Demand Generation to Scale up ORS + Zinc in India Preliminary Market Analysis

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1 Demand Generation to Scale up ORS + Zinc in India Preliminary Market Analysis

2 Demand generation efforts should be driven by rigorous analysis of target market and a harmonized approach across stakeholders Complete market analysis Identify optimal channels to reach target segments (the how ) Go live with communication effort Segment & finalize target market (the who ) Write the brief Develop creative content (the what ) Test and refine concepts Monitor, adjust and refine Complete post campaign analysis and share lessons learned Solicit input, buy-in, and investment from key stakeholders

3 Agenda 1. Overview of India diarrhea treatment landscape in India 2. Understanding the target consumer 3. Understanding the target healthcare professional 4. Lessons learned from past efforts

4 In India, ~225,000 children die every year due to diarrhea Proportional distribution of cause-specific deaths among children under five years of age, 2010 Others 25% Measels 4% Diarrhea 13% 246m episodes/year ~225,000 deaths/year Malaria 1% HIV/AIDS 1% Injuries 3% Congenitial anomalies 3% Neonatal Sepsis 6% Birth Asphyxia 10% Prematurity 14% Pneumonia 20% Source: World Health Statistics District Level Household and Facility Survey

5 However, most patients do not access the recommended diarrhea treatment: Zinc coverage remains dismal, yet offers an opportunity for impact Treatment of diarrhea in children under five, percentage, estimates 246 mln cases of diarrhea in India / year The Challenge ~1 ~35 The The Opportunity Diarrhea treatment seeking behavior Percentage, estimates Others 5% ~35 ~29 Home or No Treatment 29% Private Sector 45% Number of cases of diarrhea Treated with Zinc & ORS Treated with ORS Treated with antibiotics / other Home or No treatment Public Sector 21% District Level Household and Facility Survey Larson, C, et al. Scaling up zinc treatment of childhood diarrhoea in Bangladesh, Health Policy and Planning, 2011 SOURCE: WHO; Private Healthcare in Developing Countries: Fischer Walker, Cynthia et al. The Global Burden of Childhood Diarrhea. Maternal and Child Health: Global Challenges, Programs, and Policies. Ed. John Ehiri. New York: Springer. 2010; Fischer Walker et al; Scaling Up Diarrhea Prevention and Treatment Interventions: A Lives Saved Tool Analysis,

6 Through coordinated efforts of the government and partners, CHAI aims to significantly increase usage of ORS/zinc in 3 focal states Key Program Components 1) Generate demand: Target consumers/providers based on analysis of most effective messages and communication channels; developing creative solutions to reach beyond traditional urban markets 2) Ensure supply of zinc/ors: Ensure wide-spread availability of affordable, high-quality products in public and private sector 3) Catalyze political will: Mobilize and harmonize investments from governments and partners toward state-wide scale up goals Three focal states represent nearly half of national diarrhea burden with over 164K deaths annually Uttar Pradesh Gujarat Madhya Pradesh 6

7 Across the focal states, the vast majority of the diarrhea deaths among children (>80%) are in rural areas with over half in rural UP alone % and number of U/5 diarrhea deaths in focus area Gujarat Madhya Pradesh 2% Urban (3,000) Rural 6% (9,000) 4% Urban (5,000) 23% Rural (32,000) Total Urban: 17% (25,000) Total Rural: 83% (118,000) Rural 54% Uttar Pradesh Urban 11% (76,000) (16,000) National Family Health Survey (NFHS-3)

8 Understanding the profile of rural households will be essential to success Madhya Pradesh 72% Rural: 45% illiterate (higher for women) 80% have no television 90% no access to a toilet 69% of children attend some school 77% some sort of immunisation Uttar Pradesh 75% Rural: 42% illiterate (higher for women) 78% have no television 84% no access to a toilet 69% of children attend some school 87% some sort of immunisation Uttar Pradesh Gujarat 58% Rural: 36% illiterate (higher for women) 62% have no television 70% no access to a toilet 71% of children attend some school 85% some sort of immunisation Gujarat Madhya Pradesh National Family Health Survey (NFHS-3)

9 Currently, the majority of moms in India give fluids at home or watch and wait when their child has diarrhea I am happy to treat at home for the first couple of days using sugar-salt-lemon or any other fluid, it will usually fix itself, and if not, I can easily see my RMP 73% take action straight away All mums with child suffering diarrhea 27% watch and wait (for 1 day) Some then use antibiotics (after 1.4 days) 41% give fluids at home Some then use ORS (after 1.4 days) 34% use ORS 1 st line They then use antibiotics Diarrhea is a bit annoying and can make my child lethargic and miss playing for a few days, but other than that it is not serious. I know that it will stop in 3-4 days Split by Urban & Rural by Mid August 9

10 Ideal Treatment Seeking Behavior what do we want them to do? Current behavior: Desired behavior in Year 1: Day 1-2 Day 3-4 Day 4-5 Home Remedies Self Medication No Treatment Consult Rural Medical Provider who gives antibiotics or antidiarrheals Consult Qualified General Practitioner or AYUSH Day 1 (ideal) Or Day 2 Day 5 See HCP at 1 st sign of diarrhea HCP prescribes zinc and ORS Consult Qualified GP for re-assessment if diarrhea continues 10

11 Among consumers, efforts should target rural moms to immediately seek treatment from provider for their child s diarrhea PATH TO PURCHASE Target Audience Rural mums with children under the age of 5 years. Audience Insight Growth Priority TODAY I don t need to see my HCP. Diarrhea is a bit annoying and inconvenient, but it usually goes away by itself in a couple of days Convince mums that watch & wait or give home fluids to visit their doctor straight away FUTURE Behaviour (What are they buying/doing?) Currently doing nothing for the first day or two, then going to their local RMP to request something to stop the diarrhea. Attitude (Why are they buying/doing it?) I know that diarrhea isn t serious, I ll wait for a day or so to see if the diarrhea goes away by itself. If it doesn t improve I ll go and see my local doctor to get something to stop the diarrhea PRIMARY BARRIER Diarrhea is not serious, I don t need to treat it straight away Behaviour (What will they buy/do?) Go and see their doctor on the first day that diarrhea starts Attitude (Why will they buy it?) I understand that diarrhea is a serious condition that could harm my child. I need to see my doctor when the diarrhea starts

12 Success will depend on improved treatment-seeking and a greater understanding of the seriousness of diarrhea Diarrhea is not serious, I don t need to treat it straight away KEY KNOWLEDGE GAPS KEY MEASUREMENTS OF SUCCESS At what point does a mum deem diarrhea to be serious enough to take the child to a HCP? Visited their HCP on last diarrhea episode after x days (from x days) to get treatment I believe diarrhea is a serious medical condition from x% to x% I will visit my HCP to get treatment for diarrhea from x% to x% 12

13 Messages and communication channels need to be designed based on the influences and environment of the target rural mother Demographics: Age: Illiterate School until 12 yrs old House? Electricity? Running water? Income? Aspirations/Motivators: For child? Education? For self? Daily/Weekly Activities: May visit Haat or town once a week, but more likely that the husband goes Community centre? How often visit pharmacy? Visit with friends/neighbours? Relaxation time? Key Influencers: Healthcare professional Mother in law Husband Educated female member of community Key Insight: Diarrhea is a bit annoying and inconvenient, but it usually goes away by itself in a couple of days Interaction with HCP s: Child has been immunised by ANM at 6 months and 9 months Barriers to Using Product: Need to give child too much fluid, too often Not perceived as necessary medicine will not cure symptoms so can do without it Enablers to Using Product: Visiting a HCP HCP recommendation Availability of product Compelling price Diarrhea History: Has the mum had much experience with diarrhea? Media Consumption: No exposure to TV Radio once per week No print Husband sees TV once per week Work in progress

14 Rural Medical Providers (RMPs) are the first point of contact for most consumers when seeking health services International UN/WHO Local Government bodies: IMA / IAP Medical Representative Pediatrician/GP Medical Journals Medical Representative ASHA (qualified) Key Public Market Focus RMP and Drug Store Owner Key Private Market Focus Consumer

15 Unqualified practitioners are the most preferred source of treatment for common illnesses in India Characteristics of treatment seeking behavior in India Unqualified RMPs 65% AYUSH 25% RMP Treatment Seeking 53.69% 52.26% 53.67% 59.50% 48.94% MBBS Allopathic 10% Poorest Quintile Next 20% Next 20% Next 20% Least poor quintile RMPs treat more than 50% cases of common illnesses in rural areas Source: Centre for policy research:- Mapping medical providers in rural India A Parallel Health Care market: Rural Medical Practitioners in West Bengal, India 15

16 Reaching RMPs requires an understanding of the factors that influence their knowledge and decision-making Demographics: Male Age 35 School until 16 years old Can read basic Hindi (not English) Grew up in the village where they have their practice Sources of Information: Mentor or teacher Pharmacy in town where they purchase products (visit at least fortnightly) Pharma reps Health section of local Hindi newspaper Key Influencers: Their mentor or teacher GP prescribing practices in nearby town News from bigger towns (unlikely to be influenced by female HCP s) Key Insights: e.g By the time they get to me, they need something to stop the diarrhea not just some ORS Diarrhea History: Treat about 5-10 children/day in peak season (1-2/week in dry season) Barriers to Recommendation: No 1 motivator is repeat business so want to prescribe the best product Lack of belief in product Lack of confidence with product Lack of patient ability to pay Lack of availability Enablers to Recommendation: Confidence in product and repeat business High margins

17 The primary goal is to convince RMPs to prescribe ORS and zinc for diarrhea and to understand why this is important PATH TO RECOMMENDATION Target Audience Rural medical practitioners Audience Insight By the time they get to me, they need something to stop the diarrhea not just some ORS Growth Priority Convince the RMP to prescribe ORS AND Zinc to treat diarrhea TODAY Behaviour (What are they recommending?) They are recommending antibiotics or anti-diarrheals to stop the diarrhea. Attitude (Why are they recommending it?) By the time they get to me, they need something to stop the diarrhea not just some ORS PRIMARY BARRIERS TO RECOMMENDATION Antibiotics and anti-diarrheals are the best medicine available to treat diarrhea FUTURE Behaviour (What will they recommend?) ORS and Zinc Attitude (Why will they recommend it?) I understand that: ORS is essential to prevent life threatening dehydration Zinc helps the child to recover quickly, prevents future episodes Antibiotics are not useful in most cases of diarrhea Anti-diarrheals can be harmful to the child

18 Lessons learned from past efforts Effective Marketing Campaigns: Carefully defined, and intimate knowledge of the target market Understanding of current behaviors and attitudes Single minded message to shift behaviors and attitudes Harmonization across partner efforts use of common messages, materials Common Mistakes: Generally, a one size fits all approach Multiple messages Use of media channels that may or may not reach the target audience

19 In countries scaling up zinc/ors, coordination across partners on design, development, and deployment will be essential to success Complete market analysis Identify optimal channels to reach target segments (the how ) Go live with communication effort Segment & finalize target market (the who ) Write the brief Develop creative content (the what ) Test and refine concepts Monitor, adjust and refine Complete post campaign analysis and share lessons learned Solicit input, buy-in, and investment from key stakeholders

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