasible if the project were to end in September 1997. During the extension period, SO MARC will focus its resources on the promotion of longer-term methods (IUDs and injectable), stimulating the commercial market to contribute more efficiently to the CYP objectives of USAID. SO MARC would also expand the provider network coverage to reach 5 additional urban areas. The .... network approach would have been fully tested and documented, highlighting the major strengths and weaknesses of the strategy for other private sector projects. The additional year of support would be used to prepare the network to become fully sustainable - with day-to-day management of the network being taken over by the commercial sector. The approach would also have a strong "halo" effect on other private facilities, stimulating them to increase quality of services, lower prices, and better respond to client needs.

• Achieve graduated sales of 2.0 million units of low-dose oral contraceptives in 1998.

• Achieve sales of 90,000 units of Depo-Provera in 1998. Achieve sales of 20,000 IUD units in 1998.

• Expand the provider network coverage to include at least 200 facilities in major urban areas.

Resources To support ongoing activities, and for both scenarios, SO MARC would need to maintain a project office in Manila with a Resident Advisor and Sales Manager along with periodic support from consultants. Technical assistance will continue to be provided by SOMARC's regional and Washington staff.

24 Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support" 1,000,000 1,000,000 1,046,791 (46,791 ) 1,250,000 2,000,000 OYB Transfer 1,000,000 1,000,000 2,000,000 1,630,890 369,110 Buyin 1 500,000 500,000 400,856 99,144 Buyin 2 83,454 83,454 63,529 19,925 Buyin 3 276,591 276,591 60,455 216,136 95,000 Total $2,583,454 $1,276,591 $3,860,045 $3,202,521 $657,524 $1,250,000 $2,095,000

25 Europe/Newly Independent States ....

...

26 Kazakhstan

In Kazakhstan, as it is in most of the Central Asian Republics, the issue for SOMARC is primarily reproductive health and the traditionally heavy reliance on abortion as the primary means of fertility regulation. Abortion rates in urban centers nationally were as high as 1.97, as high as 3.04 in Almaty, and even higher for some urban groups of the population (DHS, Kazakhstan, 1995). Under the Soviet system, contraceptives were in short supply, particularly non-clinical methods. Additionally, misunderstandings about contraceptive methods of action - especially hormones - were pervasive, not only among potential users, but also within the medical community.

With few exceptions, pharmaceutical supply and distribution was under the sole authority of the State Pharmacy system, Farmatsyia. In the past year and a half, the Farmatsyia system has been dramatically altered to open the market to private independent pharmaceutical retailers and wholesalers, and to restructure Farmatsyia itself through formal privatization. Encouraged and supported by SO MARC, foreign pharmaceutical manufactures have begun to enter the market with high quality western products, sold through local partner companies. Local pharmaceutical companies are beginning to distribute products on a national basis to retail pharmacies, both as wholesalers and as owners of pharmacy chains.

• Improve reproductive health by reducing the reliance on abortion as the primary means of fertility regulation through the provision of non-clinical contraception.

SOMARC Objectives • Secure market entry agreements from international pharmaceutical manufactures for servicing the Kazakhstan market with contraceptive products, beginning with a three city pilot project;

• Secure distribution and retail sales agreements between local companies and international pharmaceutical manufactures;

• Develop a brand identity for the group of new, western quality products being supplied commercially through an integrated communications program incorporating market research based advertising, public relations, sales promotion, and special events;

• Support, develop, and encourage the establishment of market based, commercial pharmaceutical wholesalers and retailers as channels for commercial contraceptives;

• Establish a cadre of local supporters and proponents of the program to ensure it's long term durability, including building the institutional capabilities of local marketing service companies;

• Create a hospitable and supportive environment within the medical community for the use of modern contraceptives through training in modern contraceptive technology and quality service delivery.

Year I Accomplishments (1993) SOMARC conducted social marketing country assessments in Kazakhstan, Kyrgyzstan, Uzbekistan, and Turkmenistan. The CAR's team coordinated conference among potential private partners based in the U.S. to explore potential for partnership to develop the commercial contraceptive market in the CARs. SOMARC also initiated discussions with international contraceptive manufacturers regarding the potential development of the market in the CARs.

28 PREVIOUS PAGE BLANK Year II Accomplishments (1994) SOMARC developed an implementation plan for the pilot marketing program in three regions: Almaty, Karaganda, and Ust Kamenogorsk. The Training Director implemented Training of Trainers (TOT) for family planning service providers, and commenced training of pharmacists and physicians. The Regional Manager established a social marketing Advisory Board in Kazakhstan. With the technical assistance of T Baugh & Co., the local public relations firm developed and implemented a public relations campaign inclusive of media training for key spokespersons. SOMARC also publicly launched social marketing activities in Kazakhstan.

One of the most critical achievements was the importation of oral contraceptives, condoms and injectables through the private sector. SOMARC worked closely with local firms to see that they succeeded in the distribution of oral contraceptives.

Year III Accomplishments (1995) The third year of the project was a culmination of the intensive training and technical assistance directed toward reproductive health care providers and local public relations and advertising firms respectively. Due to the overall improvement in contraceptive technology knowledge of pharmacists and doctors, consumers were better able to consult their respective health care providers and gain confidence in the contraceptive products available in the private sector. Local public relation and advertising firms were also technically capable of making the Kazakhstani public aware of the importance of contraceptive choice in advancing maternal and child health. Local communication firms through an integrated communications plan fortified consumer demand for quality reproductive health services. In 1995, SO MARC was able to make concrete improvements in the distribution and availability of contraceptives.

• Expanded distribution of ~C's to all three regions and added four (4) additional brands to the Red Apple oral contraceptive product line;

• Achieved sales of 262, 141 oral contraceptives in Kazakhstan.

• Began distribution of condoms as an addition to the Red Apple product line;

• Collaborated with USAID health care finance reform contractor, Abt Assoc. and USAID Small Scale Privatization contractor Carana Corp. to develop a plan for post-privatization support of pharmaceutical distribution and retailing, through the creation of a franchiseable model pharmacy network;

Challenges for the Future SOMARC's major challenge for the future in Kazakhstan is to consolidate the advances made in the private distribution and retail system. A primary focus of the program has been the demonstration of the viability of the commercial market in delivering reproductive health services. SOMARC has been successful in establishing that the private sector is capable of playing a significant roll in health service delivery, however that capability is fledgling. The Kazakhstani companies partiCipating in the Red Apple program are all in need of continued support both in the general area of pharmaceutical business and marketing management, as well as specific assistance in the assumption of marketing responsibilities for the SOMARC program.

Scenario I Years IV - V (1996 ·1997) During 1996-1997 SOMARC will continue the expansion of the Red Apple program in Kazakhstan. New communications materials will be developed, including new TV and Radio commercials to augment and eventually replace the current, aging spots. These new materials will be disseminated through a national campaign of integrated communications, directly supporting both the manufactures and products of the Red Apple program, as well as the distributors/retailers.

29 Efforts will also be focused on strengthening and expanding the distributor network through both direct assistance and through the development of the "Franchise" program, where marketing and management assistance will be modularized and applied to the existing Red Apple distributors, as well as potential new ones.

• Achieve sales of approx. 1.S million cycles of OC's by 1997; • Achieve sales of approx. SO,OOO vials of DMPA by 1997; ... • Facilitate distribution of condoms in approximately 800 retail outlets;

• Develop and implement pharmaceutical retail sales through at least two competitive Franchise operations by 1997;

• Facilitate the participation of at least five major local pharmaceutical distribution organizations in the marketing of contraceptives by 1997; ... • Conduct sales training seminars for approx. 1S0 persons, production of point of sale materials/store displays;

• Implement follow-on and additional training activities in modern contraceptive technology and quality service delivery. Train an additional 400 (approx.) pharmacists; train an additional1S0 (approx.) doctors.

Scenario II Years IV - VI (1996 - 19981 With an additional year of support SOMARC would fully transition the project to the private sector distribution companies. While this is the goal of the project under Scenario I also, an additional year of SOMARC support would add significantly to the chances for a successful graduation of the Red Apple completely to the private sector. An additional year of support would enable the continued training of a larger percentage of the doctors and pharmacists essential to the acceptance of the commercial effort. It will also allow for the inclusion of additional distributors, products, and manufactures as the project and market grows, and further insure the sustainability of the program once direct SOMARC support ends.

• Achieve sales of approx. 2.S million cycles of OC's by 1998;

• Achieve sales of approx. 70,000 vials of DMPA by 1998;

• Achieve distribution of condoms through approx. 1 ,sao retail outlets by 1998;

• Achieve a SO% expansion in the number of retail pharmacies participating in a pharmaceutical franchise by 1998;

• Train an additional 400 (approx.) pharmacists; ..., • Train an additional1S0 (approx.) doctors;

Resources To support ongoing activities, for both scenarios these estimates include maintaining a project office in Almaty with a local Country Manager along with in-country and US based consultant/subcontractor support. Technical assistance and project oversight will continue to be provided by SOMARClWashington.

30 ... , Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' a a OYB Transfer a a Buyin 3,300,000 1,954,777 5,254,777 4,309,680 945,097 1,500,000 2,500,000 Total $3,300,000 $1,954,777 $5,254,777 $4,309,680 $945,097 $1,500,000 $2,500,000

31 Kyrgyzstan

In Kyrgyzstan, as it is in most of the Central Asian Republics, the issue for SOMARC is primarily reproductive health and the traditionally heavy reliance on abortion as the primary means of fertility regulation. Under the Soviet system. contraceptives were in short supply, particularly non-clinical methods. Additionally, misunderstandings about contraceptive methods of action - especially hormones - were pervasive, not only among potential users, but also within the medical community.

With few exceptions, pharmaceutical supply and distribution was under the sole authority of the State Pharmacy system, Farmatsyia. Today the distribution system is somewhat liberalized. In the past year and a half, private sector organizations have invested in the distribution of contraceptives for sale through a growing number of private pharmacies. Yet consumers accustomed to receiving reproductive health services through the public sector are generally unaware of the availability of supplies.

Thus there exists a need to create consumer awareness of the private sector as a source of family planning services and build the capability and credibility of the private sector to fulfill reproductive health service needs.

USAID Objectives • Demonstrate the viability of the commercial market as a supplier of health services, particularly the commercial distribution and retail sales of commerCially supplied (non-USAID procured or subsidized) contraceptives;

• Improve reproductive health by reducing the reliance on abortion as the primary means of fertility regulation through the provision of non-clinical contraception.

SOMARC Objectives • Secure market entry agreements from international pharmaceutical manufactures for servicing the Kyrgyzstan market with contraceptive products;

• Secure distribution and retail sales agreements between local companies and international pharmaceutical manufactures;

• Develop a brand identity for the group of new, western quality products being supplied commercially, through an integrated communications program developed in Kazakhstan and adapted for the Kyrgyz market, incorporating market research based advertising, public relations, sales promotion, and special events;

• Support, develop, and encourage the establishment of market based, commercial pharmaceutical wholesalers and retailers as channels for commercial contraceptives;

• Create a hospitable and supportive environment within the medical community for the use of modern contraceptives through training in modern contraceptive technology and quality service delivery.

Year I Accomplishments (1993) SOMARC conducted a social marketing country assessment. Futures coordinated a conference among potential private partners based in the U.S. to explore potential for partnership to develop the commercial contraceptive market. The Central Asian team initiated discussions with international contraceptive manufacturers regarding the potential development of the market in the CARs. Year II Accomplishments (1994) SO MARC analyzed the feasibility of a social marketing intervention in Kyrgyzstan and conducted an assessment of private sector opportunities. The Training Director orchestrated training of trainers for family planning service providers. 32 Year III Accomplishments (1995) ... SOMARC adapted Kazakhstan advertising and promotional materials for use in Kyrgyzstan, and launched mass media pilot campaign to support commercial contraceptive brands entering the market in late 1995. Development Associates completed nationwide training of pharmacists in modern contraceptive technology and quality service delivery and conducted nationwide training of physicians in injectable contraceptives and quality service delivery. Futures also implemented a program of media training for Red Apple spokespeople.

Challenges for the Future SOMARC, in the initial stages of its' pilot mass media campaign, has so far been successful in establishing that the private sector is capable of playing a significant roll in health service delivery, however that capability is fledgling. The Kyrgyz companies participating in the Red Apple program are all in need of continued support both in the general area of pharmaceutical business and marketing management, as well as specific assistance in the assumption of marketing responsibilities for the SOMARC program.

Scenario I Year IV • V (1996·1997) During 1996·1997 SOMARC will continue the expansion of the Red Apple program in Kyrgyzstan. New communications materials, developed in Kazakhstan, will be tested and adapted as necessary for the Kyrgyz market, including new TV and Radio commercials to augment and eventually replace the current spots. These new materials will be disseminated through a national campaign of integrated communications, directly supporting both the manufactures and products of the Red Apple program, as well as the distributors/retailers. Efforts will also be focused on strengthening and expanding the distributor network.

• Achieve sales of approx. 100,000 cycles of OC's by 1997;

• Achieve sales of approx. 20,000 cycles of DMPA by 1997;

• Achieve distribution of condoms through approx. 500 retail outlets by 1997;

• Implement follow·on and additional training activities in modern contraceptive technology and quality service delivery for 50 physicians and 100 pharmacists;

• Implement sales, distribution, and promotion training for approx. 150 sales staff employed by participating distributors.

Scenario II Years IV· VI (1996 ·1998) With an additional year of support SO MARC would fully transition the project to the private sector distribution companies. While this is the goal of the project under Scenario I also, an additional year of SOMARC support would add significantly to the chances for a successful graduation of the Red Apple completely to the private sector. An additional year of support would enable the continued training of a larger percentage of the doctors and pharmacists essential to the acceptance of the commercial effort. It will also allow for the inclusion of additional distributors, products, and manufactures as the project and market grows, and further insure the sustainability of the program once direct SOMARC support ends.

• Achieve sales of approx. 160,000 cycles of OC's by 1998; • Achieve sales of approx. 35,000 vials of DMPA by 1998;

• Achieve distribution of condoms through approx. 750 retail outlets by 1998;

33 • Conduct follow-on and additional training activities in modern contraceptive technology and quality service delivery: Follow-up training for an additional 100 (approx.) pharmacists; follow-up training for an additional 75 (approx.) doctors;

• Implement sales, distribution, and promotion training for an additional 150 sales staff employed by participating distributors.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 ..... Field Support' 0 0 OYB Transfer 0 0 Buyin 3,300,000 1,954,777 5,254,777 4,309,680 945,097 1,500,000 2,500,000 Total $3,300,000 $1,954,777 $5,254,777 $4,309,680 $945,097 $1,500,000 $2,500,000

ioo'

,... Moldova

Reproductive health services in Moldova, as in all other countries of the former Soviet Union, is severely affected by a lack of accurate information and knowledge about modern family planning practices, limited service provider skills, little access to modern methods of contraception, and an acknowledged unhealthy dependence on abortion. More than 800,000 abortions are officially reported annually, and women receive paid sick leave for the procedure. The high rates of maternal mortality and infertility are primarily related to the abortion rates. The family planning methods that were available, mainly high dose oral contraceptives, IUDs and condoms, were considered of very pro quality and are associated with low effectiveness, high rates of infection, and fearful side effects. Additionally, training in modern family planning service delivery is minimal for physicians, midwives and paramedical personnel, and family planning counseling provided to women influenced by the insufficient knowledge, biases and misconceptions held by providers.

USAID Objectives • Assist the Government of Moldova to provide high quality, affordable and sustainable reproductive health services through the private and non-government sectors.

SOMARC Objectives • Facilitate the marketing and promotion of contraceptive products through private providers in Moldova; and ... • Motivate the trial and consistent usage of modern contraceptives methods . Years I-III Accomplishments SO MARC was not working in Moldova.

Scenario I Year IV - V (1996 - 1997) SOMARC will assess the private sector infrastructure for the delivery of contraceptive services and design a marketing approach that would be responsive to the peculiarities of Moldova. Initially, project activities are likely to be developed and implemented in collaboration with the Family Planning Association of Moldova, the IPPF affiliate based in Chisinau (Kishinev). The intention is to provide training for physicians and pharmacists, encourage expanded sales and distribution of contraceptives by pharmaceutical companies, and create demand for contraceptives through marketing communication. During this twelve month period, SOMARC hopes to achieve the following.

• Sales of low dose pills, injectables, IUDs and condoms in all pharmacies in the capital city;

• The training of at least two representatives from each pharmacy in the capital city;

• The training of at least 50% of the obstetricians and gynecologists in the capital city;

• Testing and development of an integrated marketing communication campaign promoting contraceptive services through the private sector.

Scenario II Year IV - VI 11996 -1998) With an additional year of support, SOMARC would expand the social marketing activities to include all other urban areas in the country.

Resources

35 Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 0 0 300,000 500,000 ... OYB Transfer 0 0 Buyin 0 0 Total $0 $0 $0 $0 $0 $300,000 $500,000

....

... ,

36 Turkey

In Turkey, overall awareness of modern contraceptives is extremely high--more than 98 percent of all women know a modern method and over 94 percent know of a source where to obtain family planning. Despite this high awareness, the most prevalent method in Turkey is withdrawal (26 percent). Ever use of modern contraceptives is quite high (61.8 percent), but discontinuation rates for modern methods are also high. Prior to the social marketing project, oral contraceptives were associated with health problems and side effects. In addition, the commercial market for oral contraceptives was dominated by high-dose brands, further contributing to the concerns over side effects. Condoms were also generally plagued with an extremely poor image--the commercial market was dominated by high-priced imports.

With over 13,000 pharmacies throughout Turkey, the private sector offers huge potential for increasing the availability of modern contraceptives. In 1993, 75 percent of all pill use and 66 percent of condom use was provided by the private sector'. To support the large potential of the private sector in clinic based services, the commercial healthcare infrastructure is also growing quite rapidly in Turkey--currently in Istanbul alone there are over 60-70 private hospitals, approximately SOD private clinics, 800 OB/GYNs and SOD General Practitioners. Despite the huge potential of commercial health care, the private sector only provided 28 percent of IUD insertions and 15.5 percent of sterilization services in 1993. In addition, the POLICY project's market segmentation analysis for Turkey indicates that over 33 percent of public sector users have some ability to pay for family planning, suggesting a large potential for shifting users to the private sector.

USAID Objectives .. • Increase availability and effective use of quality family planning and reproductive health services . • Improve Turkey's self-reliance in family planning and reproductive health by enhancing public and private sector ability to meet consumer demand for these services independent of USAID support.

SOMARC Objectives • Transition the commercial market for oral contraceptives away from standard-dose to low-dose pill products and increase the overall market.

• Stimulate the commercial market for condoms.

• Achieve self-sufficiency for both the oral contraceptive and condom components in three years.

• Launch a commercially-sourced IUD and injectable product and obtain self-sufficiency within three years.

• Establish a sustainable Services Marketing network that provides a range of affordable, quality reproductive health services.

Year I Accomplishments (1993) SOMARC launched the Okey condom in Turkey in June 1991, introducing it as the first nationally advertised condom brand. During 1993, just two and a half years later, SO MARC negotiated with its condom distributor, Eczacibasi, to graduate "Okey" from USAID assistance. SO MARC launched the oral contraceptive component in December 1991, also using commercially-sourced low-dose products. During 1993, SOMARC continued major advertising and marketing support for the pill component to increase the overall market and shift the market share toward low-dose.

, Turkey Demographic and Health Survey, Hecettepe University, Institute of Population Studies, 1993. 37 ... • Achieved sales of 6.3 million units of condoms.

• Achieved annual sales of 2.6 million units of low-dose contraceptives, shifting overall low-dose market share from 50 percent in 1991 to 62 percent in 1993.

Year II Accomplishments (1994) During 1994, SOMARC oversaw the phaseout of the condom component. SO MARC also continued to support advertising and promotional activities for low-dose oral contraceptives, and then graduated the pill component from USAID assistance at the end of 1994. During this period, SO MARC also initiated formative research on long-term methods in order to expand the social marketing project. The preliminary research and assessment resulted in the design of a Services Marketing project that stimulates existing private providers to better integrate reproductive health services.

• Achieved graduated sales of 7.7 million units of condoms. Oversaw condom phaseout.

• Achieved annual sales of 3.2 million units of low-dose contraceptives, shifting overall low-dose market share to 73 percent in 1994.

Year III Accomplishments (1995) During 1995, SOMARC launched the pilot Services Marketing network within Istanbul. The network includes a range of private facilities, including hospitals, polyclinics, physicians, and pharmacies. All of the partiCipating facilities were trained in contraceptive technology, counseling, and total quality management. To participate in the network, these private facilities agreed to lower their prices for family planning services.

• Achieved graduated sales of 9.6 million units of condoms.

• Achieved graduated sales of 2.4 million units of low-dose contraceptives (major economic crisis in Turkey during 1995 contributed to decline in pill sales).

• Launched Services Marketing pilot network in 20 facilities within defined geographic area of Istanbul. Conducted site assessments in over 50 private facilities.

• Expanded local anesthesia mini-laparotomy services to two 100-bed hospitals.

Challenges for the Future SOMARC's major challenge for Turkey is to continue to identify ways to expand the private sector's role in offering a wide range of family planning services. The current constraints for consumers are a lack of awareness of availability of family planning services in private facilities--even among current clients of private healthcare--and the perception that services are expensive. In addition, many private facilities currently offer many more abortion services than family planning.

Scenario I Year IV-V (1996-1997) During 1996-1997, SOMARC will launch a commercially-sourced IUD at a price more than 50 percent less than other currently available products. In the first year, sales of the social marketing IUD product will be small (20,000 units), however the total private sector market will expand slightly. SOMARC will continue to expand the Services Marketing initiative throughout all of Istanbul and introduce the network approach in Izmir, helping to further establish family planning services in the private sector. By the end of 1997, SOMARC will have met its objectives for sustainability for the oral contraceptive and condom components thereby improving Turkey's self-reliance in family planning for temporary methods.

• Achieve graduated sales of 11 million units of condoms.

38 • Achieve graduated sales of 3 million units of low-dose oral contraceptives.

• Achieve sales of 20,000 IUD units.

• Expand Services Marketing pilot network to reach greater Istanbul to include 60 facilities and 30 facilities in Izmir.

Scenario" Year IV-VI 11996-19981 With an additional year of support, SOMARC would launch an injectable product in 1997 to continue to expand the availability of affordable methods in the private sector. The introduction of this method in the private sector would not be feasible if the project were to end in September 1997. SOMARC would also continue support of the IUD, stimulating the commercial market to expand at a much faster pace, doubling the total market by 1998, and expanding the private sector's market share to over 30 percent. SOMARC would also expand the Services Marketing approach to reach several major urban areas of Turkey. The network approach would have been fully tested and documented, highlighting the major strengths and weaknesses of the strategy for other private sector projects. The additional year of support would also allow the network to become fully sustainable--with day-to-day management of the network being taken over by the commercial sector. The approach would also have a strong "halo" effect on other private facilities, stimulating them to increase quality of services, lower prices, and in general better respond to client needs.

• Achieve graduated sales of 14 million units of condoms in 1998.

• Achieve graduated sales of 3.6 million units of low-dose oral contraceptives in 1998.

• Achieve sales of 40,000 IUD units in 1998.

• Achieve sales of 200,000 units of Depo-Provera in 1998.

• Expand Services Marketing network to all of Istanbul and other major urban areas, including more than 250 facilities.

• Train 400 additional providers in total quality management, contraceptive technology, and improved infection prevention procedures.

Resources To support ongoing activities, for both scenarios these estimates include maintaining a project office in Istanbul with a local Country Manager and Medical Adviser along with in-country consultant support. Technical assistance and project oversight will continue to be provided by SOMARClWashington.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 1,900,000 552,991 2,452,991 2,580,586 (127,595) 900,000 1,900,000 OYB Transfer 0 0 0 0 0 0 0 Buyin 0 417,009 417,009 120,489 296,520 0 175,000 Total $1,900,000 $970,000 $2,870.000 $2,701,075 $168,925 $900,000 $2,075,000

39 Turkmenistan

In Turkmenistan, as it is in most of the Central Asian Republics, the issue for SOMARC is primarily reproductive health and the traditionally heavy reliance on abortion as the primary means of fertility regulation. Under the Soviet system, contraceptives were in short supply, particularly non-clinical ... methods. Additionally, misunderstandings about contraceptive methods of action - especially hormones - were pervasive, not only among potential users, but also within the medical community.

With few exceptions, pharmaceutical supply and distribution was under the sole authority of the State Pharmacy system, Farmatsyia. Recently, the government has opened the door to privatization of the pharmacy system in Turkmenistan. Legislation/decrees have allowed for the private ownership of pharmacies. Pharmaceutical companies are beginning to explore entry into the Turkmenistan market.

USAID Objectives • Demonstrate the viability of the commercial market as a supplier of health services, particularly the commercial distribution and retail sales of commercially supplied (non-USAID procured or subsidized) contraceptives; ... • Improve reproductive health by reducing the reliance on abortion as the primary means of fertility regulation through the provision of non-clinical contraception. .... SOMARC Objectives • Move Turkmenistan towards a greater private sector involvement in the provision of health service delivery. Specifically, to the degree possible given the infancy of the Turkmenistan private sector and degree of government support for its development;

• Encourage and promote market entry agreements from international pharmaceutical manufactures for servicing the Turkmenistan market with contraceptive products;

• Encourage and promote distribution and retail sales agreements between local companies and international pharmaceutical manufactures;

• Adapt and apply as is possible, the integrated communications program supporting commercial contraceptives developed in Kazakstan, incorporating market research based advertising, public relations, sales promotion, and special events;

• Support, develop, and encourage the establishment of market based, commercial pharmaceutical wholesalers and retailers as channels for commercial contraceptives;

• Create a hospitable and supportive environment within the medical community for the use of modern contraceptives through training in modern contraceptive technology and quality service delivery.

Year I Accomplishments (1993) • Conducted market evaluation for the potential of a Social Marketing program. Concluded that there was little immediate potential for a Social Marketing initiative until further economic reforms were implemented to allow and encourage development of the private sector.

Challenges for the Future

10"

";--',-.' ·--7.--··-,...... -·,-..-,~· Turkmenistan is just beginning to encourage the development of a private sector. It is only within the last six months that private pharmacies have been allowed to exist. SOMARC's challenge is to work with this new private sector opportunity to:

1) Support its continued development through training in western business and marketing techniques and by exposing government and private sector individuals to other models of private sector involvement in health service delivery;

2) Use its presence as a basis for the implementation of SOMARC Red Apple Social Marketing program. Adapting, where possible, the successful Kazakstan program to the evolving Turkmenistan market.

Scenario 1- Years IV - V (1996 -19971 During 1996-1997 SOMARC will work to move the emerging private sector in the direction of providing commercial health services. Contingent upon the degree and speed of the development of a commercial market for pharmaceuticals, SOMARC work will include a sequence of specific activities beginning with training and market development support, and moving towards implementation of a full social marketing program based on the Kazakstan model. New communications materials, developed in Kazakstan, will be tested and adapted as necessary for the Turkmenistan market, including new TV and Radio commercials. These new materials will be disseminated through a campaign of integrated communications, directly supporting both the manufactures and products of the Red Apple program, as well as the distributors/retailers. Efforts will also be focused on developing the commercial distributor network.

• Test and adapt regionally produced mass media communications materials;

• Produce and print method specific consumer brochures, point of sail materials and training manuals;

• Conduct training activities in modern contraceptive technology and quality service delivery for physicians and pharmacists;

• Monitor and evaluative research to measure media awareness, distribution penetration and product trial;

• Facilitate distribution of contraceptives through private pharmacies in Ashkabad.

Scenario II - Years IV - VI (1996 - 19981 An additional year of support for the SOMARC effort would make a large difference in the impact of the Turkmenistan program in particular. Turkmenistan is the last of the Central Asian Republics to initiate a program, with activities getting underway only at the middle of 1996. An additional year of support would allow much needed time for the project to begin to make the transition to commercial support. While this is the goal of the project under Scenario I also, an additional year of SOMARC support would add Significantly to the chances for a successful graduation of the Red Apple completely to the private sector. An additional year of support would enable the continued training of a larger percentage of the doctors and pharmacists essential to the acceptance of the commercial effort. It will also allow for the inclusion of additional distributors, products, and manufactures as the project and market grows, and further insure the sustainability of the program once direct SOMARC support ends .

... • Achieve sales of approx. 250,000 cycles of OC's by 1999;

• Achieve sales of approximately 20,000 vials of DMPA by 1999; • Achieve sales of approximately 150,000 condoms by 1999;

41 -

• Purchase national media time for airing approx. 250 X 60 sec. TV commercials; .... • Purchase national media time for airing approx. 650 X 60 sec. Radio commercials;

• Conduct follow-on and additional training activities in modern contraceptive technology and quality .... service delivery: follow-up training for an additional 150 (approx.) pharmacists; Follow-up training for an additional 150 (approx.) doctors;

Resources To support ongoing activities, for both scenarios these estimates include maintaining a project office in Almaty and Tashkent with a local Country Managers along with in-country and US based consultant/subcontractor support. Technical assistance and project oversight will continue to be provided by SOMARClWashington.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 0 0 OYB Transfer 0 0 .... Buyin 3,300,000 1,954,777 5,254,777 4,309,680 945,097 1,500,000 2,500,000 Total $3,300.000 $1,954.777 $5,254,777 $4,309,680 $945,097 $1,500,000 $2,500,000

42 Ukraine

High rates of maternal mortality and morbidity may be related primarily to the high rates of abortion in the Ukraine. The use of abortion as a means of fertility appears to have created severe health risks for women. Although there is interest in modern family planning programs, medical personnel and potential users share strong misconceptions about modern hormonal contraceptives. Except for IUDs, which are Russian made and of poor quality, contraceptives are not typically available through health delivery points and information and knowledge about modern contraceptives are lacking.

USAID Objectives To improve and expand the delivery and availability of modern contraceptive services in order to significantly reduce the dependency on abortion for fertility control.

SOMARC Objectives • To encourage and facilitate the development and growth of private sector delivery of modern family planning services as an alternative to abortion; and

• To demonstrate the viability of the private sector as a credible and sustainable vehicle for the delivery of reproductive health services.

Year I-III Accomplishments SOMARC was not working in Ukraine .

... Scenario I Year IV - V 11996 -19971 Based on the recommendations arising from the assessment trip conducted by AI D's consultant Betty Ravenholt, SO MARC will develop and implement a pilot social marketing program in Odessa. The program will work with the fairly well developed private commercial retail sector in Odessa to market and promote a line of modern contraceptive products. Specifically, SOMARC intends to collaborate with contraceptive manufacturers and local pharmaceutical distributors to import, promote and sell low-dose oral contraceptives, injectables, condoms, IUDs, and vaginal foaming tablets. SOMARC will also provide training for physicians and pharmacists, encourage expanded sales and distribution of contraceptives, and create demand for contraceptives through marketing communication. During this twelve month period, SO MARC hopes to achieve the following.

• Sales of low dose pills, injectables, IUDs, vaginal foaming tablets and condoms in all pharmacies in Odessa;

• The training of at least two representatives from each private sector pharmacy in Odessa;

• The training of at least one physician from each private sector/non-government clinic in Odessa;

• Testing and development of an integrated marketing communication campaign promoting contraceptive services through the private sector.

• Addressing, in collaboration with the FUTURES/POLICY project, the legal, regulatory and customary issues that may adversely affect the implementation and success of the pilot social marketing project.

43 ... Scenario II Year IV • VI (1996 ·1998) With an additional year of support, SO MARC would replicate the pilot social marketing project in Kiev, with special regard to regional differences and with a view to the development of a national .... marketing program. Resources ...

Funding Fiscal Year Total Expenses Funding Funding Source 1993·94 1995 Allocations to 4/30/96 Remaining 1996·97 1996·98 .... Field Support" 0 0 350,000 600,000 OYB Transfer 0 0 Buyin 0 0 Total $0 $0 $0 $0 $0 $350,000 $600,000

44 ... Uzbekistan

In the Republic of Uzbekistan overall contraceptive prevalence has increased dramatically since the launch of the Red Apple Initiative - from 11 percent in 1993 to 44 percent in 1995. Child spacing of over a year apart has also increased radically - from 12 percent in 1993 to 60 percent in 1995. The Ministry of Health has recently reported that 44.8 percent of women of fertility age in Tashkent now practice child spacing of over two years. Prior to implementation of the social marketing program, overall knowledge and usage of low-dose oral contraceptives and injectables were extremely low among women of fertility age. The primary method of contraception used in the Former Soviet Union was abortion. IUDs were the second method of choice and accounted for over 70 percent of contraceptive usage. This contraceptive method often presents a significant health risk to women who suffer from anemia and other gynecological inflammatory diseases. In some regions of Uzbekistan, over 99 percent of women of fertility age suffer from severe anemia and 56.1 percent of women of the republic are reported to have gynecological disorders. Since the Launch of the SOMARC Red Apple Program, both the rate of abortion and IUD usage has decreased; while oral contraceptive and injectable usage has increased by 30 percent. One reason for this change in contraceptive preference is due to increased public awareness of the significant health benefits that both the injectable and low-dose oral contraceptive may provide to women who choose either of these methods.

Before Uzbekistan achieved its independence, pharmaceuticals were supplied exclusively by the public sector and prices were strictly controlled. Over 2,200 pharmacies have been privatized in Uzbekistan since independence. The private sector has played a huge role in increasing the availability of modern contraceptive products. Within a few months after the Launch of the Red Apple Initiative, the number of private pharmacies increased from 75 to 275 in the test market regions of Tashkent and Samarkand. Distributors also expanded their networks and supply of contraceptives to meet increased consumer demand. Within the first three months after the Launch, both sales of oral and injectable contraceptives increased by 75 percent. Graduated sales of oral contraceptives have increased from 305 cycles to 75,000 cycles within the first six months. These sales figures indicate that SOMARC will be able to successfully establish the commercial market for and market viability of, contraceptive products in Uzbekistan within the next three years.

USAID Objectives • Provide technical assistance and resource support to the government of Uzbekistan to improve and expand the availability of modern reproductive health services.

• Demonstrate the viability of creating commercial markets for contraceptive products in the test market regions of Tashkent and Samarkand.

SOMARC Objectives • Demonstrate the viability of creating commercial markets for contraceptive products in the region.

.. • Introduce and develop consumer demand for low-dose oral contraceptives and injectables and increase the overall commercial market. WiI • Strengthen and expand a sustainable private sector distribution network that provides a consistent and affordable supply of high quality modern contraceptive products.

• Stimulate and expand the commercial market for condoms.

• Achieve sustainability of commercial markets for the oral contraceptive, injectable and condom components to assist the government in ensuring a consistent, reliable and affordable supply of these products.

45 • Assist the Ministry of Health to establish a private sector health initiative which will assist in achieving a reduction in the overall abortion rate, infant and maternal morbidity, and in improving maternal child health.

Year I Accomplishments (1993) In 1993, SO MARC conducted social marketing country assessments in Kazakhstan, Kyrgyzstan, .... Uzbekistan, and Turkmenistan. Discussions were initiated with international contraceptive manufacturers regarding the potential development of the market in the CARs. A conference was organized among potential private partners to develop the commercial contraceptive market in the CARs.

Year II Accomplishments (1994) During 1994, SOMARC determined the infrastructure for distribution of contraceptives through the private sector through two local distributors. SOMARC also developed the implementation plan for the pilot program in the two test market regions of Tashkent and Samarkand. During this period, SOMARC also initiated consumer focus group studies to determine family planning awareness, attitudes and practices as well as responses to the proposed program logo. The preliminary research and assessment resulted in the design of an effective advertising strategy to promote public awareness about modern contraceptive methods. At the end of 1994, SO MARC implemented the Training of Trainers for which family planning service provides, and commenced training of pharmacists. SOMARC was the first technical assistance program in Uzbekistan to offer a comprehensive course on modern contraceptive technology and quality customer service. Both the physicians and pharmacists had never received prior training on modern contraceptive methods in their medical stUdies. This training provided a milestone in promoting awareness about modern contraceptive methods among health care providers throughout the Republic.

Year III Accomplishments (19951 During 1995, SOMARC launched the Red Apple Program in Tashkent and Samarkand. This social marketing initiative quickly resulted in increased sales and distribution of both injectable and oral contraceptives. Sales of both products increased by over 75 percent in the first three months following the Launch. The number of private pharmacy outlets in the test market regions which are participating in the program has increased from 75 to 275. Most of the pharmacists working at the participating outlets received training in modern contraceptive technology, client counseling, and quality customer service. Free brochures on all methods of contraception, low-dose pills, and injectables are available to clients at partiCipating Red Apple pharmacy outlets. The program is supported by a comprehensive public relations campaign which includes mass media communication materials for the Program logo, oral and injectable contraceptives, television and radio health education programs, as well as print advertising support of the participating pharmacy outlets and product lines. A consumer focus group study was conducted to pre test all communication materials.

• Adapted and produced communication materials for the logo, oral and injectable contraceptives in the Uzbek language.

• Established the Uzbekistan Reproductive Health Advisory Board with includes representatives from the private, public, and non-government sectors.

• Implemented media training for key spokespersons who would represent, and advocate on behalf of, private sector reproductive health initiatives.

• Implemented system to monitor contraceptive sales through participating distributors.

• Achieved graduated sales of 15, 053 cycles of lOW-dose oral contraceptives.

Challenges for the Future SOMARC's major challenge for Uzbekistan is to identify ways to expand the private sector's role in delivery of family planning services in the rural regions. The current constraints for consumers in the 46 ... rural regions include a lack of awareness and knowledge about the availability of modern contraceptive methods as well as limited financial means. In addition, there are a limited number of private jOint-stock pharmacy outlets in the rural regions which offer clients a limited selection of contraceptive products.

Scenario I Year IV-V (1996-19971 During 1996-1997, SOMARC has proposed to expand the Red Apple Program in Ferghana and Andijan regions of Uzbekistan. This would expand the distribution network to include a minimum of 425 participating private pharmacy outlets. SOMARC will launch two new condom products at a price which will be 40 percent less than other products currently available. In the first year, estimated sales are conservative (500,000 units), but the private sector market for this product will expand greatly. By the end of 1997, SOMARC will have established the commercial viability of five brands of low dose oral contraceptives, injectables and condoms, thereby improving Uzbekistan's self-reliance on the commercial sector to provide a consistent supply of contraceptive products.

• Achieve graduated sales of 500,000 cycles of low-dose oral contraceptives in 1997.

• Achieve graduated sales of 20,000 units of Depo-Provera in 1997.

• Achieve graduated sales of 500,000 units of condoms in 1997.

• Expand the Red Apple Program to include Ferghana and Andijan regions of Uzbekistan with more than 425 private pharmacy outlets.

• Implement a Pilot Pharmacy Program to offer clients OB/GYN conSUltation services at 5 large pharmacy outlets in Tashkent to support marketing and usage of injectable contraceptives.

• Train 100 additional health care providers in modern contraceptive technology, injectable contraceptive usage, and quality customer service.

Scenario II Year IV -VI (1996 - 1998) With an additional year of support, SOMARC would launch the Red Apple Program in Bukhara, Navoi and Khorezm regions in 1997 to continue to expand the availability of affordable contraceptive methods in the private sector and assist the Ministry of Health in improving reproductive health in both the urban centers and oblasts of these regions. The expansion of the Program into these regions would not be feasible if the project were to end in December, 1997. The additional year of funding would also allow the expanded distribution network to become fully sustainable- with day to day management of the network to be maintained by the private commercial sector.

• Achieve graduated sales of 1 million units of condoms in 1998.

• Achieve graduated sales of 1 million cycles of low-dose oral contraceptives in 1998. • Achieve graduated sales of 50,000 units of Depo-Provera in 1998.

• Expand the Red Apple Program to include all major regions of Uzbekistan, including Bukhara, Navoi, and Khorezm regions with more than 750 private pharmacy outlets.

• Train 300 additional health care providers and pharmacists in modern contraceptive technology, DMPA, quality customer service and HIV/STD counseling.

Resources

47 To support ongoing activities for both scenarios these estimates include maintaining a project office in Tashkent with a Country Manager, along with in-country consultant support. Technical assistance and project oversight will continue to be provided by SOMARClWashington.

Funding Fiscal Year Total Expenses Funding Funding 1993-94 Source 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 0 0 OYB Transfer 0 0 Buyin 3,300,000 1,954,777 5,254,777 4,309,680 945,097 1,500,000 2,500,000 Total $3,300,000 $1,954,777 $5,254,777 $4,309,680 $945,097 $1,500,000 $2,500,000

...

48 North and West Africa/Middle East

49 Egypt

The Egyptian national family planning program has achieved remarkable success over the past 15 years, a record of steady progress made possible by the combined support of the Government of Egypt and a sustained external donor effort led by USAID. Program progress is exemplified by the increase in the national contraceptive prevalence rate (CPR) from 24 percent in 1980 to 48 percent in 1995, and a corresponding decrease in the fertility rate from 5.2 to 3.6 over the same time span.

Awareness of modern family planning methods is virtually universal - the 1995 DHS determined that 99.8 percent of married Egyptian women knew about modern methods and more than 90 percent were aware of method sources and availability. The trend toward long-term methods is encouraging, as the IUD at 30 percent has supplanted the pill, now at a distant 10 percent as the contraceptive method of choice.

But much remains to be done in a nation of 59 million people with a 2.1 percent population growth rate. While it reached a new high in 1995, the CPR can be said to have "plateaued", as the increase since 1992 (47.1 percent) has not been significant. And largely rural Upper Egypt, a traditionally neglected area with about a third of the nation's population, continues to lag far behind Lower Egypt (Greater Cairo and the Delta region). The CPR among the rural women of Upper Egypt stands at 24 percent, almost half the combined total for urban and rural women in Lower Egypt.

For the national population program to continue its progress, the commercial private sector (defined as private service providers, private pharmacists and pharmaceutical companies) must expand and strengthen its already significant role as the source for an estimated 43 percent of all contraceptives distributed in Egypt.

USAID Objectives • USAID's overall strategic objective in the Egyptian population/family planning sector is to reduce fertility, based on the dual rationale that fertility reduction directly improves maternal and child health by reducing the incidence of high risk births, and secondly, contributes to slower population growth, reducing the pressure on land, public services, infrastructure, food, employment, and the environment.

SOMARC Objectives • Support and enhance the role of that segment of the private sector involved in contraceptive commodity marketing and distribution through a range of organizational, training and advertising and promotion efforts;

• Continue facilitating the transition of contraceptive social marketing to an open market, private sector effort that must move forward without previously available USAID-donated contraceptives marketed at subsidized prices.

Year I Accomplishments (1993) After the termination of support in December 1992 to the Contraceptive Social Marketing Project by USAID due to legal problems, SOMARC met the challenge of re-opening the private sector by assessing private sector pharmaceutical distribution capability, issuing an RFP to eight selected companies, selecting a two-company consortium to serve physicians and pharmacists, and placing USAID-donated contraceptives (732,000 IUDs, 3.6 million Norminest oral contraceptive cycles, and 28 million New Golden Tops condoms) back on the Egyptian market by early December 1993.

• To support the marketing and distribution effort, SOMARC issued an RFP and selected a Cairo advertising agency to announce the market re-entry.

• Achieved 1,091,874 sales of Golden Tops Condoms.

51 PREVIOUS PAGE BI).NK • Achieved 57,789 IUD sales

• Achieved 492,471 sales of Norminest oral contraceptives.

Year II Accomplishments (1994) During 1994 SOMARC undertook the dual task of directing and monitoring sales of USAID .... donated products through the consortium, and facilitating the transition of contraceptive marketing to the private sector.

• Conducted a "mini-launch" advertising and promotion campaign to support market re-entry during the first quarter; .... • Gained approval for price increases for USAID-donated contraceptive commodities to prepare consumer for free market prices;

• Acted as facilitator for contact between American and Egyptian companies in continuing availability of CuT 380A in Egypt after 1995.

• Achieved sales of 14,095,080 condom sales.

• Achieved 546,662 IUD sales.

• Achieved 1,820,229 oral contraceptive sales.

Year III Accomplishments (1995) In 1995 SO MARC continued the successful marketing and phase-out of USAID-donated contraceptives and provided continuing support to the private sector transition of all three products. In addition, SOMARC provided significant support for the private sector introduction of the injectable, a new method category.

• Worked closely with the manufacturer and Egyptian companies to continue the availability of Norminest OC after 1996; ... • Saw the introduction of new CuT 380A's to the Egyptian private sector, as well as price reductions in other IUDs to make the product more affordable to the consumer -- both the result of SOMARC facilitation efforts. ....

• Achieved 10,352,518 condom sales.

• Achieved 115,8131UD sales

• Achieved 290,817 oral contraceptive sales.

• Achieved 76,201 contraceptive injectable sales. .... Challenges for the Future The principal challenge for SO MARC in Egypt is to help strengthen the commercial private sector and enhance its contribution to the national family planning effort. While reasonably sophisticated, the ... sector is far from mature and needs to improve its marketing capacity and skills to assure a dependable fiow of high-quality, affordable contraceptives for the Egyptian consumer. In addition, the sector faces a range of policy issues, such as import tariff and consistent quality standards, that it needs to confront. 52 Scenario I Year IV-V 11996-97\ During 1996-97, SOMARC support of the commercial private sector will encompass a range of activities, including the establishment of an informal private sector contraceptive marketing and distribution working group to help the sector address policy issues and generally act in concert to address those issues; establish and monitor a national private sector contraceptive sales reporting system; provide a range of advertising and public relations support that will include television, print and point-of-purchase material; and formal training in sales and marketing skills to company sales representatives. Concurrently, SOMARC will work closely with the senior leadership of the Ministry of Health and Population to foster working relationships and a unified approach to common goals between the private sector and the GOE.

• Achieve 10,000,000 condom sales

• Achieve 400,000 IUD sales

• Achieve 7,000,000 oral contraceptive sales

• Achieve 175,000 contraceptive injectable sales.

Scenario II Year IV-VI 11996-98\ An additional year of support would enable SOMARC to build on the initial year of organization, media activity and training to help the Egyptian contraceptive marketing private sector emerge as the effective, ongoing replacement for the subsidized efforts of the past. Activities would continue as Scenario I (1996-97) should be viewed as the base of a start-up effort.

• Achieve 20,000,000 condom sales

• Achieve 450,000 IUD sales

• Achieve 7,200,000 oral contraceptive sales

• Achieve 225,000 contraceptive injectable sales.

Resources The assignment of a Resident Advisor and the continuance of the SOMARC project office in Cairo with local, full-time professional support, are required to support the activities outlined for Scenarios I and II. SOMARClWashington will continue to provide technical assistance and project monitoring.

53 Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 750,000 200,000 950,000 759,458 190,542 OYB Transfer 0 0 Buyin 1,000,600 1,000,600 841,590 159,010 Buyin (amend) 322,351 260,753 . 583,104 434,351 148,753 1,892,418 3,452,000 Total $2,072,951 $460,753 $2,533,704 $2,035,399 $498,305 $1,892,418 $3,452,000 -

....

..I

54 .. Ghana

Although Ghana was the first country in Africa to establish a Population Policy in 1960, a lack of political commitment to the goals of the policy resulted in continued population growth in the order of approximately 3 percent per year.

In 1988, under the Contraceptive and Health Supply bilateral project, USAID implemented a social marketing initiative with the goal of expanding modern contraceptive usage through the private sector, ensuring a consistent supply of affordable contraceptives, and helping the government to increase prevalence from 7 percent to 12 percent by 1993. The social marketing program (GSMP) was implemented through a local pharmaceutical distribution organization (Danafco) with technical assistance ( specifically in market research and demand creation) provided by SO MARC II.

In 1992, the Family Planning and Health Project (FPHP) USAID's succeeding bilateral agreement established The Ghana Social Marketing Foundation as the local entity responsible for the management and implementation of the social marketing program. The goal under FPHP was to increase contraceptive prevalence to 15 percent by 1996 primarily through an increase in the use of the social marketing products - orals, condoms and vaginal foaming tablets. The Futures Group International was awarded the contract to manage the bilateral project and in particular to develop the institutional capability of GSMF to implement the social marketing initiative.

In 1995, the third USAID bilateral project - Ghana Population and AIDS project (GHANAPA) was established with the goal of increasing prevalence to 20 percent, expanding long term method use, and shifting the burden of service delivery from the public to the private sector. The Ghana Social Marketing Foundation was directly funded to manage the development and implementation of private sector family planning service delivery, with field support funds provided to SOMARC III for technical assistance to GSMF.

USAID Objectives • Reduce the burden on the public sector to provide family planning services by expanding the delivery of family planning services through the private and NGO sectors. Specifically by the year 2000, the public sectors share of market would be reduced to 40 percent for short term methods and 75 percent for long term methods.

• Improve the sustainability of family planning service delivery by vesting in the institutional development of GSMF and other local NGOs providing family planning services.

SOMARC Objectives • Transfer technology and skills to GSMF to enhance the institution's capacity to develop and manage a cost effective social marketing initiative and to achieve total sustainability (excluding commodity supplies) within ten years.

Year I Accomplishments (1993) The social marketing program was managed directly by the FPHP. SOMARC was not directly involved.

Year II Accomplishments (1994) The social marketing program was managed directly by the FPHP. SOMARC was not directly involved.

55 Year III Accomplishments (1995) • Provided training in administrative and management skills for the Financial Manager and Administrative Manager of GSMF.

• Provided social marketing training for three technical officers of GSMF including facilitating a study tour of the social marketing programs in Columbia and Jamaica.

• Provided training in research analysis and report writing for the staff of GSMF and selected local research institutions.

• Provided sales training for the staff of the three distribution organizations subcontracted by GSMF for the social marketing program.

• Established computer network system for GSMF and marketing organizations to' improve management information systems.

• Provided TA and Training for the development of public relations plans, implementation strategies and media relations.

• Provided technical assistance for the development of marketing strategies for long term methods.

• Assisted in the formulation of a strategy to implement an endowment fund for GSMF as part USAID's sustainability strategy.

• Assisted in the development of new initiatives to donors other than AID as part of GSMF's sustainability goals.

Challenges for the Future SOMARC's major challenges for the future are help build GSMF into a strong, viable institution for the delivery of reproductive health services, establish the necessary technical skills in GSMF to accomplish their goals, monitor and help main the quality of the services provided by GSMF.

Scenario I - Years IV - V (1996 - 1997) SOMARC will focus on capacity building, technology transfer and technical assistance accordingly to:

• Provide social marketing training for three additional technical staff members, inclusive of a study tour to Jamaica.

• Provide management training for the executive director of GSMF.

• Assist in the training of the Advisory Board and in the Boards development of a strategic plan for the institution.

• Assist in the development and execution of new integrated marketing communication programs to promote the sale and use of GSMF's products. • Provide continuing technical assistance in the execution of public relations strategies. ., • Provide technical assistance for the marketing of long term methods and the development of a services marketing strategy. ~I 56 • Provide technical assistance to monitor the financial and marketing activities of GSMF.

Scenario" - Years IV - VI (1996 - 1998) With an additional year of support, SOMARC would be able to consolidate the competency of GSMF, establish a solid marketing strategy for long term methods, and initiative new activities that would further ensure the financial viability and sustainabifity of GSMF.

• Provide technical assistance for the implementation of a services marketing initiative that would create a network of 100 doctors/clinics, 250 pharmacists, 700 chemical sellers, three tertiary hospitals (for referrals) and covering the three largest regions in Ghana. The target would be to serve 20 - 30,000 family planning clients per annum through this network.

• Introduce a new brand of pills, vasectomy, and flavored oral rehydration salts.

• Seek new lalternate donors for contraceptives.

• Continue skills training particularly in strategic marketing and market research.

Resources Field support funds of approximately $300,000 per year would be required to maintain the technical assistance support from SOMARC.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' $200,000 $200,000 $203,674 $(3,674) $260,000 $560,000 OYB Transfer 0 0 Buyin 0 0 Total $0 $200,000 $200,000 $203,674 ($3,674) $260,000 $560,000

57 Jordan

The overall purpose of the Contraceptive Social Marketing (CSM) Project in Jordan is to make a variety of high quality contraceptive methods available through private sector channels at affordable prices to couples who choose to practice family planning. Among the products targeted for this project are low .... dose oral contraceptives, IUDs, injectables, and implants. At the request of the Government of Jordan/Ministry of Health and USAID/Jordan, the SOMARC Project of The Futures Group International (FUTURES) redesigned the MBSP in October 1992. The MBS Project was restructured after a careful and thorough assessment of the project situation and needs. SOMARC was asked to implement the marketing and communications components of the restructured project because of SOMARC's extensive experience in similar contraceptive social marketing programs. .... Jordan has a highly sophisticated commercial sector as does the Jordan economy. SO MARC was approved to manage the pilot project from January 1994 to July 1995. Limited preliminary tasks could be accomplished during this 18 month period, but if viewed as an initial success by the MOH and USAID, the project could be extended into a major long-term approach to increase the availability and use of modern contraceptive products and services in Jordan.

USAID Objectives • Increase the availability and usage of high quality family planning products and services at affordable prices to middle and low income women (C and D socioeconomic groups) by capitalizing on the private sector to lay the foundation for future sustainability.

SOMARC Objectives • Use commercial methods and networks to make family planning, reproductive health and AIDS/STD prevention products and services more affordable and available to low income families.

• Increase contraceptive usage.

• Achieve self-sufficiency.

• Create a contraceptive services delivery network of private sector practitioners.

Year I Accomplishments (1994) The first year accomplishments included the start-up activities associated with a social marketing program. These included, obtaining USAID/AMMAN and Jordanian Ministry of Health's support of the project, writing the marketing plan draft, finalizing the acceptance of letters of agreement by Arab Supplies and Schering for oral contraceptives and G.M. Khoury for the IUD, appointing a residentadvisor and opening the Jordan Birth Spacing Project's office, reviewing secondary research, and begin bimonthly retail audits to monitor category sales movement.

Pan Arab advertising campaign development began with focus group research conducted in Amman. Information obtained from these focus groups was used for the development of project logo, advertising and promotional materials. Physicians training of DMPA began in late 1994 and continued into the new year. Training of trainers for contraceptive technology was conducted in Amman. Cubeisy was selected to manage and implement advertising activities.

Year 1/ Accomplishments (1995) Personnel changes took place in early 1995, the JBSP office moved and was managed by a newly appointed project administrator. Contraceptive technology training sessions were conducted throughout Jordan (Amman, Karak and Irbid) for pharmacists and pharmacist assistants. More than 800 pharmacists and their assistants were trained during the second and third quarter of the year. Training materials, consumer education materials, point of purchase materials, and publication materials were - 58 designed and produced using the new project logo. The marketing plan was approved by the Ministry of Health. Funding for the JBSP was extended through December 1996.

In late 1995 promotional and public relations activities officially launched and introduced the JBSP to the Jordan consumer. Promotional and public relations activities included provider receptions introducing Ob/Gyns and GP to the JBSP and soliciting their support and involvement, press debriefing with Arabic and English-language reporters presenting for the first time the objectives and purpose of the JBSP, and a media photo opportunity. Anew resident advisor was named to head the JBSP. JBSP soap opera "Sarkha" which promoted the benefits and advantages of birth spacing was well received. Femulen (mini-pill) was added to the JBSP products list. Research projects were conducted on the Pan-Arab television spots, the promotional materials, JBSP logo, and viewers attitudes toward the soap opera.

Year III Accomplishments (1996) Training continued throughout Jordan, more than 900 pharmacists and pharmacist assistants have participated in contraceptive technology seminars, and 300 physicians have attended DMPA and contraceptive technology educational programs. Approval was given by the Ministry of Health to air three of the Pan Arab television spots. Work continued on the JBSP logo ad. Public relations activities continued with press coverage, television, and radio interviews on the project. A "Dear Doctors" column began to run in Arabic newspapers sponsored by the JBSP.

Challenges for the Future SOMARC's challenge is to project impact sales and increase the usage of the products. All the mechanics have been put in place, delays with advertising and promotional approval have moved sales projects into the third and fourth quarter of the year. The next challenge is to institute the servicing network of private sector physicians.

Scenario I (1997) If the Jordan social marketing project is extended past December 1996, SOMARC will organize ... and introduce a pilot program of the social marketing servicing network initiative in Amman. Preliminary steps will include the assessment of healthcare providers and evaluation of partiCipants, as well as one on-one interviews with patients, introduction of the servicing market concept and reaching agreements with participating clinics and physicians. By the third quarter of 1997, SO MARC will officially launch a pilot network in Amman which will include strong promotional and marketing of the service providers. SOMARC will also continue to promote and market the JBSP methods with the aim of reaching sustainability for the pills, IUDs, and injectables by the end of 1998.

• Achieve 540,000 oral contraceptive sales.

• Achieve 12,600 contraceptive injectable sales.

• Achieve 15,000 IUD sales.

Scenario II (1998) SOMARC will expand the social marketing servicing network pilot to include all of Amman and possible other Jordanian cities. Promotion will continue on JBSP methods with the aim of reaching sustainability for the pills, IUDs, and injectables by the end of 1998.

• Achieve 840,000 oral contraceptives sales

• Achieve 19,600 contraceptive injectable sales. • Achieve 20,000 IUD sales.

Resources

59 To support ongoing activities including maintaining a project office in Amman with a local resident advisor, project administrator, the addition of a medical advisor, and in-country consulting support. Technical assistance and project oversight will continue to be provided by SOMARClWashington.

Funding Fiscal Year Total Expenses Funding Funding .... Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 50,000 50,000 44,322 5,678 OYB Transfer a a .... Buyin 1,144,338 1,144,338 931,536 212,802 700,000 1,200,000 Total $1,194,338 $0 $1,194,338 $975,858 $218,480 $700,000 $1,200,000

....

60 Morocco

Overall awareness of modern methods of contraception in Morocco is high- 97 percent of women know at least one modern method, most likely oral contraceptives (97 percent). Despite the fact that almost two thirds (62 percent) of Moroccan women claim to have used a modern method at some point. only 36 percent currently use any modern method, indicating there is a very high discontinuation rate. Oral contraceptives dominate the contraceptive market representing 78 percent of all modern method usage. However OC's suffer from a high discontinuation rate, primarily due to side effects. This suggests that many women may want to have other contraceptive options available to them. Awareness of the IUD is 84 percent and the injectable is 55 percent, however use of these methods is very limited (3 percent and 0.1 percent respectively). The IUD has suffered from a poor consumer image as well as a high price through private practitioners.

The role of the private sector as a source for the pill and condoms has increased in importance from 21 percent in 1987 to 39 percent in 1992, exclusively due to the increased availability of condoms and pills through pharmacies (primarily the SOMARC brands). Other methods however, have not been widely available or affordable through the private sector service providers. Eighty percent of IUDs are procured through public sector. Until recently the injectable has not been available through either private or public sector channels.

USAID Objectives • To increase the use and range of modern high quality contraceptives available and purchased through commercial channels at prices that are affordable to low-income couples.

• Introduce a culturally sensitive social marketing approach to the expanded use of modern contraceptives, starting with the condom, followed by low-dose oral contraceptives and subsequently by long-term methods (injectables and IUDs).

• Improve Morocco's self-reliance in family planning by enhancing the private sector's role in meeting consumers' demand for products and services independent of USAID support.

SOMARC Objectives • Increase the overall awareness and usage of modern contraceptives, starting with the condom and progressing to medium and long-term methods.

• Attain self-sufficiency of the social marketing condom within four years.

• Introduce a low-dose pill at a more affordable price to public and subsequently achieve self sufficiency.

• Expand the use of long-term methods with the introduction of a low "priced, high quality injectable and IUD". • Shift users of contraceptives from public to private sources.

• Build up a cadre of well trained private physicians, pharmacists, nurses and other paramedics able to provide affordable services/counseling in family planning.

61 Year I Accomplishments (1993) SOMARC began its social marketing activities in Morocco with the introduction of Protex condom in 1991. Protex was the first brand of condoms to be nationally advertised. Already by 1993 the distributor, .... Promopharm, was in a position to take over the importation, packaging and promotion of Protex, without further USAID funding. Meanwhile in 1992, SOMARC negotiated with Wyeth to lower the price of Minidril and with Schering to launch Microgynon at the same low price, so that both OCs could be introduced under the SO MARC project brand Kinat AI Hilal (Crescent Moon Pill). During 1993 SO MARC continued PR advertising and training activities on behalf of Kinat AI Hila!.

• Graduated the Protex condom from SOMARC assistance (September 1993).

Year II (1994) Accomplishments During 1994, SOMARC built on the early success of Kinat AI Hilal by developing and launching a second generation of TV and radio advertising. Meanwhile, the training of pharmacists was completed and extended to include pharmacy assistants. While emphasizing oral methods, the training covered all contraceptives technology and quality customer services. Also in 1994, SOMARC began preparations for the introduction of long-term methods, through market research studies aimed at consumers and service providers, as well as negotiations with the manufacturers of injectables and IUDs.

• Achieved graduated sales of 2.2 million condoms.

• Achieved sales of 1.5 million cycles low-dose pills.

Year III (19951 Accomplishments In 1995 SOMARC continued advertising support for Kinat AI Hilal and developed plans for its attaining a level of self-sustainability. Terms for the procurement and distribution of long-term methods were negotiated with the manufacturers, and a local advertising agency was selected to implement the marketing plan.

• Negotiated terms with Upjohn/Roussel Diamant for the procurement and distribution of social marketing injectable, Depo-Provera.

• Achieved graduated sales of 2.5 million condoms.

• Achieved sales of 1.5 million cycles low-dose pills.

Challenges for the Future SOMARC's continuing challenge in Morocco is to expand the private sector's role in family .... planning and to offer a wider range of methods. While condoms and OCs are well established, SOMARC will add the injectable and IUD as long-term methods available to private consumers at affordable prices. Among the constraints are the limited acceptance of these methods by private physicians and the inability to single out physicians that have been trained via SO MARC as service providers. In time these constraints will be overcome through extensive training in counseling and display of project materials within the doctor's office.

Scenario I: Year TV-V 11996-1997\ During 1996-1997 the two OCs marketed by SOMARC as Kinat AI Hilal will graduate to self sustainability, with no further need of USAID funding. In the third quarter of 1996 the AI Hilal (Crescent Moon) product family will add Depo-Provera injectable, followed by FEI's CuT 380A IUD. 80th of these long-term methods will be introduced through pharmacies at prices substantially below those for other private sector products.

• Launch FEl's IUD.

Scenario II: Year IV-IV 11996-1998\ 62 Following the introduction of the injectable and IUD in the second half of 1996, training of physicians, pharmacists, midwives and private nurses in 1996/97 will be limited to the five target regions (Casablanca, Rabat/Sale, FeslMeknes, TangerlTetouan and Marrakech). With an additional year of funding, SOMARC would expand training to include all urban areas (ea. Oujda, Agadir, Safi, Essaouira, EI Jadida) so that the products would have full national coverage by the end of 1998. By that time there would be a network of trained physicians, pharmacists, midwives and nurses known by word of mouth that could form the nucleus of a self-sustaining group of private providers able to offer advice on an entire range of high quality contraceptives in pharmacies at affordable prices.

Resources

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' $1,300,000 $600,000 $1,900,000 $1,000,756 $899,244 $750,000 $1,500,000 OYB Transfer 0 0 Buyin Total $1,300,000 $600,000 $1,900,000° $1,000,756 899,244 ° 750,000 $1,500,000

....

63 Senegal .... Awareness of condoms in Senegal was relatively high prior to the launch of social marketing product (Protec). All men interviewed in the SOMARC baseline survey were aware of condoms for AIDs prevention, and 95 percent were aware of condom use for family planning. While trial is also high (73 percent), regular use is somewhat lower (39 percent). One of the main reasons cited for inconsistent use was "they are not always available" (30 percent). It appears that users depend heavily upon their friends as their primary source of condoms (46 percent), and very infrequently on other sources which may be more easily accessible, such as pharmacies (only 9 percent cite pharmacies as a primary source). The image of condoms in Senegal is generally positive, with the exception that they are not perceived for use with wives. Thus, the primary barriers to expanded and more consistent use of condoms appear to be limited availability as well as the perception that they are predominantly for use only with occasional .... partners for AIDS prevention.

USAID Objectives • To increase the awareness, acceptability and use of modern, high quality contraceptives available through commercial channels at prices that are affordable to low income couples.

• To introduce a culturally sensitive social marketing approach to the expanded use of modern contraceptives, starting with the condom.

• To promote condom use for both family planning and prevention of STDs/AIDS.

SOMARC Objectives • To increase usage of condoms for both family planning and prevention of STDs/AIDS in Senegal.

• To expand the role of the private sector in providing family planning methods at prices affordable to low income couples.

• To train pharmacists and assistants to be able to provide quality customer service, including counseling on the proper usage of condoms.

Year I Accomplishments (1993) During 1993, SOMARC arranged a study tour to Morocco for leading Senegalese physicians and pharmacists to see a successful social marketing program in progress within a Moslem country. SO MARC prepared an initial implementation plan for introducing a branded condom in Senegal. ... • Conducted study tour in Morocco for Senegalese representatives from the Ministry of Health, USAID, and the National Order of Pharmacists.

• Designed implementation strategy for condom pilot project.

Year II Accomplishments (1994) Early in 1994, SOMARC presented a revised implementation plan for a nationwide, condom social marketing pilot project, and this plan formed the basis of the subsequent marketing plan. SO MARC proceeded to select the local subcontracting partners for packaging/distribution, promotion/advertising, administration services and market research. Start-up activities began in each of these fields under the guidance of the local Project Committee and SOMARC's Project Coordinator. Year III Accomplishments (1995) In 1995 a TOT program was followed by training of all available pharmacists, pharmacy assistants and depot managers, with the financial assistance of AIDSCAP. Pre-testing took place for the Protec logo

64 and packaging as well as radio and TV advertising. Media training, a PR campaign and distribution of POP materials and the product to pharmacies were arranged before the official launch event in June, 1995. Subsequently promotional activities, and mass media advertising began.

• Officially launched project in June, 1995.

• Achieved sales of 712,500 condoms in 9 months.

Challenges for the Future The major challenges facing SOMARC in Senegal are 1) the low prevalence of contraceptive usage, 2) the relatively small participation of the private sector in family planning, 3) the high cost of medium and long-term methods available in pharmacies, 4) the need for SOMARC to obtain funding beyond September 1996 in order to continue and eventually expand social marketing activities. As soon as the future funding is approved, SOMARC is well positioned to propose programs addressing the other challenges in Senegal.

Scenario I Years TV-V 11996-1997)

For 1996 various activities are already planned to further the growth of Protec condom sales at the national level, through additional media coverage, a tour of 15 cities and sponsorship programs. In May, 1996 a mid-term evaluation of the SOMARC project will take place. Assuming that the results are favorable, additional USAID funding will be sought to expand social marketing to cover middle and long term methods, non pharmaceutical distribution (ea. CBD) and/or MCH products such as ORS.

Scenario II Years IV-VI 11996-1998)

In the event that funding is approved for expanding the distribution coverage and/or additional contraceptive/MCH products, the related training, PR, IEC and promotional/advertising activities will get fully underway only in 1997. An additional year of support will enable these activities to be completed at the national level, so that their full impact can be felt and evaluated. Meanwhile, the condom is expected to attain self-sufficiency within this period.

Resources

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support" $185,000 $100,000 $285,000 $304,610 $(19,610) $100,000 $175,000 OYB Transfer 500,000 500,000 105,425 394,575 500,000 1,000,000 Buyin 500,000 98,114 598,114 561,548 36,566 150,000 225,000 Total $685,000 $698,114 $1,383,114 $971,583 411,531 $750,000 $1,400,000

65 Sub-Sah13ran Africa

PREVIOUS PA~E StANK 67 Madagascar

Madagascar, an Insular country with 14 million people and 55 percent below the age of 20, is one of the few countries with a low AIDS prevalence rate. Epidemiological surveys on HIV and syphilis prevalence conducted in November 1995 among pregnant women, STDs clinics users and commercial sex workers (CSWs) in the capital town of Antananarivo and the two port towns of Toamasina and Toltary indicated that there are approximately 5,000 HIV-positive individuals. In November 1995, there were only 20 notified cases and an estimated 130 non notified cases of AIDS. However, STDs rates among the population is high and it is estimated that 1 million Malgaches are at risk of HIV infection. Based on projections scenario it is estimated that HIV prevalence could reach respectively approximately 15 percent of the adult population by year 2015.

According to the 1992 Demographic Health Survey, there is wide unmet demand for family planning. Current modern contraceptive prevalence is low at 9 percent, an increase of 5 percentage points since the 1992 DHS. Although there are no reliable statistics about abortion, which is illegal, it is a well known fact that abortion is often used as a family planning method. Knowledge of at least one modern method of contraception is 57 percent, with the injectables, oral contraceptives and female sterilization the most known methods. Twenty-five percent of women who know about a method did not know where they could obtain it. Among non-users, 36 percent declared their intentions of using a method within the year, and 33 percent of married women planned to wait at least two years before their next child and 40 percent declaring they did not want any more children. There is an interest from the private sector to distribute and promote condoms. In addition, there is a significant potential with private medical providers to expand reproductive health service delivery.

USAID Objectives • Expand family planning service delivery and provide access to these services as quickly as possible.

SOMARC Objectives • Rapidly expand distribution and sales of condoms, injectable and oral contraceptives. The project will supplement the existing private sector with a project dedicated sales force.

• Create consumer awareness for condoms, injectable and oral contraceptives.

Year I Accomplishments (1993) SOMARC was not working in Madagascar in 1993.

Year II Accomplishments (1994) SOMARC conducted an assessment to implement condoms and oral contraceptives social marketing in Madagascar.

Year III Accomplishments (1995) The major thrusts during this year was to design specific interventions and to make logistics arrangements to start the program. Conducted research to determine the acceptability of introducing the Protector condom campaign among Malagasy men and women.

• Selected an advertising agency to adapt the Protector condom communications campaign.

• Selected an implementing agency and designed a distribution strategy.

• Procured vehicles for the project.

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Challenges for the Futures There are three areas of challenges for SOMARC in Madagascar: (1) Launching three products (condoms, pills and injectables) in the course of 21 months will be a major undertaking for SOMARC. SO MARC will have to put in place an effective supervisory system as the project is hiring and training a local staff; (2) SOMARC may also face initial consumer resistance to condoms which may affect sales and distribution. The current constraints for the condom is the lack of "feeling" at risk for HIV transmission as AIDS by the majority of Malgannes. AIDS has not taken the toll it has in Central and East African countries ad does not appear yet to be a major epidemic by the Malgaches. For the oral and injectable contraceptives, the key challenge will e for SO MARC to address Significant regulatory issues to promote their benefits and availability to consumers; (3) for the injectables and oral contraceptives, the challenge will be the ability for SO MARC to train and to legally enroll sufficient private providers in the program to have an impact on contraceptive distribution. .... Scenario I Years IV-V 11996-19971 In June 1996 SO MARC will launch Protector condoms. SOMARC will test the Malagasy version of the Protector communications campaign for its comprehension among Malagasy men. SOMARC will implement a communications program to make it "wise" to use condoms for both family planning purposes and for AIDS/STDs prevention. Communications efforts will concentrate on well identified traditional communications media: limited efforts will be invested in organizing and using nontraditional media. Condom distribution will be achieved by a system using both the existing commercial whOlesalers network and a Protector dedicated sales force. SOMARC will concentrate distribution to the USAID-bilateral project geographic areas. SOMARC will ensure condom distribution and promotion in only three of the six port towns (concentration of HIV transmission risk groups) of Madagascar although no major investment .... of financial resources will be done there.

The condom launch will be followed in December 1996 by an injectable and in February 1997 by oral contraceptives SOMARC will test the Pilplan name for the oral contraceptives and conduct focus groups research among women to derive positioning statement for the communication campaign on the injectables. SOMARC will train pharmacists and private physicians in contraceptive technology, counseling, infection prevention, and referrals for complications. However, training will be limited to providers in urban areas. Depending on the outcome of negotiations with the Ministry of Health, SO MARC may initiate an advertising campaign on Pilplan and a promotions campaign for providers offering the injectables.

Currently, it is not in SOMARC's priority in Madagascar to graduate program activities by transferring them to NGOs or private sector groups. The key emphasis of the 21 months of the program will be to increase distribution and promotion of condoms and contraceptives rapidly.

• Achieve 2,600,000 condom sales by 1997.

Scenario" Year IV-VI 11966-1998) With an additional year, SO MARC will increase program impact in Madagascar by increasing efforts for condoms and contraceptives. SOMARC would be able to engage in country-wide distribution for condoms and ensure distribution in the high-risk groups of all main cities including all the port towns. For the oral and injectable contraceptives, SOMARC would also have a bigger contraceptive impact by providing training and enrolling providers serving part urban areas and in designated populous rural areas. SOMARC could also invest in nontraditional media to have impact on hard-to-reach populations.

SOMARC would also be in a better position to collaborate with other local health and family planning projects. USAID/Madagascar is financing bilateral family planning program (APPROPOP) whose goal is to ultimately transfer management and program technologies to health NGOs by 1999. If SO MARC is allowed to continue up to September 1998, it would be possible for SOMARC to work with the APPROPOP project to transfer social marketing activities to local institutions. SOMARC would also collaboration with the BASICS (Child Survival Project) to include the marketing of oral rehydration salts (ORS) and other child survival products.

Resources 70 SOMARC will have a small project office in Madagascar staffed by a local Marketing/Public Relations Manager and a Distribution Manager and sales supervisors. The SOMARC/Nairobi office will provide project supervision of the local staff. Together with the SO MARC/Rabat office, SOMARC/Nairobi will also provide technical assistance in the areas of research and distribution/promotion.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 700,000 700,000 320,630 379,370 1,000,000 2,000,000 OYB Transfer a a Buyin 281,594 281,594 a 281,594 150,000 Total $0 $981,594 $981,594 $320,630 $660,964 $1,000,000 $2,150,000

•

71 Uganda

In Uganda, overall awareness of at least one method of contraception is very high. Among currently married women age 15-49, 93 percent know at least one method of contraception, and 92 percent of those knowing a method also know of at least one modern method. The most commonly .... recognized methods in Uganda are contraceptive pills (83 percent), condoms (78 percent), and injections (78 percent). One-third of the women age 15-49 have used a method of family planning at some time in their lives. 2

Although awareness and ever-use are high, contraceptive prevalence is low. However, the 1995 Uganda Demographic and Health Survey (UDHS) shows promising trends. The contraceptive prevalence rate in Uganda has tripled overall six year period, from 4.9 percent in the 1989 DHS to 14.8 percent in the 1995 DHS. Use of modern methods has grown faster than overall prevalence, from 2.5 percent in the 1989 DHS to 7.8 percent in the 1995 DHS. Uganda's fertility rate has fallen from 7.3 percent in 1989 to 6.84 percent in 1995.3 Pills and injections are the most popular methods, used by 3 percent of women. Myths and rumors surrounding pills are still pervasive, but appear to be declining since the start of oral contraceptive social marketing in 1993. Injectable contraceptives are popular and widely desired. Their use has been limited in part by a lack of consistent supplies from the government's central stores to the government medical centers that operate at the district level. To date injectables have been almost exclusively available only through the public sector. There is very little commercial sector distribution of injectables.

Uganda's family planning environment is strongly influenced by the high prevalence of HIV/AIDS. Estimated national HIV/AIDS prevalence is 12 percent and is as high as 30 percent among some urban populations. The HIV/AIDS situation in Uganda has opened the environment to more frank and responsible discussion of condom use as one means to prevent the transmission of the disease. There is still a lot of unmet demand for family planning in Uganda, including condom use for disease prevention and/or family planning. Also, there is tremendous potential to develop Uganda's private sector as a source of family planning products and services.

USAID Objectives USAID/Kampala objectives for the SO MARC project are national in scope while concentrating ... heavily on the ten districts covered by the USAID/Kampala Delivery of Improved Services for Health (DISH) project. The DISH project started in August 1994 and is currently slated to end in September 1999. Then ten DISH districts represent approximately 30 percent of Uganda's population and include some of the districts with the highest HIV/AIDS prevalence rates in the country. The overall objective of the DISH project is to integrate delivery of family planning, HIV/AIDS prevention, and STD prevention and treatment services. More specific objectives as they relate to social contraceptive supply, use, and social marketing are:

• Achieve a contraceptive prevalence rate of 9 percent by 1996 (already achieved per 1995 DHS results). ....

• Provide high quality, reasonably priced contraceptives to as many eligible private sector points of sale throughout Uganda as possible.

• Provide more targeted an direct distribution to all eligible private sector points-of-sale in the rural and urban areas of the ten DISH project districts, including community-based. .... • Reduce the prevalence of STDs including HIV/AIDS through correct and consistent condom use.

2 Uganda Demographic and Health Survey 1995, Preliminary Report. Statistics Department, The Ministry of Finance and Economic Planning. 3 Ibid. 72 • Reduce the prevalence of STDs including HIV/AIDS through pilot activities to improve correct use of antibiotics for STD syndromes.

SOMARC Objectives • Expand the availability of Protector condoms nationally, especially in DISH districts, by enlisting nontraditional sales outlets such as general merchants, market vendors, bars, clubs, lodges, etc., to sell Protector.

• Increase correct use of New Pilplan oral contraceptives and reduce myths and rumors through consistent distribution to pharmacies, drug shops, clinics, and trained community-based distributors with accompanying method training and educational advertising/promotion.

• Introduce a private, social marketing brand of Depo-Provera distributed through private clinics and NGOs.

• Introduce an over-the-counter, prepacked antibiotic treatment kit for male urethritis to e distributed through clinics, pharmacies, and drug shops (drug shops pending Drug Authority approval).

• Create a partially self-financing national distribution network incorporating Uganda's major consumer product and pharmaceutical distribution companies.

Year I Accomplishments (1993) SOMARC launched Protector condoms in Uganda in 1991. In 1993, SOMARC introduced Pilplan oral contraceptives. All products are provided by USAID/Kampala donations to the Government of Uganda. During 1993, there was no advertising for Protector or Pilplan. At that time the only available media were government radio and television which prohibited condom and pill advertising. 1993 sales results were:

• Achieved sales of 1.8 million units of condoms.

• Achieved sales of 66,026 cycles of pills (launched June 1993)

Year II Accomplishments (1994) During 1994 the media environment in Uganda changed to allow limited radio advertising of Pnotector condoms. Two FM radio stations reaching the greater Kampala area began operations early in 1994 and accepted Protector advertising. SOMARC also started Protector's sponsorship of a weekly reproductive health program for young people called "Capital Doctor" on one of the FM stations. Later in 1994, a series of educational advertisements for Pilplan were produced in multiple languages and approved for broadcast on the government radio station, achieving national broadcast. The Pilplan advertisements were also broadcast on the Kampala FM stations.

A number of NGOs were recruited in 1994 to distribute Protector and/or Pilplan to rural and under served areas through community-based agents. A special project was initiated through the Uganda Private Midwives Association (UPMA) to place midwives in fixed and mobile sites to sell products and provide family planning education.

• Achieved sales of 4 million condoms. • Achieved sales of 247,491 cycles of pills.

Year III Accomplishments (1995) During 1995 SO MARC assessed the changing product distribution environment in Uganda and selected a new main distributor. A ten-person distribution, sales, and training team was recruited to focus largely on the ten DISH districts. Additional NGO subdistributors were recruited and trained to sell

73 Protector and Pilplan. A detailed plan was prepared to introduce Depo Provera as a social marketing product and consumer research for the new product was conducted. USAID/Kampala requested SOMARC to develop preliminary plans to introduce a prepacked, over the counter antibiotic treatment kit .... for male urethritis. Plans were made to amend the SOMARC Buy-In to the DISH project to expand the scope of work and budget to cover the proposed pilot antibiotic treatment kit project. SOMARC also conducted research to reposition Pilplan for the new AI.D. commodity, Duofem, and made required changes in packaging and product information in preparation for an early 1996 product launch of "New .... Pilplan." Uganda was the first AI.D. social marketing country to make the transition to the Duofem product. 1995 sales results were:

• Achieved sales of 5.9 million condoms.

• Achieved sales of 307,000 cycles of pills.

Challenges for the Future SOMARC's major challenge in Uganda is to integrate the product line and the distribution system into the Ugandan private sector in order to achieve some level of self-sufficiency in distribution. This is especially important for the Protector condom. The demand for Protector is growing rapidly and the cost of commodities and packaging materials are beginning to constrain project budgets. Alternative sources of condom commodities are now being developed and there is a very good possibility that the USAID commodity can be replaced by sources from other donors. At the same time, the Protector brand is now well-known and is attracting the interest of several large consumer product distribution companies. There is potential to create a consortium of distributors to carry the product at a very limited cost to the project.

Another major challenge is to distribute the new injectable product as widely as possible without compromising quality of care. Private sector clinics provide only limited family planning services now and offer tremendous potential as distribution sites. SO MARC's challenge, particularly in the early stages of the new product introduction, will be to manage the sites that are enlisted to carry the product.

SO MARC will also be challenged to create a successful pilot of the over the counter antibiotic kit for STD treatment. Again, the private sector will playa key role in the success of this project.

Scenario I Year IV-V 11996-1997) During 1996-1997 SO MARC will launch a social marketing injectable contraceptive, Injectaplan, in August 1996. The introduction plan will phase in clinical service sites offering Injectaplan, as each site will require training and follow-up monitoring, with the goal of enrolling approximately 200 sites from the August 1996 launch until September 1997. SOMARC will also evaluate the potential to introduce Injectaplan through pharmacies and/or drug shops on a limited baSis, which will require close coordination with and approvals from the National Drug Authority.

During 1996-1997 SO MARC will also conduct all research, brand development, and materials and advertising for the pilot over the counter STD treatment kit for urethritis. The USAID Mission Buy-In amendment to support this activity is expected to be completed in June 1996. The planned product launch is targeted for January 1997. During Year IV-V there will be only limited time to test the product in the market and collect pilot results.

• Achieve sales of 19 million Protector condoms (10 million in calendar year 1996, 9 million in the first nine months of calendar year 1997). • Achieve sales of 838,125 cycles of New Pilplan oral contraceptives (450,000 in calendar year 1996, 388,125 in the first nine months of calendar year 1997).

• Achieve sales of 81,000 vials of Injectaplan injectable contraceptive (August 1996-September 1997).

• Introduce pilot antibiotic kit in four DISH project districts and achieve sales of 12,500 units of the kit (February 1997 -September 1997).

., .... ;." . Scenario" Year IV-VI (1996-1998) With an additional year of support, SOMARC would reach a larger number of new outlets for Injectaplan and achieve pilot introduction in pharmacies andlor drug shops. SOMARC would also expand distribution of the antibiotic treatment kit for STDs and design long-term strategies based on pilot activity results. There would be opportunities to conduct studies of user compliance with the over the counter treatment kit in order to measure more carefully how much this approach improves correct use of STD treatment. SOMARC would also have the opportunity to consolidate private sector distribution support, especially for Protector condoms, and achieve steps toward a self-sufficient distribution and commodity procurement system. Finally, and perhaps most important, SO MARC would be able to fully support and complement all of the objectives of the DISH project through most of the DISH projecfs current life.

• Achieve sales of 34.7 million Protector condoms (January 1996-September 1998).

• Achieve sales of 1,413,843 cycles of New Pilplan oral contraceptives.

• Achieve sales of 300,000 vials of Injectaplan injectable contraceptives.

• Achieve sales of 50,000 antibiotic STD treatment kits.

Resources

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' $800,000 $500,000 $1,300,00 $1,752,88 (452,888) $1,000,00 $1,500,00 a 8 a a OYB Transfer a a Buyin 427,463 500,000 927,463 711,265 216,198 1,635,000 2,435,000 Total $1,227,46 $1,000,00 $2,227,46 $2,464,15 ($236,690 $2,635,00 $3,935,00 3 a 3 3 ) a a

75 Latin America and the Caribbean

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77 Brazil

Brazil has a contraceptive prevalence rate close to 70% and, while awareness of existing methods is almost universal, actual use is concentrated in two methods: female sterilization, which has a very unclear legal status, and the pill. Low use of temporary methods has contributed to continued widespread abortion (not always performed in proper conditions) and a general low quality of Brazilian women's reproductive health.

During the 60's and 70's, Brazil was a major recipient of US bilateral aid. Direct assistance from the US to the Brazilian government was forbidden in 1983, due to political and economic situations like the national debt and nuclear non-proliferation issues. Nonetheless, USAI D has continued to provide funds for population assistance in Brazil. Nearly USD $50 million were provided between 1984 and 1994.

At present, a phase-out strategy is in place. Population assistance provided by USAID will decrease in the coming years. In the meantime, the Brazilian public sector and some NGOs will be assuming more responsibility in method and service provision.

USAID Goals • Improve the quality of family planning programs in Brazil by expanding the limited range of methods available , improving the use of existing methods and increasing the information available on reproductive health.

• Ensure that there are viable service-delivery systems in target areas when USAID assistance ends by working with states and the private sector to promote sustainability.

• Document the impact of USAID population assistance to Brazil through data collection and analysis at key points in program implementation.

SOMARC Goals • Help expand the range of methods offered in the public sector

• Reach self-sufficiency within three years for the Contraceptive Procurements Organization (CEPEO).

• Stimulate IUD distribution in the commercial sector.

• Launch a new condom to the local market as a commercial program to help a family planning organization achieve high levels of self-sufficiency.

Challenges For The Future SOMARC has the challenges to expand the IUD offer to the public sector by reaching many states and to offer a mix of temporary methods that are adequate for public health services and the NGOs. On the other hand, the purpose of this increase in contraceptive supply is to contribute positively to the financial health of associations that receive assistance in order to gradually substitute USAID support.

Scenario I (1996-1997) In 1996, SOMARC will launch the "Prosex" condom to the Brazilian market. The plan is to sell 1 ,5 million condoms the first year, especially in the areas of influence of Rio de Janeiro and Sao Paulo. Although the planned amount may not seem impressive for a market like Brazil, one must take into account that it will be BENFAM's first commercial operation, and that it will generate approximately USD $500,000, which will initially be reinvested in the project.

On the other hand, the organization implemented to distribute contraceptives to the public sector (CEPEO) will launch a commercial IUD in 1996, targeted for private practitioners. There is also a plan to launch a contraceptive pill in 1997, targeted for the public sector, and which will complement the supply of condoms started for that same purpose in 1995.

79 PREVIOUS PAGE BLANK Furthermore, the aim is to get the two associations that receive TA from SO MARC to work together, so that the condom sold by CEPEO com"s from BENFAM and the IUD distributed by BENFAM comes from CEPEO,

• To sell 1 ,5 million condoms (BENFAM).

• To sell 700,000 condoms (CEPEO). • To sell 140,000 IUD units to the public sector...... Scenario II 11996-1998) With an additional year, SOMARC could introduce an injectable to the public sector, thus completing the temporary-method mix mentioned earlier. SOMARC would also stimulate the supply of condoms and help BENFAM double the amount of units sold. The commercial sale of IUDs would be developed and made more representative of the total amount of products supplied. Both projects would reach self-sufficiency.

• To sell 3 million condoms (BENFAM).

• To sell 1,700,000 condoms to the public sector (CEPEO)......

• To sell 1,300,000 oral contraceptives. (CEPEO)

• To sell 100,000 injectables. (CEPEO).

• Both projects attain self-sufficiency.

Resources Technical assistance from Mexico and Colombia with support from Washington.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 450,000 500,000 950,000 578,877 371,123 500,000 850,000 OYB Transfer a a Buyin a 0 Total $450,000 $500,000 $950,0001 $578,877 $371,123 $500,000 $850,000

...

80 Ecuador

The knowledge of contraceptive methods in Ecuador is very high: 92.6 percent of women of reproductive age and in union know of some method, and 91.9 percent know of a modern method. The most common ones are the pill, female sterilization and the IUD. Knowledge of the following modern methods has increased notably in the past few years: condom, implants, and male sterilization. Contraceptive prevalence in Ecuador is 35.3 percent among women of reproductive age and 56.8 among women of reproductive age in union. The most commonly used methods are female sterilization (19.8 percent), the IUD (11.8 percent) and oral contraceptives (10.2 percent). From 1989 to 1994, female and male sterilization, the pill, and condoms boasted the largest increase in prevalence.

The private sector is the main source of contraceptive methods (62.2 percent). It provides the IUD to 79.8 percent of users, pills to 80.7 percent of users and condoms to 90.3 percent of users. Female sterilization is the exception, for which 63 percent of users go to the public sector. As for private drugstores, there are approximately 3,500 of them in Ecuador, where 51.2 percent of pills and 71.7 percent of condoms are obtained.

The market for injectables is just developing in Ecuador. Health guidelines from 6 years ago indicate that "Depo Provera" and "Noristera!" should not be used in Ecuador. In spite of these guidelines, drugstores sell the injectables "Depo Provera" from Upjohn, "Topasel" from Boehringer (Aug. 94), and "Mesigyna" from Schering (Aug. 95).

USAID Objectives • Continue to reduce overall rates of population growth as well as levels of fertility and mortality in Ecuador.

• Increase the use, effectiveness, and sustainability of family planning services in Ecuador.

SOMARC Objectives • Promote the correct and continued use of contraceptive pills, especially the low-dosage kind.

• Stimulate the growth of the commercial condom market.

• Promote the use of IUDs.

• Support the development of injectable contraceptives in Ecuador.

• Promote and increase the use of family planning, reproductive health, and overall health services offered by the NGO that developed the MSA program.

• Achieve self-sufficiency for the CSM program by the end of the year 2000.

Year I Accomplishments (1993) Fundaci6n Futura, a local non-profit agency established in Ecuador, has been implementing CSM activities since 1989 with SO MARC technical assistance and funding. The project launched a CSM condom, "Protektor", and supported a commercial oral contraceptive, "Microgynon".

As a result of a detailed audit conducted by SOMARC, it has been decided that the project implementation strategy is to vary substantially, since Futura will no longer exist as it does now, as it will become the property of APROFE and CEMOPLAF. Basic management and implementation for all project activities will be handled in a joint effort by APROFE, the 10callPPF affiliate who works in the coastal region, and CEMOPLAF, a very effective NGO working in the Andean region.

81 .. -

Year II Accomplishments (1994) In November 1994, and by agreement with USAID and the Technical Support from The Futures Group-SOMARC, CEMOPLAF decided to implement a contraceptive social marketing program, in an attempt to fuse its existing structure for Communitary Contraceptive Distribution as well as distribution through associated physicians with the necessary structure to develop a Social Marketing/Communitary Contraceptive Marketing program (CSM-CCM).

• Liquidated Fundacion Futura.

• Transferred all Futura assets to CEMOPLAF and APROFE.

• Designed the CSM-CCM program for CEMOPLAF.

• Initiated the CEMOPLAF marketing program.

• Made negotiations to ensure the continuity of the "Protektor" brand in the market.

Year III Accomplishments (1995) APROFE decided not to participate in the CSM program. It was decided to continue the program in Ecuador with CEMOPLAF only. The condom "Protektor" was relaunched, and distribution began of brand name products in the commercial and community sectors. Distribution for the relaunching of Protektor was begun through wholesale suppliers. At the same time, CEMOPLAF's sales force was organized, based on the existing structure for community distribution, and a sales training program was implemented. From July 1995, sales were emphasized by CEMOPLAF saleswomen. The relaunching of "Protektor" was supported by placing "Protektor" stickers reading "Sold Here" on drugstore windows; promotions to drugstores were begun in the form of discounts by volume and giving pharmacists and drugstore clerks promotional products as gifts, such as caps, T-shirts and pens; "Protektor" was advertised on the radio during an international soccer championship and a "Protektor" advertisement was placed on the main square during the Quito festivities.

Furthermore, oral contraceptives from Organon, Schering and Wyeth laboratories were distributed in the commercial sector, and sale of an injectable was begun. In the community sector, physicians and medical assistants from CEMOPLAF clinics distributed contraceptive products that had been either donated or bought from laboratories at a special price for this purpose. To support CEMOPLAF's image, family planning and reproductive health services, family planning spots for TV and radio included CEMOPLAF's logo and the phrase "For your family's health." ... • Relaunched "Protektor," with sales in the commercial and community sectors.

• Created a sales force at CEMOPLAF, based on the community distribution strategy.

• Sold 1.1 million condoms by the commercial sector ("Protektor", 700,000 units) and the community sector.

• Sold 190,000 contraceptive pill cycles by the community sector (170,000) and by the commercial sector.

• Sold 52,000 IUDs directly to physicians and medical assistants associated to CEMOPLAF and sale to wholesalers.

• Created a formation of trainers in contraceptive technology and safety. 82 • Launched the training program in contraceptive technology and safety for pharmacists, drugstore clerks and community saleswomen.

Challenges for the Future The greatest challenge for SOMARC in Ecuador is to improve accessibility to modern contraceptive methods and to increase the private sector's offer of high-quality/low-cost contraceptive methods. It is expected that selling at a price that is affordable for the lower classes, will also contribute to accomplish the goal of self-sufficiency for the Social Marketing/Community Marketing program.

Scenario I Year IV-V (1996-1997) In 1996-1997, with technical support from SOMARC, CEMOPLAF will launch the following: a new low-dosage pill by a commercial brand at the lowest price in the Ecuadorian commercial market; a new brand of middle-price condoms; and a commercial brand of IUDs. A new package for "Protektor" will be designed to include instructions for the use of condoms printed on it and thus reduce costs (at present, the package is distributed with a full-color insert). Injectable contraceptives will be distributed in the commercial and community sectors. CEMOPLAF's commercial and community distribution structures will be reinforced and actions will be taken to accomplish 80 percent coverage of drugstores nationwide for CEMOPLAF products. Pharmacists and clerks will be trained in Contraceptive Technology and Safety. It is expected that by 1997 the goal of at least 40 percent self-sufficiency for the program will be achieved.

• Consolidate "Protektor".

• Launch a new low-dosage pill by a commercial brand at a social price.

• Launch a commercial brand of IUDs through CEMOPLAF.

• Distribute injectable contraceptives to the commercial and community sectors at a social price.

• Train at least 300 pharmacists and drugstore clerks in Contraceptive Technology and Safety in order for them to provide information at the sales pOints.

• Achieve 80 percent distribution coverage of drugstores nationwide.

• Sell 2.6 million condom.

• Sell 328,000 pill cycle.

• Sell 83,000 IUD. • Support the sale of "Protektor" with mass publicity on TV and radio and to support CEMOPLAF's image and family planning and reproductive health service through family planning spots for TV and radio with CEMOPLAF's logo and the phrase "for your family's health."

Scenario II Year IV-VI (1996-1998) ... Through an extra year of technical support, SOMARC will reinforce the new brands of pills, condoms and IUDs introduced into the market. To support program self-sufficiency, it will launch a new brand of premium-price condoms. SO MARC will continue to stimulate the private sector to allow for continuity of the social marketing program and will expand community sales to regions that have no CEMOPLAF centers. It is expected that by late 1998 the goal of at least 60 percent self-sufficiency will be accomplished.

• Launch a middle-price condom. 83 --

• Strengthen the new low-dosage pill.

• Launch a new premium-price commercial condom in 1998.

• Reinforce the new condoms.

• Sell 4.5 million condoms.

• Sell 569,000 pill cycles.

• Sell 140,000 IUDs.

• Train at least 500 pharmacists and drugstore clerks in Contraceptive Technology and Safety in order for them to provide information at the sales points.

• Support CEMOPLAF's image and family planning and reproductive health service through publicity and promotion material.

Resources To support the activities for both scenarios, it will be necessary to keep CEMOPLAF's present basic structure, incorporating whOlesale suppliers to the distribution structure. SOMARC Mexico will continue to provide technical support.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 11995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' $115,000 $100,000 $215,000 $198,333 $16,667 $100,000 $200,000 OYB Transfer a 0 Buyin 200,000 200,000 55,028 144,972 150,000 Total $115,000 $300,000 $415,000 $253,361 $161.639 $100,000 $350,000

84 EI Salvador

Awareness of contraceptive methods in EI Salvador is very high: 98 percent of women of reproductive age know at least one method, the most common ones being female sterilization (93 percent), oral contraceptives (91 percent) and condoms (93 percent). Prevalence among women of reproductive age is 33.8 percent among women in union 53 percent, having increased notably in the past few years, due mainly to temporary methods. Between 1988 and 1993, the use of permanent methods varied from 30.2 percent to 31.9 percent, and that of temporary methods varied from 16.9 percent to 21.4 percent. The most commonly used methods are female sterilization (31.5 percent), oral contraceptives (8.7 percent), and injectables (3.6 percent). From 1988 to 1993, injectables boasted the largest growth in prevalence (from 0.9 to 3.6 percent).

In EI Salvador, the three most important sources of contraceptive methods are the Ministry of Health (48.9 percent), the Salvadoran Demographic Association, (ADS) (15.3 percent), and the Institute for Social Security (14.5 percent). As for private drugstores, there are approximately 1,000 of them in EI Salvador, where 26.7 percent of pills, 39.8 percent of injectables, and 57 percent of condoms are obtained. With a population density of 240 people per square kilometer, EI Salvador is the most densely populated mainland nation in Latin America.

USAID Objectives • Improve the quality of both health and education, and to stabilize the population growth. To decrease the rate of population growth as well as of fertility and mortality levels in EI Salvador.

• Promote a greater contraceptive prevalence and increase coverage for reproductive health care programs.

• Increase nationwide accessibility to modern contraceptive methods, especially in rural areas.

• Assist NGOs which provide reproductive health services in achieving financial sustainability and to phase out donor assistance.

SOMARC Objectives • Promote the correct and continued use of contraceptive pills, especially the low-dosage kind through ADS.

• Participate in the development of injectable contraceptives in EI Salvador through ADS.

• Promote the correct use of condoms through ADS.

• Promote and increase the use of family planning, reproductive health and overall health services offered by ADS, the NGO that developed the MSA program.

• Assist ADS in increasing its revenue generating capacity and financial sustainability through its social marketing program.

Year I Accomplishments (1993) During Year I, SOMARC's role in EI Salvador was limited. SO MARC assisted ADS with a revision ... of its marketing strategy and proposed a new distribution system and technical assistance plan . Year II Accomplishments (1994) SO MARC conducted a broader assessment of ADS's social marketing program in EI Salvador. As a result of the assessment, SOMARC proposed a technical assistance plan which was presented and agreed to by USAI D lEI Salvador for implementation in 1995. • Negotiated terms and conditions for continued and long-term technical assistance provision.

Year III Accomplishments (1995)

85 In 1995, SOMARC assisted ADS in introducing the sale of condoms in convenience stores at Shell gas stntions; introduced the CONTEMPO line of condoms to the Salvadoran market; modified the packaging design for Condor and "Panther" condoms to reduce costs without affecting quality; readjusted the price of contraceptives by segmenting the target market into condoms and orals and improving ADS's margins; created a brand to replace the oral contraceptive "Noriday" with "Duofem" sold under the brand name "Perla" created a new packaging for "New Perla" solved pending credits by suspending shipments to long-term debtors; and promoted the sale of its products and others through special promotions to pharmacists.

• Achieved 1.6 million condom sales from 8 commercial and 2 social marketing brands. Sales of 1.1 million condoms of the social marketing brands, "Condor" and "Panther", represented 69 percent of ADS' total sales.

• Achieved sales of 378,000 oral contraceptive cycles. Sales of "Perla", the social marketing brand, represented 85 percent of ADS' total sales.

• Launched "Contempo", a lineaf premium-price condoms, resulting in a large profit for ADS.

• Introduced condoms through convenience stores at Shell gas stations.

• Created a new brand name and package for the substitution of the oral contraceptive "Noriday" by "Duofem", sold under the "Perla" brand name.

• Addressed credit problems created by overdue payments from debtors.

• Reduced costs readjusted prices and improved ADS's margins.

Challenges for the Future SO MARC's biggest challenge for EI Salvador is to reinforce the financial position of ADS's social marketing program so that it can provide financial resources to ADS as donors begin to withdraw. There are two spheres to the strengthening of this program: one is administrative and financial, while the other relates to distribution and promotion. In addition, the association has been working on marketing reproductive health services, and it has found that it is necessary for the new marketing structure to adapt to the growing needs of the organization and of the Salvadoran people. Scenario I Year IV-V (1996-19971 The oral contraceptive "Duofem" will substitute "Noriday" in 1996-1997. The brand name "Perla" will still be used, as it is the market leader. Also, results from the a recent KAP study, will be used to identify and create new promotional strategies for condoms, as well as to identify new potential areas in the Salvadoran contraceptive market. Equally important is the administrative restructuring of marketing and sales, since ADS will distribute reproductive health products directly. In this case, it is a must to create a sales and management organization

• Sell 3.2 million condoms.

• Sell 664,000 oral contraceptive cycles.

• Sell 30,000 injectable units. • Substitute 95 percent of "Perla" with "Nueva Perla".

• Design and implement the structure for the marketing department, adapted to ADS's new needs.

• Increase distribution coverage from 300 to 600 sales points (60 percent of the total).

Scenario II Year IV-VI (1996-19981 86

.. ,-."~""".--~-'-"""-- ,", '.-'>--:"''''-~--.-..... If one more year is granted, SOMARC can help ADS decrease its dependence on a single condom supplier and to introduce an injectable in their contraceptive portfolio. The possibility of including other reproductive health products that are not necessarily contraceptives will also be studied. The process of administrative restructuring will be reinforced, and ADS will then have the support of the marketing department to promote its services. This is particularly useful for Salvadoran women because reproductive health services are offered at a reasonable price; it becomes even more relevant as one considers the plans to privatize the Social Security and the public sector in general.

• Sell 5.7 million condoms.

• Sell 1.2 million oral cycles.

• Sell 77,000 injectable units.

• Reach a distribution coverage of 90 percent (900 drugstores).

Resources Technical support will continue through SO MARC Mexico, with support for service marketing from Washington.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 7,000 300,000 307,000 83,775 223,225 OYB Transfer 0 0 Buyin 100,000 100,000 1,869 98,131 Total $7,000 $400,000 $407,000 $85,644 $321,356 $0 $0

87 .... Guatemala

APROFAM, a family planning agency, was established a little over 25 years ago with the purpose of communicating and instilling family planning in the family unit. Like most family planning associations established at that time, it is an associate of IPPF. .'"

In Guatemala, the development of family planning has been linked to that of APROFAM and has gone through several phases which can be summarized as follows creation of a family planning culture, the creation of a culture of modern contraceptive method use, and self-sufficiency and social marketing.

Around 10 years ago, IPROFASA (Importer and Exporter of Pharmaceutical Products) was created by APROFAM and several of its former executive directors, with the support of USAID. From the beginning, IPROFASA was established as a commercial company belonging to APROFAM and its former directors. IPROFASA's basic goals are to make modern contraceptive methods more accessible to the Guatemalan population in social classes C (middle) and D (low middle); to increase knowledge about and correct use of modern contraceptive methods sold by I PROFASA, using available means of communication, and to achieve financial self-sufficiency and create income for APROFAM.

From the beginning, USAID has donated the following products to IPROFASA: two brands of condoms, two brands of oral contraceptives and one brand of vaginal foaming tablets. IPROFASA has launched three commercial contraceptives: "Scudo Oro" condoms, the company's own brand; "Ciclofemyna" injectables, licensed by Mexico's Laboratorios Latinoamericanos; and "Iprogel" vaginal foaming tablets with nonoxynol 9 made for them in Mexico.

Less than two years ago, IPROFASA progressed into other areas of the pharmaceutical market with three other products: "Prolexina", a cephalosporin-type antibiotic; "Iprotidina", a Tagamet-type anti ulcer medicine; and "Iprofeno", an ibuprofen-based anti-inflammatory analgesic. IPROFASA has distributed the dermatologic product "Eucerin PH5" through a contract with the wholesale distributor in order to make use of this opportunity and to generate additional income that will help cover its cost.

USAID Objectives According to the latest agreement signed by IPROFASA and USAID, which ends on August 30, the goals of the project are:

• Achieve financial self-sufficiency for the social marketing program, thus relieving the Mission of financial obligations.

• Decrease the amount of donated contraceptives by commercializing the products to the less affluent classes. This commercialization must allow IPROFASA to buy its own supplies.

• Reach a total of 243,000 couple-protection years between 1992 and 1996 through the sale of condoms and oral, vaginal and injectable methods.

SOMARC Objectives In 1994, USAID asked SOMARC to provide technical support to IPROFASA's social marketing plan. According to instructions from USAID/Guatemala, the main task to be undertaken by this technical support is to create a self-sufficiency plan for IPROFASA. Therefore, from January 1995 to August 1996 (the date when the agreement ends), the main goal for SO MARC's technical support is:

• Create a self-sufficiency plan and to help implement it, once USAID/Guatemaia and IPROFASA give their approval. ... • Provide technical support for the creation, execution and follow-up of marketing plans for each of IPROFASA's products.

88 • Provide technical support for the execution and analysis of projects for the new products to be launched by IPROFASA as soon as this technical support is in place.

• Analyze alternatives and implement a strategy to guarantee IPROFASA's continuity in the oral contraceptive market, in light of the imminent loss of "Perla" (Noriday) and "Iproday" (Norminet) due to the fact that donation of these products has ended.

Year I Accomplishments (1993) SO MARC was not working in Guatemala.

Year II Accomplishments (1994) SO MARC was not working in Guatemala.

Year III Accomplishments (1995) SOMARC took over the technical support for the social marketing program in Guatemala in January 1995.

Guatemala's social marketing program was developed by IPROFASA with economic and technical support from USAID through contract agreements between the two as well as between USAID and private companies that have provided technical support.

In spite of the fact that USAID supports the contraceptive part, it has accepted that IPROFASA introduce products from the IPRO family (not contraceptives) and act as wholesaler for the commercialization of "Eucerin PH5". SOMARC's technical support for this year can be summarized as follows:

• Analysed of IPROFASA's actual economic and marketing situation at the moment in which the technical support began.

• Created a self-sufficiency plan.

• Designed and hired an audit of drugstores with contraceptives (oral, injectables, vaginal and condoms).

• Developed the 1995 publicity strategy.

• Created an accounting record system that provides a reliable financing of products and realistic information about operative expenses.

• Created marketing plans by product and the use of these when decisions are made regarding new products.

• Planned and executed a strategy to increase prices.

When technical support began in 1995, it was discovered that there was an accounting irregularity at IPROFASA, which did not give reliable figures regarding product cost, making it practically impossible to determine the contribution made by each product. It was therefore necessary to reconstruct the records for imports, purchases, expenses, etc., in order to obtain more reliable cost and expense figures to be used in the creation of a self-sufficiency plan.

Based on these premises, IPROFASA's self-sufficiency plan was created. It is being used at the moment and assures that, by August 1996, the company will have enough working capital to guarantee its continuity. Logically, to reach this goal, it was necessary to develop a strong strategy to reduce staff as well as other expenses; to establish a price-increase policy with no economic subsidy to users (negative 89 contribution) while maintaining social prices at least for donated products; and to define the middle and low-middle classes as target population for the program, leaving the lower classes to be covered by the Ministry of Health and NGOs like APROFAM.

As a result of the analyses, of the austerity required to attain self-sufficiency, and of the need to concentrate economic and human efforts to strengthen the present products, it was decided to indefinitely postpone the almost 15 projects for new products, until the company has enough capital to launch these products within the framework of modern marketing, thus reducing the chances for failure.

When the cost analysis was performed, it was found that the products which made up the largest ... sales volume had a negative contribution or one that was close to zero, so a price-increase strategy was created for all products. It was necessary to calculate the contribution of each one of the products from the IPROFASA line and to determine the new price for the company's economic and financial reality as well as for the commitment to attain self-sufficiency by August 1996. Since most of the increases were so high, a partial quarterly increase strategy was established, which would not dramatically affect the sales volume and market participation, which has been achieved to date.

Challenges for the Future With IPROFASA's program, it is evident that USAID/Guatemaia has decided not to provide further financial support to this program, except for a little more donated product. ....

Scenario I Year IV-V /1996-1997) Work begun in 1995 is expected to be finished in 1996, as well as training in applied systems, with the purpose of allowing IPROFASA's managerial staff to continue applying established strategies and to fulfill the goal of giving continuity to the company. Upon USAID's request, a guide for the end-of program report that concludes the agreement IPROFASA-USAID agreement will be created and submitted to USAID.

By 1997, and if it is possible to make an extension of the present contract at no additional cost, it is only expected to keep in contact with IPROFASA, including at least two trips for technical support, with the purpose of finishing the training of their staff as well as creating and beginning the implementation of a business and marketing plan for the company for the next three years.

Graduation from the program by the end of 1996 if an extension is not granted, or by mid-1997 if it is.

Scenario II Year IV-VI (1998) SOMARC will most likely not continue activities beyond 1996 in Guatemala once IPROFASA's technical assistance package is completed.

Resources

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support" 100,000 150,000 250,000 44,523 205,477 OYB Transfer 0 0 Buyin 291,209 291,209 97,682 193,527 Total $100,000 $441,209 $541,209 $142.205 $399,004 $0 $0

Haiti

In Haiti awareness of modern methods is relatively high although usage of modern methods is low at only 13 percent. Access to contraceptives has been limited, especially in the past few years of political upheaval, primarily to NGO facilities. Commercial contraceptive products, aside from Panther condoms and Minigynon oral contraceptives, are often very expensive and therefore out of reach for most mid to low

90 income couples. Haiti has however many private doctors and pharmacies in urban and peri-urban areas that are potential service delivery sites for contraceptives.

SOMARC launched a commercially sourced oral contraceptive in 1989 which remains on the market at a relatively low cost. However since the cost of living has increased dramatically while incomes have fallen, SOMARC is currently in the process of launching two donated products - a pill and an injectable that will ensure access to contraceptives through the commercial sector for a wider group of mid to low income women.

USAID Objectives • To increase availability and effective use of quality family planning and reproductive health services.

SOMARC Objectives • Launch two new donated products through commercial sector pharmacies and clinics -- Confiance injectable contraceptive and Pilplan oral contraceptive.

Year I Accomplishments (1993) SO MARC launched Minigynon, a low dose oral contraceptive pill in 1989. Minigynon was commerCially sourced, and as a result, continued to be made available during several years of political unrest, including during 1993.

Year II Accomplishments (1994) SOMARC was not active in Haiti in 1994 due to political unrest and economic sanctions.

Year III Accomplishments (1995) SOMARC reentered Haiti in 1995 to provide technical assistance to earlier social marketing program. During this time, SOMARC began preparations for the launch of DMPA, including development of its marketing plan, provided training, and development of a brand name and packaging.

Challenges for the Future Since SOMARC's technical assistance to Haiti will discontinue after current funding is exhausted, SOMARC's major challenges are to firmly establish two new brands and to ensure a smooth transition of technical assistance to the implementing agency, Sante Plus.

Scenario I Year IV-V (1996-1997) SOMARC will discontinue technical assistance in Haiti when current funding is exhausted (November 1996) due to the provision of social marketing TA under the new HS2000 project managed by Management Sciences for Health.

In Haiti, SO MARC recently launched a donated injectable contraceptive -- Confiance -- and will have launched a donated low dose pill-- Pilplan -- by August of 1996. By November 1996, SOMARC will have conducted the following activities in support of the launch of Pilplan and Confiance: country wide contraceptive technology trainings, a mass media advertising campaign, and a public relations campaign including a media spokesperson training.

During the first year of distribution, sales of Confiance are estimated at 10, 000 vials and sales of Pilplan are estimated at 50,000 cycles. In addition, SOMARC has worked with local implementing agency, Sante Plus, to effect a smooth transition of technical assistance under the new project. In discussions with USAID/Haiti, Sante Plus and SOMARC it has been agreed that Sante Plus should combine their efforts with Population Services International, (P.S.I.). P.S.1. has established a local NGO in Haiti and manages the Panther condom program in Haiti. Although Sante Plus will continue as a separate entity in the marketing of products established under the SOMARC project, they will receive assistance from P.S.1. in strategic planning and in the solicitation of funds from the HS2000 project and from other international donors such as UNFPA. 91 ....

Resources ....

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' 150,000 458,000 608,000 552,762 55,238 OYB Transfer a a Buyin 377,231 377,231 367,354 9,877 Total $527,231 $458,000 $985,231 $920,116 $65,115 $0 $0

92 Jamaica

In Jamaica, contraceptive awareness is almost universal. Contraceptive prevalence is at 62 percent, with a Total Fertility Rate of 3.0 births per woman. Jamaica's National Family Planning Board (NFPB) outlines the following objectives in its strategic plan for 1993-1998 as reducing total fertility, increasing contraceptive use (from 62 percent to 68 percent by 2000), reducing the un met need for family planning, shifting to long-term and permanent contraceptive methods, and increasing private sector participation in service delivery.

Whereas 85 percent of consumers access primary health care from private sector sources, the source for family planning has been the public sector. Jamaica currently has some 280 pharmacies across the island, most of which are in the Kingston Metropolitan Region, and other urban centers; and 460 Doctors, offering private services.

A wide range of oral contraceptive pills are available commercially. The Ministry of Health is considering the reclassification of low dose orals to restricted OTC status, which will allow brand advertising. Pills can only be sold in Pharmacies, and pharmacists must provide counseling. SO MARC is working with the NFPB to facilitate the reclassification. Depo Provera has traditionally been a public sector-provided method. Since the launch of Personal Choice, an increasing number of Doctors have started to stock the product. IUDs are considered by pharmacists to be high-priced items (retail US$15- 20) and are supplied only when pre-ordered. Vasectomies are traditionally performed by urologists in the private sector at very high cost to the patient. Male sterilization has been plagued with myths and misinformation and is not generally offered as a contraceptive option.

USAID Objectives • Increase the private sector role in contraceptive supply, at prices affordable to Jamaicans in the cd socio-economic group;

• Expand the national program to reach pockets of unmet need;

• Encourage a shift to long term methods so as to reach fertility goals. The current method mix is predominantly pills and condoms.

• Address a number of legal, regulatory and policy barriers which constrain the expansion of family planning services.

SOMARC Objectives The USAID funded Social Marketing Program, Personal Choice, is designed to expand the role of the private sector in family planning by fostering:

• an increase in overall contraceptive usage;

• a shift in the method mix from short term supply methods to long term contraceptive methods;

• a shift in contraceptive product and service delivery from the public sector to the private sector.

SO MARC designed Personal Choice to stimulate demand for contraceptive products and services among the target market of 1) current public sector users, and 2) new family planning acceptors, in the C and D socio-economic groups. SO MARC provides technical assistance, market research, advertising, public relations and promotion, and resources for training and quality of care. All products and services are supplied and distributed by the private sector.

Year I Accomplishments (1993) 93 .... During 1993, program design followed research into consumer attitudes and behavior throughout Jamaica. SOMARC negotiated agreements for the commercial supply of 2 low dose pills, with Upjohn for Depo Provera and with Doctors trained in the no-scalpel technique of vasectomy. Sub-contracts were negotiated with a local advertising agency, management support organization, and research company to undertake work in those substantive areas.

Year II Accomplishments (1994) SOMARC developed a Marketing Plan to guide the activities for 1994/95. based on which Letters of Agreement were negotiated for the supply and distribution of products and services. An integrated mass media campaign was designed and pre-tested to motivate trial among the target market. .... Contraceptive technology training took place for private physicians and pharmacists. With this training, SOMARC has supported the Ministry of Health requirement for reclassification of low dose orals, that is, providing pharmacists with the skills to give counseling to their customers. SOMARC also negotiated with the Fair Trading Commission a waiver of its clause regarding anti-competitiveness. Personal Choice products were pipelined at the end of 1994, in anticipation of the communications launch.

Year III Accomplishments (1995) Media training was done to create a speakers bureau on behalf of Personal Choice. Method specific physician training was done in collaboration with participating distributors, as well as with professional medical associations. Collaboration with the USAID funded Private Providers Project was sought in the area of training and creative development in the two pilot areas of that project.

An integrated campaign of public relations and advertising was launched early in 1995 for the Personal Choice logo, low dose pills and the contraceptive injection. A program of public education, supported by minimal print advertising was piloted in Kingston and Montego Bay for the no-scalpel vasectomy. Speaking engagements were used widely for public education about no-scalpel vasectomy as a contraceptive option.

• Achieved sales of 390,571 cycles of the low dose pill.

• Achieved sales of 3,600 vials of Depo Provera.

,"I • 16 vasectomies performed by Personal Choice Providers (only 1 performed by one provider prior to the program launch in June 1995).

Challenges for the Future SOMARC's challenge in Jamaica is to widen the range of family planning options available to Jamaicans at an affordable price. In the area of clinical methods, the challenge will be (1) to increase the role of private sector physicians in providing services that are accessible, as well as affordable, and (2) removing provider and consumer biases to the IUD and male sterilization. SOMARC will also work to improve access through developing provider networks for family planning methods in general and clinical methods in particular, with quality of care and affordability being paramount.

Scenario I Year IV-V 11996-1997) During 1996/97 SOMARC will introduce a commercially-sourced IUD, the Copper T380a into the market, at a price some 60 percent below current commercial prices. A provider network will be developed to support this method. With the NFPB no longer receiving donated supplies of IUDs, SOMARC's introduction of an IUD will be timely. During this period, heavy support will be given to the contraceptive injection, and will continue physician training in this method. • Achieve sales of 7,500 vials of Depo Provera;

• Achieve low dose sales of 500,000 cycles;

• Achieve sales of 500 IUDs;

94 • Perform 50 vasectomies.

Scenario" Year V-VI /1996-1998) Given an additional year of support, SO MARC would transition to full-scale services marketing, with a comprehensive family planning services approach, strengthening the available private sector services, with particular emphasis on adolescents and on long-term methods. Additionally, the no-scalpel vasectomy would be expanded to include a mass media component, with services more widely available.

• Achieve sales of 10,000 vials of Depo Provera.

• Achieve low dose sales of 800,000 cycles.

• Achieve sales of 1000 IUDs.

• Provide 150 vasectomies procedures.

Resources To support ongoing activities as outlined would require maintaining a project office in Kingston staffed locally along with in-country consultant support and sub-contractors. Technical assistance and project oversight will continue to be provided by SOMARClWashington.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support' a a OYB Transfer 0 a Buyin 958,968 958,968 943,081 15,887 Buyin 2 462,193 462,193 114,054 348,139 500,000 1,000,000 Total $958,968 $462,193 $1,421,161 $1,057,135 $364,026 $500,000 $1,000,000

...

95 Mexico

In Mexico, contraceptive method's usage in 1976, was that as of 30 percent of sexually active women in fertile age (15 to 49 years old). In the period from 1976 to 1982, this figure turned to 47.7 percent. From 1982 to 1987, contraceptives' usage diminished -while only presenting an annual increase of an average of one percentile point per year- which shows a recuperation within the next five-years period achieving 63.1 percent of prevalence in 1992. It is important to highlight the fact that contraceptives' usage varies remarkably according to populace educational level. In 1992, women in reproductive age living in localities with less than 2,500 inhabitants, practiced contraception in a very less proportion than women in reproductive age living in urban areas (44.6 percent and 70.1 percent respectively). In 1976, 70 percent of users practiced contraception by using a hormonal method, IUD or surgery. In 1992, usage of non-hormonal methods increased up to 88 percent. Nevertheless, the proportion of orals' users goes lower: only one of every six woman used pills in 1992. In 1980, injectables' usage decreased dramatically. In contrast, the most used methods are IUD and STO. STO's usage has increased rapidly as well as consistently: from 8.9 percent in 1976, to 43.3 percent in 1992'

The most noticeable source for oral contraceptives' obtention in the country, are pharmacies (around 22,000 countrywide) moreover, they represent the first source of obtention for all those women starting a contraceptive practice. Six out of ten users go to pharmacies to get oral contraceptives, while eight out of ten woman using local methods go there to get them. However, in spite of the large number of pharmacies, there is still a wide range of unreached market for contraception, including both niches: women and men while also in both channels: private sector and government which together would reach urban and rural areas all throughout the country.

USAID Objectives • To increase contraceptive prevalence rate.

• To enhance public and private sector ability to meet consumer demand for Family Planning and Reproductive Health activities independent of USAID support.

SO MARC Objectives • Help those NGOs that have received SOMARC's TA and financial support, reach self-sustainability through income-generating programs.

• Help to strengthen and promote the two appointed out by USAID I mplementing Agencies' particular model for Reproductive Health and Family Planning services provision.

• Promote wider and better use of modern contraceptive methods through programs and activities supported by SOMARC.

• Help to widen the distribution network (throughout non-traditional outlets) for low-dose oral contraceptives by coordinating and strengthening the relationship between the commercial and the public sector including lA's participation.

• Help to design massive communication campaigns that would hold as one of their goals that one of dissolving myths, rumors and misconceptions among contraceptive methods and/or practices.

4 Programa Nacional de Poblacion 1995-2000 - Consejo Nacional de Poblacion, Mexico, 1995. (Population National Program 1995-2000 - Mexican National Population Council, Mexico, 1995). 96 Year I Accomplishments (1993) SOMARC directed a couple of MEXFAM's oldest Clinics towards the obtention of an Institutional belonging feeling under the new self-sustainability and customer-service orientation. In order to achieve the prior, market research was needed to be performed as well as consumer profile surveys were conducted, both: within MEXFAM's facilities, as well as in MEXFAM's Clinics surroundings (potential clientele). In that same year, SOMARC realized that this new orientation/overview towards self sustainability, would require a complete understanding and consequently acceptance from MEXFAM's all levels personnel; which was gradually gained through the implementation of several workshops offered by SOMARC.

SOMARC supported and directed marketing research for FEMAP and encouraged the Federation to agree with the idea of holding a sole Marketing Management (centralized direction regarding this aspect) instead of each affiliate managing its own business' marketing department, as a way to assure results' effectiveness and a high degree of success towards self-sufficiency, since clearness in objectives consecution while a better control of all kinds of resources being directed by only one entity for the whole Federation's benefit.

Year II Accomplishments (1994) For 1994, MEXFAM had partially assumed the new orientation the Institution should follow, so the creation of a Marketing Department as to be the "cornerstone" for the Organization's better performance towards self-sustainability was accepted and supported with SOMARC's help. MEXFAM then, started to elaborate an Institutional Marketing Plan which would include all activities, services and procedures to be known and followed up by the Institution in order to be successful in this new phase-out venture; also slightly analysis of perspectives for the near future was included. SOMARC's guidance in this process was necessary as to direct and supervise the adequate marketing strategies and tools to be applied. Advertising and promotional activities were carried out, as well as quality of care awareness was also integrated as part of MEXFAM's reproductive health service delivery task.

• In 1993, MEXFAM provided a total of 18,411 services, while in 1994 this figure shows to be as that of 45,392.

• FEMAP got its affiliates' acceptance for the convenience of creating a Marketing Department for the whole Federation that would enable the Federation to produce a Corporate Marketing Plan once consumer's profile studies and market research were performed under SOMARC's guidance.

Year 11/ Accomplishments (1995) During 1995, SOMARC perceived the need to develop and establish a Corporate Image for the Institution to be better identified and very well-known by people in general, afterwards all the marketing efforts applied and to still be generated, as because of its name, MEXFAM was thought to be a government entity, while really being a private organization. All MEXFAM's facilities were standardized under as a sort of franchise model: name changed from that of "Clinics" to that of "Medical Service Centers" (MSC), facades and interiors were painted using the same colors' combination in each building regardless of its location or size, a logo design was tested and accepted to become the Institutional one presenting the attribute of being composed by two elements that in the future would become only one identification sign, neon signs were installed in roofs, signaling in streets showing Medical Service Centers' location were put, as well as indoors signs to let patients know: each cabinet purpose, toilets' classification, a directory containing services provision/offering, doctors specialty's and consultations' price, besides working hours, etc.; uniforms for personnel were tailored, and institutional stationary was produced; moreover, a slogan "PEOPLE SERVING PEOPLE" was created as another marketing tool for MEXFAM. Along all this process, SOMARC dictated several workshops to MEXFAM's personnel; subjects being: Marketing, Finances, Management, etc.

A Marketing Plan for each MSC was later on developed by each unit's administrator.

FEMAP publicized a Corporate Image jointly with a slogan: "An aspiration to equity"; both are currently being adopted by all those FEMAP's affiliates. FEMAP has also received support to dictate

97 workshops to its personnel mostly related to Marketing Plans elaboration envisioning the perspective of self-sufficiency consecution. ... Challenges for the Future SOMARC's major challenge for Mexico is to strengthen and reinforce the adequate appliance from both lAs, of all marketing tools that have already been conceived as necessary to move forward self .... sustainability. While helping the prior, also SOMARC would continue to identify ways to get increase in prevalence rate while facilitating a stronger linkage between private and public sector.

Scenario I Year IV-V 11996-1997) During 1996-1997, SOMARC will conduct a pilot model in which MEXFAM would receive SOMARC's support and directions to be implemented in no more than five MSCs that would be expected to follow up certain strategies in order to improve their Marketing implementation. These strategies and directions will mainly be related to: internal, external and interactive Marketing being complemented with a training component. The rest of MEXFAM's similar facilities might be eligible -as convenient- to follow up this same model according to their own resources and capabilities. Results of the mentioned pilot model would be measured in terms of income generation, as well as in terms of number/level of services provision.

With regard to FEMAP, Corporate Image standardizing efforts will be accomplished, while FEMAP jointly with SO MARC would choose the most eligible affiliates to implement a pilot model to be followed up on Marketing efforts while oriented towards a self-sufficiency perspective. A Marketing Service Workshop would be dictated to FEMAP's affiliates' administrators, so they be enable to apply SOMARC's expertise within this field.

SOMARC would help to find new distribution channels for oral contraceptives while working together with the private and the public sector, while incorporating lAs' sources (infrastructure and experience).

Scenario II Year IV-VI 11996-1998) With an additional year of support, SOMARC would help MEXFAM to direct a technology transferring process in order to impel the whole Institution to follow the same Corporate direction towards self-sufficiency. Not only through MSCs, but also through the rest of MEXFAM's communitary programs and/or projects (once the cross-subsidize strategy has been taken advantage of).

If all MSCs reach a healthy' financial level and MEXFAM's Programs result to be favored by this strategy, it would be feasible that MEXFAM might start an expansion strategy either considering more ... MSCs to be opened and/or more or different than the current programs carried out.

For FEMAP, the same steps than those ones already followed by MEXFAM would be applied, .. - though FEMAP's case because of the entity's different nature, size and structure than MEXFAM's might move slower.

With regard to the commercial and public sector linkage, it would be very convenient to develop a nationwide Program once learned lessons and results from the envisioned pilot Project are measured.

98 Resources To support ongoing activities, for both scenarios these estimates include maintaining the Regional Office in Mexico City with a local Project Officer and an assistant's support apart from the Regional Director. Project oversight will continue to be provided by SOMARClWashington.

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field Support" 800,000 500,000 1,300,000 1,343,512 (43,512) 500,000 1,000,000 QYB Transfer a 0 Buyin a a Total $800,000 $500,000 $1,300,000 $1,343,512 ($43,512) $500,000 $1,000,000

99 Peru

There has been an active social marketing program in Peru managed by the non-profit, family planning organization, APROPO, for several years. More recently, USAID/Peru has emphasized the need to improve APROPO's technical and financial capability to manage the social marketing program given USAID's intention to phase out donor assistance to this organization.

USAID Objective • Improve the quality of Peruvian families through increasing access to modern family planning methods.

• Increase provision of modern contraceptive methods through commercial sector distribution channels.

• Phase out donor assistance to the social marketing initiative and implementing agency.

SOMARC Objective • Provide technical assistance to APROPO to help them improve the financial sustainabilily of their range of social marketing products.

• Achieve self-sufficiency of the oral contraceptive component.

Year I Accomplishments (1993) SOMARC assisted APROPO in renewing its contracts with the four suppliers of contraceptive products to the social marketing initiative, maintaining product prices at the lower end of the commercial market, and agreeing upon a future pricing strategy given Peru's inflationary economy.

• Achieved sales of 700,524 oral contraceptives.

• Achieved sales of 56,108 contraceptive injectables.

• Achieved sales of 120,325 vaginal foaming tablets.

Year II Accomplishments (1994) During 1994, SOMARC assisted APROPO with the development of a marketing plan to introduce a new condom, Piel. The social marketing condom was launched in conjunction with World Cup Soccer, generating extensive exposure for the new product.

• Achieved sales of 1,367,600 condoms.

• Achieved sales of 680,069 oral contraceptives.

• Achieved sales of 67,876 contraceptive injectables.

• Achieved sales of 976, 000 vaginal foaming tablets.

Year III Accomplishments (1995) During 1995, APROPO was informed that USAID would no longer continue its financial assistance to the institutional beyond its current contract. APROPO then looked toward its social marketing programs as the primary mechanism to ensure its financial sustainabilily. During this time, SO MARC assisted ..... 100 APROPO in assessing the financial viability of its current products as well as several new products, such as an IUD, pregnancy prevention kit, and a second brand of condoms.

• Achieved sales of 4,328,000 condoms, transitioning condoms from USAID donations to commercial purchase from a U.S. manufacturer, Aladan.

• Generated over US$500,000 in net revenues from the sale of Pie I condoms.

• Achieved sales of 585,000 oral contraceptives.

• Achieved sales of 53,000 contraceptive injectables.

• Achieved sales of 149,000 vaginal foaming tablets.

Challenges for the Future SOMARC's major challenge for the future is to help APROPO realize its sustainability objectives. USAID's plan to phase out donor assistance is quickly approaching, and APROPO is not completely prepared for financial sustainabi[ity.

Scenario I Years IV-V (1996-1997) SO MARC will continue to assist APROPO in the social marketing of several new products, including the Detector personal pregnancy kit, a vaginal specula, and a second brand of condoms.

• Achieve sa[es of 5,500,000 condoms.

• Achieve sales of 580,000 oral contraceptives.

• Achieve sa[es of 80,000 vaginal foaming tablets.

• Achieve sa[es of 60,000 contraceptive injectab[es.

• Achieve sa[es of 10,000 pregnancy kits.

• Achieve sa[es of 1,500 Apro ''T''.

Scenario II Year IV-VI (1996-1998) APROPO's contract with USA[D is scheduled to end in 1997. Therefore additional activities for SOMARC to assist APROPO are not likely during 1998.

101 Resources

Funding Fiscal Year Total Expenses Funding Funding Source 1993-94 1995 Allocations to 4/30/96 Remaining 1996-97 1996-98 Field support 700,000 400,000 1,100,000 1,017,349 82,651 500,000 1,000,000 OYB Transfer 0 0 Buyin 99,914 99,914 24,975 74,939 50,000 100,000 Total $700,000 5499,914 $1,199,914 $1,042,324 $157,590 $550,000 $1,100,000

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