Condom Social Marketing: Selected Case Studies

Transcription

1 Condom Social Maketing: Selected Case Studies Joint United Nations Pogamme on HIV/AIDS UNICEF UNDP UNFPA UNDCP UNESCO WHO WORLD BANK

2 Acknowledgements These case studies wee pepaed by Michael P. Fox, Consultant, fo the Depatment of Policy, Stategy and Reseach (PSR), UNAIDS, Geneva, with significant contibutions of time, infomation, data and mateials fom the head offices and national poject offices of Population Sevices Intenational, The Futues Goup Euope, Intenational Family Health, as well as fom the Asociación Colombiana Po-bienesta de la Familia (PROFAMILIA) and Johns Hopkins Univesity /Cente fo Communication Pogams. In addition, valuable inputs wee given by Mitchell Waen and the AIDSMak poject. The case studies poject was initiated and coodinated by Bunmi Makinwa, Communications Advise, PSR, UNAIDS. UNAIDS/00.37E (English oiginal, Novembe 2000) ISBN Joint United Nations Pogamme on HIV/AIDS (UNAIDS) This document is not a fomal publication of UNAIDS and WHO and all ights ae eseved by these bodies. The document may, howeve, be feely eviewed, quoted, epoduced o tanslated, in pat o in full, povided the souce is acknowledged. The document may not be sold o used in conjunction with commecial puposes without pio witten appoval fom UNAIDS (contact: UNAIDS Infomation Cente). The views expessed in documents by named authos ae solely the esponsibility of those authos. The designations employed and the pesentation of the mateial in this wok do not imply the expession of any opinion whatsoeve on the pat of UNAIDS concening the legal status of any county, teitoy, city o aea o of its authoities, o concening the delimitation of its fonties and boundaies. The mention of specific companies o of cetain manufactues poducts does not imply that they ae endosed o ecommended by UNAIDS in pefeence to othes of a simila natue that ae not mentioned. Eos and omissions excepted, the names of popietay poducts ae distinguished by initial capital lettes. UNAIDS - 20 avenue Appia Geneva 27 - Switzeland Telephone: (+41 22) Fax: (+41 22) unaids@unaids.og - Intenet:

3 U N A I D S B E S T P R A C T I C E C O L L E C T I O N Condom Social Maketing: Selected Case Studies Joint United Nations Pogamme on HIV/AIDS UNICEF UNDP UNFPA UNDCP UNESCO WHO WORLD BANK Geneva, Switzeland Novembe 2000

4 Condom Social Maketing Table of Contents 1. Intoduction 5 2. What is social maketing? 6 Condom social maketing 7 The ole of UNAIDS in social maketing 7 3. Diffeent appoaches to social maketing 9 4. Case studies 12 Community-based distibution in Haiti and Mozambique 12 - Haiti 13 - Mozambique 19 Community-based social maketing in India 24 Social maketing based on tageted sevice delivey in Cameoon 29 Social maketing with existing commecial bands in Kenya 35 A local pivate secto initiative in social maketing in Colombia Key lessons Selected bibliogaphy (pincipal souces) 49 3

5 UNAIDS Aconyms AIDS CA CBD CBO CBSM CSM DHMT DKT FGE FP FPAK GTZ HIV IEC IFH IICH IPPF KAP MCH NACP NGO PMSC PROFAMILIA PSI SM STD TFGI UK /DFID UNAIDS UNDP UNFPA UNICEF USAID WHO Acquied immunodeficiency syndome Community agent Community-based distibuto Community-based oganization Community-based social maketing Condom social maketing Distict health management team DKT Intenational The Futues Goup Euope Family planning Family Planning Association of Kenya Deutsche Gesellschaft fü Technische Zusammenabeit Human immunodeficiency vius Infomation, education and communication Intenational Family Health Indian Institute of Community Health Intenational Planned Paenthood Fedeation Knowledge, attitude and pactice Matenal and child health National AIDS Contol Pogamme Nongovenmental oganization Pogamme de Maketing Social au Cameoun Asociación Colombiana Po-bienesta de la Familia Population Sevices Intenational Social Maketing Sexually tansmitted disease The Futues Goup Intenational United Kingdom /Depatment fo Intenational Development Joint United Nations Pogamme on HIV/AIDS United Nations Development Pogamme United Nations Population Fund United Nations Childen s Fund United States Agency fo Intenational Development Wold Health Oganization 4

6 Condom Social Maketing 1. Intoduction Since its establishment in 1996, UNAIDS has pomoted and suppoted social maketing, and especially the social maketing of condoms, as a key stategy in the fight against the spead of HIV/AIDS and STDs. Social maketing pojects and pogammes exist in dozens of developing counties but, at the same time, thee ae still many moe counties with the potential to adopt o expand simila activities. This document is the fouth in a seies on social maketing poduced by UNAIDS to povide basic infomation on this activity and how its concepts and techniques may be applied in esponse to the spead of HIV/AIDS, paticulaly in developing counties. Pevious documents wee Social Maketing: An Effective Tool in the Global Response to HIV/AIDS, as an intoduction to social maketing which descibes its main concepts and techniques; Social Maketing: Expanding Access to Essential Poducts and Sevices, which highlights lessons leaned fom thee examples of social maketing applied to male and female condom pomotion in developing counties; and A Global Diectoy of Condom Social Maketing Pojects and Pogammes, as a compendium of existing condom social maketing pojects in Condom Social Maketing: Selected Case Studies pesents six applications of diffeent social maketing techniques dawn fom among on-going pojects in developing counties in the field of epoductive health and pevention of HIV/AIDS and STDs. Individually they illustate diffeent, eal-life appoaches to condom pomotion though social maketing in esponse to paticula challenges and needs. All descibe activities fom which significant lessons may be leaned. In addition, they demonstate the flexibility of social maketing and how the technique can be adapted to deal with diffeing situations and constaints. The booklet is intended mainly fo distibution to individuals and oganizations, fom both the public and pivate sectos, who ae inteested in leaning moe about social maketing, and how its concepts and techniques can be applied in esponse to the spead of HIV/AIDS and STDs, paticulaly in developing counties. It is also intended to povide basic infomation, as an aid to taining, pogamme planning and elated activities. 5

7 UNAIDS 2. What is social maketing? Social maketing may be defined as the adaptation of commecial maketing and sales concepts and techniques to the attainment of social goals. It seeks to make health-elated infomation, poducts and sevices easily available and affodable to lowincome populations and those at isk while at the same time pomoting the adoption of healthie behaviou. In fact, it may be said that the ultimate goal of social maketing is to effect healthy and sustainable behaviou change. Making quality poducts and sevices affodable and available is just one pat of the social maketing equation. Encouaging thei use epesents the othe. Maket eseach and a stong communications component ae essential to the success of a social maketing pogamme. Social maketing has become inceasingly popula among govenments and donos as an efficient and effective means of addessing seious health issues in developing counties. It has its oots in family planning but the concept is now applied acoss many fields in public life and health, in both developed and developing counties, including such aeas as potection of the envionment, campaigns against smoking and alcohol abuse, and the pevention and cae of malaia, leposy and tubeculosis. Howeve, the use of social maketing in esponse to the challenge of impoving the sexual and epoductive health of women and men in developing counties has attacted paticula attention. Social maketing complements, and does not eplace (o even seek to eplace), fee access to health sevices and poducts. It theefoe does not compete with the public health system and in fact suppots existing systems. By making low-cost poducts available outside the health system, social maketing pogammes alleviate the pessue on existing sevices and thus allow the health system to use limited esouces moe efficiently. In addition, and paticulaly in the case of condoms, social maketing can be an altenative souce of poducts and infomation fo people who may be unable o unwilling to access locations whee pivacy is too often impaied. Fo instance, though social maketing condoms ae widely available in places whee people outinely go, as opposed to epoductive health clinics, which tend to be much less fequented by men and young people. The possibility of anonymity in a commecial tansaction then becomes attactive, paticulaly to women and sexually active young people. Govenment suppot, then, is key to the success of social maketing pogammes and these ae often developed in close collaboation with host county govenments in line with national pioities and needs. Many govenments ecognize the significant contibutions of social maketing to impoving the sexual and epoductive health of thei low-income populations and extend impotant financial and political suppot to the activity. In many counties, fo example, socially maketed poducts, fequently condoms, ae allowed tax exemptions o may be diectly subsidized by local o national govenment in ode to educe costs and pices; othe examples include the use of IEC mateials developed by social maketing in public schools and clinics, o the elaxation of estictions on 6

8 Condom Social Maketing the use of mass media fo educational communications on sexual and epoductive health issues. Condoms ae a case in point, whee only a few yeas ago it was vey ae to find a county whee advetising this poduct was pemitted in the mass media channels, something that has now become quite common. Condom social maketing In the mid-1980s, condom social maketing (CSM) emeged as an effective tool in combating the spead of HIV/AIDS. Though social maketing pogammes and pojects in many counties affected by the epidemic condoms have become moe easily available, affodable and acceptable to sexually active men, women and young people in geneal as well as to those in high-isk goups. Although the pogammes have geneally focused on the poduct, concomitant communications and IEC activities have significantly contibuted to aised awaeness of the isks of infection and the means of pevention, eaching people, govenments and institutions in all sectos of public and pivate life. Condom social maketing pogammes have made condoms moe accessible, affodable and acceptable in many of the wold s pooest counties. In 1997 these distibuted about 900 million male and female condoms. By 1999, at least 71 diffeent social maketing pogammes fo male and female condoms wee active in 59 developing counties. It has been said that in the case of condoms social maketing has acted as a nomalize of the poduct, educing the stigmas populaly attached to it. Until ecently in many developing counties, public access to condoms was difficult as the poduct was often available only in phamacies and health clinics and geneally thought to be moe appopiate fo use by and with commecial sex wokes. Now, thanks to yeas of pesistent social maketing activities, condoms in many counties ae widely available fom a vaiety of outlets, openly discussed in public and in the media, and ae seen by many, including many of those at high isk of HIV infection, to be common household items. The destigmatization of condoms in many counties illustates how social maketing can help populations to ovecome social and cultual esistance to pactising effective pevention of STDs and HIV/AIDS. The ole of UNAIDS in social maketing The Joint United Nations Pogamme on HIV/AIDS (UNAIDS) is the leading advocate fo global action on HIV/AIDS. UNAIDS leads, stengthens and suppots an expanded esponse aimed at peventing the tansmission of HIV, poviding cae and suppot, educing the vulneability of individuals and communities, and alleviating the impact of the epidemic. Since its establishment in 1996, UNAIDS has pomoted and suppoted social maketing, and paticulaly the social maketing of condoms, as a key stategy in the fight against the spead of HIV and AIDS. 7

9 UNAIDS As a cosponsoed pogamme, UNAIDS plays a unique and impotant ole in ganeing suppot fo social maketing pogammes. At the national level, UNAIDS encouages govenments and NGOs to suppot, develop and implement HIV/AIDS pevention social maketing initiatives within thei counties. This may include advocating fo the inclusion of social maketing in national plans, the allocation of esouces to social maketing pogammes fom multilateal and bilateal donos, and the facilitation of a positive legislative envionment fo social maketing. The exchange of expeiences between oganizations and counties is also encouaged. In counties whee social maketing pogammes ae being launched, UNAIDS takes an active ole as fundaise and, moe ecently, as a potential povide of technical assistance in collaboation with leading social maketing oganizations, such as Population Sevices Intenational (PSI) and supplies of poducts, such as with The Female Health Company, sole manufactue of female condoms. In addition, though its egional and county netwok of pogamme advises, Theme Goups and cosponsos, UNAIDS offes an excellent means of disseminating infomation, expeiences, best pactices and lessons leaned in social maketing. UNAIDS stimulates social maketing in the field: Myanma, the Russian Fedeation, Haiti, Cuba and Ghana Female condoms Application of social maketing to othe HIV/AIDS-elated poducts and sevices UNAIDS pomotes expanded inteest in social maketing: UNAIDS website Social maketing assessments in Bulgaia, Cuba, Guyana, Libeia, the fome Yugoslav Republic of Macedonia, and Tukey Regional Maketing Taining Exchange with pojects in Albania and Romania Foum 2000 on Social Maketing (in development) UNAIDS povides key esouces such as best pactice mateials and case studies, including: Social Maketing: An Effective Tool in the Global Response to HIV/AIDS Thee Key Lessons Leaned in Condom Social Maketing A Global Diectoy of Condom Social Maketing Pojects and Pogammes 8

10 Condom Social Maketing 3. Diffeent appoaches to social maketing Social maketing pogammes geneally use the existing commecial infastuctues in counties to develop and distibute specifically banded poducts such as condoms. This taditional appoach, also known as the own band model, is the most common amongst social maketing pogammes in developing counties and is closely associated with Population Sevices Intenational (PSI) and DKT Intenational, oganizations that pioneeed intenational social maketing in the 1970s and 1980s. It applies standad commecial maketing and sales techniques fo pomotion and distibution though wholesale and etail sales points to the mass maket. The social maketing oganization may eceive unbanded poducts fom intenational o national donos, o may diectly pocue quality poducts fom manufactues, and develops its own bands and packaging fo distibution. This entails the establishment of a pofessional in-county sales foce and management stuctue, fequently involving a local patne oganization. Howeve, the ability to opeate as effectively as possible in a wide vaiety of contexts is a key element in any social maketing pogamme. In most developing counties low-income populations fom the geat majoity and within it thee is a fequent need to taget specific, often difficult to access, population goups with paticula needs. In addition to woking though taditional sales netwoks involving wholesales and existing etail outlets fo consume goods, social maketing pogammes must fequently seek to develop non-taditional outlets and infomal distibution systems to meet the needs of specific goups, and even communities, within the population. The potential use of altenative distibution systems is an essential aspect of social maketing. Today, in many developing counties, socially maketed condoms ae to be found in both taditional etail outlets such as phamacies and dugstoes and non-taditional points such as bas, coffee shops, bothels, beauty palous, wokplaces, gas stations, and bus and tuck teminals. Theefoe, othe ways of social maketing of poducts have been developed and ae also common. These appoaches ae not mutually exclusive although one o moe may be applied exclusively by a pogamme o poject, o also as pats of a poject fo stengthening and impovement of an existing taditional appoach. These models, o possible appoaches to social maketing, include: Community-based systems of poduct pomotion and distibution ( communitybased distibution /CBD) whee non-pofessional sales agents ae ecuited fom among paticula goups within the geneal population. The individuals eceive basic taining in IEC and sales and ae usually ewaded financially fom small magins on thei sales. This appoach is inceasingly chosen as a means of eaching geogaphical aeas and socio-cultual goups that ae difficult to access. Many 9

11 UNAIDS pogammes incopoate the method to complement moe taditional, etail outlet sales; some pogammes, usually un by local NGOs, ae based entiely on the system. An innovative and pomising vaiant of the CBD appoach has ecently been developed and piloted ove two yeas in Chennai, India, by Intenational Family Health (IFH) and its local patne NGO, the Indian Institute of Community Health (IICH). In this model ( community-based social maketing /CBSM) sales agents ae ecuited fom among the geneal public as well as fom within specific goups. In addition to benefiting fom basic taining in epoductive health and fom commissions on thei sales, the agents also benefit financially fom ecuiting othes to act as educational and sales agents. CBSM is deived fom commecial netwok and multi-level maketing techniques successfully applied in developed counties, and has shown potential in apidly attaining community penetation and involvement in epoductive health issues and HIV pevention. The manufactue s model, whee suppot is povided fo the pomotion and distibution of bands developed and owned by a manufactue (foeign o local) o local manufactue s agent, fequently an impote of the poduct. The suppot usually takes the fom of gants diectly to the manufactues and/o thei distibution agents so as to educe thei commecial maketing costs and theefoe allow geate investment in key activities, such as pomotion and advetising. A etail pice significantly below the usual maket pice is the expected end esult. In contast to the taditional /own band model the manufactue s model is the least common. The appoach has been almost exclusively associated with The Futues Goup Intenational (TFGI) and its intenational, USAID-suppoted SOMARC poject. The tageted sevice delivey appoach involves planning appopiate social maketing activities, though which the poject stives to each and distibute poducts to specific taget goups, usually high-isk o othe pioity segments of the geneal public. These goups ae often inadequately seved by othe sevice delivey mechanisms, including standad social maketing activities. Thei identification usually esults fom maket segmentation studies caied out once the basic distibution stuctue to the mass maket is established, so tageted sevice delivey is often a component of pogammes mainly stuctued aound the taditional o wide commecial appoach. Howeve, many local oganizations, usually NGOs, adopt this appoach eithe fom necessity (esticted esouces) o fom paticula inteest. Thee ae many ways of applying social maketing concepts, appoaches and techniques at the national, local o community levels. Flexibility in planning and implementation ae key to successfully meeting the needs fo infomation and poducts such as condoms in the fight against the spead of HIV and AIDS. 10

12 Condom Social Maketing Planning and implementing social maketing pogammes is by no means esticted to lage, well-funded intenational oganizations. Local initiatives in social maketing by oganizations within the national pivate secto, including NGOs, exist in many counties. These can ange widely in size and pupose fom small, localized pojects esticted, fo instance, to taining and employing ex-commecial sex wokes in a paticula location as sales and IEC agents only fo condoms, to compehensive, full-scale epoductive health pogammes active at the national level. Of paticula inteest to local initiatives is the fact that well-managed and adequately suppoted social maketing pojects ae among the most cost-effective of health inteventions. The pojects can ecove a lage popotion of costs and evenues fom sales which can be invested in othe activities, such as capacity-building o stengthening the pogamme itself if the oganization woks exclusively in social maketing (the Social Maketing Company of Bangladesh, fo example). If the oganization has othe activities, as does PROFAMILIA in Colombia, then these evenues can also be used to subsidize these activities within a policy of coss-subsidization. The following concete examples of social maketing applied to the pevention of HIV/AIDS and STDs in diffeent counties and contexts ae offeed to illustate the vaious appoaches descibed above. The cases descibed below ae examples of the uses of these appoaches to social maketing that have been adopted in some counties by diffeent oganizations; all the cases focus on ways of condom distibution and pomotion that wee designed and implemented in esponse to diffeent situations. 11

13 UNAIDS 4. Case studies Community-based distibution in Haiti and Mozambique The use of individuals dawn fom the community and tained in IEC and condom pomotion and sales is key to the pefomance of the condom social maketing pogammes in seveal counties, among them Haiti and Mozambique. Howeve, the pincipal easons fo adopting this stategy, eithe on its own o complementing othe foms of condom distibution, may vay as also the foms it takes may vay. The examples of Haiti and Mozambique seve not only to illustate the potential effectiveness of CBD systems in condom social maketing, but also to demonstate diffeent easons fo the choices and diffeent ways of woking by CSM pogammes. In both counties the social maketing pogammes must deal with the difficulties involved in making condoms easily accessible to dispesed and lagely ual populations and communities. In Haiti the mountainous teain, pocketed with valleys inhabited by semi-isolated communities and seved by a pecaious tanspotation infastuctue, was a key facto in the decision to ecuit sales agents fom the communities though existing local NGOs. The agents wok to stengthen a system that includes taditional commecial distibution based on an existing commecial netwok fo othe consume goods. Significant volumes of condom sales ae achieved though the community-based distibutos (CBDs), but taditional distibution accounts fo most of the volume. On the othe hand, in Mozambique the existence of lage communities, isolated by the geogaphical teain, was much less poblematic than the fact that many yeas of civil wa had devastated the national infastuctue fo tanspotation and communications as well as the economy and an incipient commecial secto. Standad distibution of poducts was theefoe extemely difficult, even in uban aeas, and thee was no commecial distibution up-county. It was decided to focus initially on establishing a distibution system based on a netwok of locally ecuited and tained sales and motivation teams. One team was established pe povince; the ole of the motivation agent was focused on ceating demand fo condoms (paticulaly amongst high-isk goups though intepesonal communications activities), whilst the equally impotant ole of the sales agent was to meet the demand by supplying the etaile. This was necessay due to the fact that condoms in Mozambique wee still a elatively new and unknown poduct. A moe fomal, taditional means of distibution though a wholesale-etaile chain could be expected to build up ove time. In 1999, 49% of sales wee to community agents, 34% to commecial distibutos and 16% to wokplaces and NGOs. The popotion of sales to community agents in the yea 2000 is expected to be 45% and futhe eductions ae expected as the commecial secto gows. 12

14 Condom Social Maketing Haiti Relevant facts about Haiti Haiti has a total land aea, which is vey mountainous, of squae kilometes, and a total estimated population of 8.1 million of whom almost 70% live in ual aeas (in contast with the aveage fo Latin Ameica and the Caibbean which is 74% uban); 55% of the population is below the age of 20. The capital, Pot-au-Pince, has an estimated population of 1.5 million. Ethnically, 95% of the population is Afo-Caibbean. Fench and Ceole ae the official languages and male/ female liteacy ates ae estimated at 48/42 %. The pincipal eligions ae Chistianity (Roman Catholic) and Vodun. Haiti is the pooest of the Latin Ameican and Caibbean counties. Its GNP pe capita in 1995 was estimated by the Wold Bank to be US$ 250 and the vast majoity of the population live on subsistence incomes, mainly fom agicultue. Haiti anks 156 on UNDP s Human Development Index and life expectancy at bith is estimated at 54 yeas, much lowe than the egional aveage of 70 yeas. The pevalence of HIV infection amongst Haitians aged yeas is estimated at 5.17% by the end of 1999, pehaps the highest in the egion, with an estimated people living with HIV/AIDS and deaths due to AIDS in Aleady by the late 1980s HIV pevalence among sex wokes tested in majo uban aeas anged fom 42% to 53%. The pevalence of STD is known to be high, and a 1992 study of male STD clinic patients found that 25 % of patients tested wee HIV-positive. Pogamme: Haiti Social Maketing fo AIDS pevention Population Sevices Intenational (PSI) has been active in social maketing fo epoductive health and eduction in high-isk sexual behaviou in Haiti since 1989, focusing its effots pincipally on poviding accessible and affodable condoms to the 13

15 UNAIDS low-income segments of the population fo HIV/STD pevention. By the end of 1996, two banded condoms (one male, one female) had been successfully launched on to the maket and in that yea othe contaceptive poducts (pills and injectables) wee added to the ange of poducts. Howeve, geogaphical, economic and political conditions in Haiti make it extemely difficult to implement a social maketing pogamme of egula poduct distibution though the commecial wholesale-to-etaile stuctue adopted in most counties. In Haiti the majoity of the population lives in ual aeas that ae not easily accessed due to the mountainous teain and a pecaious infastuctue of oads and tanspotation. The vast majoity of the population has little o no egula income, and, additionally, political instability and unest is a constant aspect of daily life. Thus it was decided in 1990 to implement a supplementay pogamme fo ceating a system based on the sale of poducts, mainly male condoms, togethe with elated IEC activities. This was effected though tained individuals, locally ecuited fom the communities and population goups tageted by the oveall pogamme, i.e. a system of community-based distibutos, and motivated by a easonable financial incentive usually with a commission on sales. Some othe key advantages found in Haiti by PSI of pomoting and distibuting condoms, and othe poducts, though CBDs ae: *Cedibility, as elatives, fiends and neighbous tend to be moe favouably eceived than salespeople fom outside; *Availability, as CBDs ae usually much moe easily accessed at any time of the day o night; *Pivacy and discetion, whee condoms can be obtained on a one-to-one, pesonal basis; *Effective counselling, dealing with individual needs and, especially in the case of condoms, ensuing coect and consistent use. In ode to achieve this, PSI/Haiti fomed an initial patneship with fou local NGOs, late expanding this numbe to nine with wide access to ual communities, and ceated and egisteed its own NGO, Pogamme de Santé et Infomation (PSI/Haiti). Initially, PSI tained 175 membes of the NGOs to act as wholesale distibutos selling to etail outlets and as etail sales agents to consumes. The taining sessions included such topics as STDs and HIV/AIDS pevention, social maketing goals and stategies, intepesonal communication and diect sales techniques, condom use demonstations and basic money management. Following taining, each CBD was povided with a fee stock of condoms, up to 10 etail dispenses each containing 144 condoms, in ode to begin selling and, with the esulting evenues, epuchase moe supplies afte etaining an ageed magin. PSI/Haiti in fact povided the CBDs with the means (capital) to become mico-entepeneus. Thee was an initial concen that some CBDs might pefe to sell thei condoms to highe-income goups athe than thei tageted populations and, also, that the IEC obligations of the CBD ole might be neglected in favou of sales. PSI/Haiti theefoe monitoed the activities of many CBDs and discoveed that, whilst in fact some wee selling condoms to moe affluent people, they wee not neglecting thei taget goups who epoted that condoms wee available wheneve needed. Whethe the educational obligations wee being neglected was admittedly moe difficult to evaluate, but the damatic 14

16 Condom Social Maketing incease in sales ecoded showed that individuals wee being convinced to puchase and use condoms, indicating that the IEC function was being caied out. The poject was vey successful. In all, moe than 3000 points of sale fo male condoms wee ceated thoughout Haiti, ensuing availability fo hundeds of thousands of customes and included, besides taditional makets and commecial sales outlets, bas, hotels and even beauty salons in both uban and emote ual aeas. Ove the fist fou yeas, monthly sales of PSI/Haiti s male condoms ( Panté ) inceased fom to ove pieces and continues to incease. It is estimated that at least 33% of total sales though all channels employed in Haiti wee due to CBDs, and a lage shae of egula sales outlets wee opened by these individuals. Sales gaph with total socially maketed condom sales volumes millions Futhe indicatos of success include the obsevations that, by the end of 1996, between 70 and 95% of sexually active adults, including 85% of adolescent males, 70% of adolescent females and 95% of commecial sex wokes, knew about Panté and ecognized that condoms potect against AIDS. In 1998 nealy one in five women epoted having used condoms specifically fo STD/HIV potection. At the same time, howeve, suvey esults show that both awaeness and use ae still lowe than could be expected in ual aeas and that effots must be maintained o even inceased. Accoding to epots fom PSI/Haiti, the main constaints and obstacles encounteed included: Rappot between NGOs and social maketing in pomoting HIV pevention is not automatic, and thee wee occasional conflicts between an NGO s mission and that of the poject. It was easie fo NGO salespeople to sell to moe affluent customes in the cities than to the ual outeach tagets, and to confine thei activities to selling instead 15

17 UNAIDS of meeting thei educational obligations. Howeve, this conflict was ecognized ealy and successfully counteed though monitoing and taining. The peiod of the poject coincided with the aftemath of the militay coup in 1991, when daily life was paticulaly difficult in Haiti. The intenational economic embago cut off impoted fuel and aw mateials, factoies and businesses closed, and hundeds of thousands of wokes wee foced into abject povety. In this uncetain envionment, highly motivated CBDs povided stability to the poject, finding ways to continue thei wok despite the poblems and danges, and continuing to open up new sales outlets and shae infomation on AIDS and its pevention. Key lessons leaned fom the expeience wee: Oveall, CBDs can make vey significant contibutions to both condom availability and accessibility, although individual pefomance can be expected to vay consideably. CBDs ae able to open new sales egions and outlets that will be egulaly seviced late by the pofessional sales foce. The diect costs to the oganization of adding CBDs to its sales foce, as opposed to pofessional salespesons, is small compaed to the benefits. Howeve, moe supevision and management time is equied, paticulaly in the fist months of opeations. Even small magins on sales can be attactive and motivating to CBDs. The pesonal income geneated by CBDs also appeas to counteact voluntee bun-out and many CBDs woked continuously fo yeas. Howeve, the income should be pesonal and not emitted to an oganization to which the CBD might belong. NGOs and community-based oganizations (CBOs) should not count on this activity as a souce of income. Nevetheless, NGOs ae much bette able to each non-taditional outlets than commecial distibutos. Condom band pomotion is most effective when accompanied not only by mass media IEC but also by intepesonal, community-based condom pomotion campaigns. To function effectively in Haiti with maximum coopeation fom govenment and intenational agencies, PSI needed to opeate though NGOs as well as though commecial distibutos. 16

18 Condom Social Maketing Haiti: Additional infomation Poject duation: Oiginal poject fom 1991 to 1996, but continued funding has pemitted activities though Implementing agencies: a) At the national level: Pogamme de Santé et Infomation (PSI/Haiti) managed the poject, with the diect involvement of fou national NGOs, and in patneship with the Ministy of Public Health and Population. b) At intenational level: Population Sevices Intenational (PSI) and USAID (AIDSCAP). Funding souces: USAID; additionally, the Govenment of the Nethelands, PSI Patneship Fund, Wold Bank, UNFPA, UNAIDS, the Begstom Foundation and the Summit Foundation. Poject objectives: The goal of the poject was to educe high-isk sexual behaviou and thus the tansmission of HIV/AIDS. The main objectives wee to: *Taget low income populations by making affodable condoms accessible; *Ceate consume demand based on high awaeness of coect and consistent condom use; *Reduce the incidence of othe STDs (e.g. gonohoea, syphilis, and chlamydial infection), which significantly facilitate the tansmission of HIV/AIDS. Taget aeas: The whole county, with emphasis on the ual aeas whee 70% of the population live, and whee access to condoms and othe poducts is vey limited. Moe than 3000 points of sale, ceated diectly though CBDs, and though them to non-taditional etail outlets such as night clubs, bas and beauty salons. Taget audience: Geneal and high-isk populations, especially young people (age goup 15 to 24 yeas), including female commecial sex wokes, migants and tanspot wokes. Othe CSM pojects in Haiti: None Fo additional infomation on this pogamme: PSI/Haiti Rue Theodule #1 Boudon Pot-au-Pince Haiti 17

19 UNAIDS Examples of condom pack and postes The PSI-banded male condom, Kapòt Panté ( Panthe ), was launched in Haiti in 1990 and is now available nationwide at a low pice of US$ 0.07 fo a packet of thee. This is an affodable pice fo a population with an estimated pe capita annual income of US$ 400 and is oughly 10 times lowe than the commecial bands. Tageted consumes wee high-isk populations, with emphasis on young people aged 15 to 24 yeas, and since 1994 on women. Intensive mass advetising depicted the Panté as denoting stength and masculinity. National media wee heavily involved in pomoting condoms fo the pevention of AIDS and in addition, education of the client was an integal pat of the wok of each CBD. The Canival peiod (Januay to Apil) is the highest isk peiod fo sexual tansmission of disease and PSI/Haiti ended the millennium with a highly visible campaign to make Canaval 2000 the safest since HIV and AIDS came to Haiti. 18

20 Condom Social Maketing Mozambique Relevant facts about Mozambique Mozambique has a total land aea of squae kilometes and a total estimated population of 19.3 million of whom 66% live in ual aeas; 56% of the population is below the age of 20. The capital, Maputo, is on the coast and has an estimated population of 2.2 million. Ethnically, the population is made up of vaied goups with seveal majo languages but Potuguese is widely spoken and is the official language; male/female liteacy ates ae estimated at 58/23%. The pincipal eligions ae indigenous beliefs (60%) and Chistianity (30%). Mozambique is one of the pooest counties in the wold. Its GNP pe capita in 1995 was estimated by the Wold Bank to be US$ 80 and the county anks 166 on UNDP s Human Development Index; half of the national income is deived fom agicultue. Life expectancy at bith is estimated at 47 yeas, below the aveage fo Afica of 51 yeas. 19

21 UNAIDS The pevalence of HIV infection amongst adults in Mozambique was estimated at 13.2% by the end of 1999, among the highest in Afica, with people living with HIV/AIDS and deaths due to AIDS in By 1996 HIV pevalence among antenatal women tested in diffeent locations acoss the county was found to be between 18% and 23%; in addition, the pevalence of STD is known to be high and by 1995, depending on the location, studies of male STD clinic patients found that between 23% and 40% of those tested wee HIV-positive. Pogamme: Communications and Condom Maketing fo AIDS Pevention: the pomotion of safe sex among high-isk individuals in Mozambique As a esult of the end of its civil wa in 1992, HIV tansmission ates in Mozambique ose damatically with the etun of efugees fom neighbouing counties whee HIV pevalence had been highe than in Mozambique. The govenment had a pogamme of fee distibution of condoms but this had been seveely affected by the yeas of civil wa and pospects fo impovement wee thin. In 1994 the govenment s National AIDS Contol Pogamme (NACP) invited PSI Intenational to design and implement an AIDS pevention social maketing poject to pomote safe sexual behaviou and the use of condoms as a component of the NACP s own pogamme. The oveall goal fo PSI was to impove the health of sexually active men and women and thei childen, by educing tansmission of HIV/AIDS and othe STDs. The poject that was implemented in ealy 1995 had two specific objectives: *Incease the use of condoms, paticulaly by pesons vulneable to HIV tansmission, though the intoduction, pomotion and sale of a condom specifically developed fo social maketing in Mozambique ( JeitO, the condom band name, meaning in Potuguese style o flai, which lends itself to popula slogans such as Living with Style); *Incease the demand fo condoms though the implementation of an integated behaviou change communications stategy which would pomote safe sex, especially tageting high-isk goups such as commecial sex wokes, long-distance tuck dives, STD clinic attendees, night club patons, militay and police, people with non-egula sex patnes, youth (in and out of school) and women. Having begun as a pilot poject in limited uban and peiuban aeas in fou povinces in 1995, the poject was expanded to the national level by 1996 with sales and motivation teams established in all ten povinces. Togethe with the National AIDS Contol Pogamme, fom the total of 140 disticts in Mozambique, 71 pioity disticts fo AIDS pevention wee then identified based on the following citeia: *High incidence of STDs *Common bodes with high HIV pevalence counties *High volume of tucking *High uban population density *High incidence of etuning efugees and migant laboues. 20

22 Condom Social Maketing The poject then ecuited and tained 65 Community Agents (CAs) fom these disticts. The CAs wee tained in intepesonal communications (fo example, each CA conducts monthly 15 small goup discussions with poject taget goups) and in sales techniques fo JeitO condoms, focusing on ensuing access to these by high-isk goups though non-taditional outlets. The CAs eceive a monthly stipend fo thei wok in communications and, additionally, a magin fom thei sales of condoms. Supevision of the CAs is povided by the PSI Povincial Sales /Motivation agent. They ae also egulaly evaluated and povided with efeshe taining when necessay. New CAs ae ecuited and tained as vacancies ae filled whilst maintaining the total of 65. The CAs have an impotant ole in the oveall poject stategy to pomote behaviou change, i.e. coect and consistent use of condoms, eduction in the numbe of sexual patnes, teatment of STDs and, paticulaly fo young people, sexual abstinence until maiage. The poject developed a famewok based on six factos deemed necessay fo behaviou change to occu: *Pesonal peception of being at isk *Education on condoms *Existence of an enabling, suppotive envionment *Ready access to condoms *Self-efficacy, o having the intent and skills to take peventive action *Appopiate condom band positioning: the JeitO band concept. In applying this famewok, the poject developed activities designed to affect each of the factos based on infomation gatheed fom the diffeent taget goups. The activities ae designed aound a mutually einfocing media mix, emphasizing intepesonal communications (dama, theate and small goup discussions) along with mass media (adio and TV spots, music videos and cassettes) and pomotional mateials. The poject has eight theate goups tained to conduct five diffeent tageted plays in evey povince of Mozambique, and on any given day it can be expected that five plays ae pefomed somewhee in the county. The esults have been impessive. To date, an estimated total of pee education AIDS/STD sessions have been held, eaching about 1 million membes of the taget population. In addition, 150 taditional heales and some taditional bith attendants have been tained in pomoting the use of condoms with thei clients. A KAP suvey conducted in 1997 in uban and peiuban aeas evealed that 87% of espondents wee awae that condoms exist, 31% had used condoms at least once and 78% cited condoms as a means of peventing HIV infection (as compaed to 38% in a simila suvey in Malawi). Moe than 3000 condom sales outlets have been established nationwide, including non-taditional outlets fo condoms in Mozambique such as bas and clubs, kiosks and tobacconists, gas stations, maket stalls, NGOs, supemakets, steet vendos, taditional heale outlets and within wokplaces. Demand fo and sales of socially maketed condoms then ose damatically, although sales wee affected by a shotage of subsidized poduct in

23 UNAIDS Sales gaph: JeitO condoms millions Accoding to epots fom PSI/Mozambique, the main constaints and obstacles encounteed included: The JeitO package of fou condoms is sold to consumes fo the equivalent of US$ 0.08 and condoms ae still dono-suppoted; in 1998 thee was a shotage of subsidized condoms due to dono shotfall. PSI in Mozambique is seen as an intenational oganization in spite of the fact that the management of the poject is 98% Mozambican and it has a close elationship with the national govenment. One solution might be to entust the capacity in social maketing to a local NGO. Key lessons leaned fom the expeience include: Govenment can be an active patne in social maketing and even include it in its own pogammes, as in this case with the NACP in Mozambique whee the condom social maketing poject is a component of the national HIV pevention stategy. The govenment ecognizes the need fo coodinating fee condom distibution though the national health system with the social maketing poject, binging condoms to the entie population egadless of the individual client s puchasing powe. This is an objective of the cuent NACP stategic plan. The pincipal facto in the success of the poject has been the emphasis given to involving the community in sales and pomotion, ight down to individual input though pee education and diect pomotion at points of sale. The success of the poject has been in lage pat due to its intensive pomotional activities not only though the media and theate pefomances, but also by the individual community-based pomotion by sales outlets, CAs, pee educatos and taditional pactitiones. 22

24 Condom Social Maketing Mozambique: Additional infomation Poject duation: Pilot poject in 4 povinces, 2 yeas fom 1995 to Phase I, extended to national scale, 3 yeas 1997 to Phase II, planned fo a futhe 3 yeas. Implementing agencies: a) at national level: National AIDS Contol Pogamme, Ministy of Health, PSI/Mozambique, national media. b) at intenational level: PSI/Washington, USAID. Funding souces: Fo the pilot study and Phases I and II, USAID and the Govenment of the Nethelands, with the addition of UK/DFID fom Taget aeas: Pilot poject in 4 povinces (Maputo, Sofala, Manica and Tete). Phase I, extension to national level. By Decembe 1996, the poject was opeating in all 10 povinces, and by Decembe 1998, the national stuctue was fully consolidated. Othe CSM pojects in Mozambique: None Fo additional infomation on this pogamme: PSI/Mozambique, Av. Patice Lumumba 204, C.P. 4059, Maputo, Mozambique 23

25 UNAIDS Community-based social maketing in India Relevant facts about India The Indian sub-continent has a total land aea of 3.3 million squae kilometes and a total estimated population of 998 million of whom 73% live in ual aeas; 49% of the population is below the age of 20. The capital, New Delhi, has an estimated population of 6 million. Ethnically, 72% of the population is Indo-Ayan, 25% is Davidian and othes account fo 3%. Thee ae moe than 14 official languages, including Hindi and English, and male/female liteacy ates ae estimated at 66/38%. The pincipal eligions ae Hindu (83%) and Islam (11%). India s GNP pe capita in 1997 was estimated by the Wold Bank to be US$ 370 and the vast majoity of the population live on subsistence incomes, mainly fom agicultue. India anks 132 on UNDP s Human Development Index and life expectancy at bith is estimated at 63 yeas, as compaed to a egional aveage of 67 yeas. 24

26 Condom Social Maketing The pevalence of HIV infection amongst Indians aged yeas is estimated at 0.70% by the end of 1999, with an estimated people, including childen, cuently living with HIV/AIDS. This is moe than any othe county in the wold except South Afica. India s epidemic, howeve, is divese. While some states cuently show almost no HIV infection othes have eached adult HIV pevalence ates of ove 2%. The southen state of Tamil Nadu has an estimated population of 60 million, of which some 4 million live in the capital, Chennai. The fist case of AIDS in India was epoted in Madas (now Chennai) in Local suveillance systems have shown that HIV infection has isen significantly; fo example, ates among pegnant women tipled between 1995 and 1997 to 1.25%. Bold safe-sex campaigns, including intensive condom pomotion, in Tamil Nadu have esulted in damatic inceases in condom use in isky sexual encountes. An innovative appoach to both social maketing and the CBD system has ecently been pilot-tested ove thee yeas in Chennai (Madas), India, by Intenational Family Health (IFH) and its local patne NGO, the Indian Institute of Community Health (IICH). Called Community-based social maketing (CBSM), the model is deived fom commecial netwok and multi-level maketing techniques successfully applied in developed counties in diect, peson-to-peson poduct pomotion and sales. As such, it was felt to have potential fo apidly attaining community penetation and involvement in condom pomotion and distibution and STD/HIV pevention in geneal. In the Chennai pilot test, the fist of its kind, the poducts developed and maketed in this way wee condoms and sanitay napkins. An additional attaction of the model is that CBSM offes not only an efficient means to effective pomotion of epoductive health awaeness and pactices but also the oppotunity fo significantly inceased income to many individuals and households. It would theefoe contibute diectly to impoved quality of life in the community. The CBSM expeience also illustates how some intenational donos ae willing to suppot new, even expeimental concepts and techniques in social maketing. Pogamme: axess, a community-based social maketing pilot poject Among the vaious possible ways of effecting community-based distibution of poducts, including condoms, within social maketing is that of ecuiting and taining sales agents fom among membes of the geneal public, exclusively o in addition to membes of paticula isk goups. In addition to benefiting fom commissions on thei sales of condoms, these agents would also benefit financially fom thei successful ecuitment of othes in the community to act as additional sales agents and educatos. The numbe of sales and IEC agents inceases pogessively though the establishment of sales and communications netwoks and is expected to esult in a highe demand fo infomation and poducts as the community becomes inceasingly involved. 25

27 UNAIDS The sales agents, o patnes, ae people fom all walks of life who coectly use quality health poducts and know why these poducts should be used. The patnes sell the poducts to othes and eceive a magin on the sales. In addition, they involve othes who will also use, sell and in thei tun involve othes. When one ecuits new patnes in this way, he/she is financially ewaded based on the volume of the poduct that was used by the people ecuited. The system diffes significantly fom standad social maketing in that healthelated infomation and poducts ae disseminated solely by individuals athe than though mass advetising and the wholesale distibution of poducts to selected commecial etailes. As infomation and poducts ae spead in this way though the community, new netwoks ae continuously ceated, esulting in inceasingly widespead and coect knowledge about family planning, the pevention of STDs and AIDS, and the use of healthpomoting poducts. In ode to test this concept fo deliveing health poducts and infomation to the less pivileged and moe vulneable segments of the population in developing counties, IFH developed the following pincipal activities: *Development of a sophisticated PC-based softwae package to egiste and tack patnes, individual sales, efeals, payments and commissions due; *Development of a family band ( axess ) fo condoms and sanitay napkins. Othe poducts such as iodized salt and soap wee late added to the poject; *Development of a taining package fo netwok maketing and health IEC; *Establishment of a specific NGO as a cente fo administation, poduct depot and taining to un the poject independently unde the band name. Othe local NGOs wee late added; *Recuitment and taining of community-based patnes in lowe-income aeas of Chennai as sales and IEC agents; *Qualitative, diagnostic eseach to monito pefomance, patne activities and identify constaints; *Fomal evaluation afte two yeas activities. The poject was designed by IFH in 1994 and Following implementation in Chennai in 1996, the CBSM activities as such began in ealy 1997 and evaluation, as planned, was conducted afte two yeas in late The pilot test was theefoe successfully completed. 26