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  • 1. THE MARKET FORFAMILY PLANNING IN NEPAL Adrian BlairHarvard Business School Social Enterprise Summer Fellow July 2003 Page 1 of 111
  • 2. Table of ContentsAbbreviations 3Acknowledgements 5Introduction 6Part One – Customers 9Part Two – Other Brands 36Part Three – Social Marketing Programme Potential 91Part Four – Context 95Part Five – Conclusion and Recommendations 101Sources 108 Page 2 of 111
  • 3. AbbreviationsADB Asian Development BankADRA Adventist Development and Relief AgencyAIDS Acquired Immune Deficiency SyndromeBCC Behaviour Change CommunicationCBS Central Bureau of StatisticsCEDA Centre for Economic Development and AdministrationCHP Community Health Promoter (employed by MSI)CHV Community Health VolunteerCRS Contraceptive Retail Sales CompanyDHS Department of Health ServicesDFID Department For International DevelopmentEU European UnionFCHV Female Community Health VolunteerFHD Family Health DivisionFHI Family Health InternationalFMCG Fast Moving Consumer Goods (eg. chocolate bars)FP Family PlanningFPAN Family Planning Association of NepalHIV Human Immuno-deficiency VirusHMG His Majesty’s GovernmentIPED Institute for Population, Environment and DevelopmentIPPF International Planned Parenthood FederationIEC Information, Education and CommunicationINGO International Non-Governmental OrganisationIUD Intra Uterine DeviceJHPIEGO John Hopkins Programme for International Education in Reproductive HealthJHU John Hopkins UniversityJSI John Snow InternationalKfW Kreditanstalt fur Wiederaufbau (the German Development Bank)LDC Less Developed CountryLMD Logistics Management DivisionMCH Maternal and Child HealthMOH Ministry of HealthMOPE Ministry of Population and the EnvironmentMSI Marie Stopes InternationalMWRA Married Women of Reproductive AgeNAYA Nepal Adolescents and Young AdultsNDHS Nepal Demographic and Health SurveyNFCC Nepal Fertility Care CentreNGO Non-Governmental OrganisationNSV No Scalpel VasectomyOC Oral Contraceptive Page 3 of 111
  • 4. PHCC Primary Health Care CentrePSI Population Services InternationalRH Reproductive HealthRHFV Reproductive Health Female Volunteer (FPAN’s equivalent of FCHV’s)SMD Social Marketing and DistributionSPN Sunaulo Parivar Nepal (the Nepal branch of MSI)SRH Sexual and Reproductive HealthTFR Total Fertility RateUN United NationsUNFPA United Nations Population FundUNICEF United Nations Childrens FundVSC Voluntary Surgical Contraception Page 4 of 111
  • 5. Acknowledgements Everyone at PSI – an endless source of knowledge, support, and fun. The Team - Shruti, Binisha, Prasanna, and Santosh. Dr. Bidhan Acharya and his team for some difficult work delivered in a very short time. The many others who generously gavetheir time and information, asking for nothing in return. Aurore – distant, never forgotten. Page 5 of 111
  • 6. IntroductionAt its current growth rate of 2.25%, Nepal’s population will double by 2030.1 Theconsequences for an already crowded country of population approaching 50m are barelyconceivable. Yet nobody wants this to happen - least of all ordinary Nepalis, whose idealfamily size of 2.5 is barely above replacement level. 2 Hence the urgent need to narrowthe gap between this ideal and the current TFR of 4.1. 3This study aims to help social marketers address the problem through more effectivemarketing of family planning (FP).To do this, it will identify the major groups of people with an “unmet need” for FP, andattempt to deepen our understanding of their requirements and decision-makingprocesses. It will go on to examine what options are currently available to them, thecapabilities of social marketing programmes, and the prevailing socio-economic contextwithin Nepal.In the light of this analysis, a target market will be recommended for new socialmarketing FP products.The way different parts of this structure fit together is illustrated below:Logical framework for target market recommendation1 CBS (2002)2 NDHS (2001)3 The actual TFR may be even higher. Retherford (2002), using the same raw data but a differentcalculation method to the NDHS, put it at 4.7. Page 6 of 111
  • 7. Social marketing Customers Existing brands Context programme potential Who are they, where are they, and Are others already Are social marketing What favourable what do they want? giving it to them? organisations in or unfavourable Nepal capable of political, social • Who are the biggest If so, with what satisfying them ? and economic groups with unmet FP need? degree of success? factors exist? • What don’t we know about them? Which of these • Fill knowledge gaps are likely to through primary and change? academic research Target market selection Positioning Follow-on work The 4 Ps after this study Action and evaluationComparison with other LDCsContraceptive use in Nepal has come a long way over the last seven years. Chart 1.2shows the clear correlation in LDCs between the wanted fertility rate and the proportionof women using a modern method.Nepal in 1996 was lagging well behind the level one would expect given wanted fertilityof 2.9. By 2001, although this had decreased by just 7% to 2.7, the CPR had increasedby 36% (though Nepal still lagged slightly behind the trend level).Correlation between number of children wanted and contraceptive use in 50 LDCs44 Alan Guttmacher Institute; NDHS (2001) Page 7 of 111
  • 8. 80 Brazil 70 Dominican Republic 60% Women using a modern method Egypt 50 Zimbabwe India 40 Nepal 2001 30 1996 Malawi 20 Haiti 10 Niger 0 0 1 2 3 4 5 6 7 8 Wanted fertility rateDespite this steep increase in the CPR, “unmet need” for contraception in Nepal over thesame time period decreased only slightly, from 31% of married women in 1996 to 28% in2001 (having increased between 1991 and 1996). The next section attempts tounderstand this 28% in more depth. Page 8 of 111
  • 9. Part One - CustomersThis section will: 1) Profile the most attractive segments of potential target customers for new FP products 2) Provide a qualitative overview using PSI’s BCC framework of reasons why people in these groups are not yet using FP 3) Rank some of the key influencing factors on these groups in order of importance1) Target customer segments for new FP productsThis section runs through seven important variables by which the market for FP productsin Nepal can be segmented. These variables are: • Marital status; • Desire for more children; • Current use of contraception; • Age; • Residence; • Level of education; • Parity.For each variable, a recommendation will be given for new FP products.Three criteria are used to make this selection: - Acuteness of need for FP - Size of potential market for FP products - Consistency with the aims of social marketing.Variable 1: Marital status (married / unmarried)Few Nepalis give birth outside the context of marriage. But this does not mean extra-marital pregnancy is not a problem.A 2001 study of 1,400 unmarried 12-18 year-olds found that 9% of girls admitted tohaving had sex. Of these, 26% said they had not used a condom, and 14% (ie. 1.3% ofthe total sample) had got pregnant.55 UNICEF (2001) Page 9 of 111
  • 10. To avoid the stigma of extra-marital birth, a woman in this situation generally opts forone of two unpalatable choices: abortion, or a speedy marriage. From the limited dataavailable, most women appear to opt for the latter. In a 1994 community-based study, ofthe 1.7% of pregnant women who terminated their pregnancy, less than 1 in 10 wereunmarried or divorced.6The clear implication is that (although most studies of unmet need to date have focusedon married people) young unmarried “spacers” (people who wish to delay their nextbirth) as well as their married counterparts have an “unmet need” for temporary methods(ie. they wish to delay their next birth but are not currently using contraception). This isparticularly important in the Terai, currently the only area of Nepal experiencing asignificant decline in nuptiality amongst young people (see “Context” section). Reducingteenage pregnancy may also have the knock-on effect of reducing the number of earlymarriages, hence reducing teenage fertility overall.Further evidence for the attractiveness of spacing to young unmarried people wasprovided by a 1999 study of 808 unmarried 12-19 year olds in Kapilvastu and Baitadidistricts (western terai and far-western hill respectively). The ideal age for a woman’sfirst birth, the adolescents said, was 21 years (on average); and the mean ideal spacinginterval between births was 3.7 years.7 In other words, the current situation where over1/3 of married women give birth in their late teens, and 31% in this age group have aninterval of just 7-17 months before their second birth, is not at all satisfactory for today’steenagers.8Demand for “limiting” (having no more children) at this age, however, is almost non-existent. It therefore makes sense that FP products should be targeted at married peoplewanting no more children, and both married and unmarried people who wish to delaytheir next birth.Recommendation 1: Married and unmarried (spacers); Married only (limiters)Variable 2: Desire for children (spacer / limiter / wants children soon)Women wishing to delay the next birth beyond two years are known as “spacers”, andthose with no desire for more children as “limiters”. This does not in itself indicateanything about method choice. A limiter, for example, may be using a temporarymethod, or indeed no method at all.96 S. Thapa, P.J. Thapa and N. Shrestha (1994) - Abortion in Nepal: Emerging Insights, Journal of NepalMedical Association 1994, Vol. 32, p. 175-190, quoted in Gautam (1999)7 Karki (1999)8 NDHS (2001) p.61-629 The commonly used terms “spacing method” and “limiting method” often add to this confusion.“Temporary method” and “permanent method” are clearer. Page 10 of 111
  • 11. People wanting children soon have little use for FP, and so are not an attractive targetmarket. By contrast, FP can help spacers and limiters achieve their objectives.Moreover, there are a large number of women in both groups: 0.7m MWRA are spacers,and 2.3m are limiters.10Recommendation 2: Spacers and LimitersVariable 3: Current use of contraception (met need / unmet need / no need)Because social marketing aims to expand overall use of FP rather than gain share fromexisting providers, new products should be targeted at people who are not currentlyusing. Therefore they should not be targeted at people with a “met need”.People in the “no need” category may want more children soon (see above), be in-fecund,menopausal, or not sexually active. Either way, they are clearly not an attractive targetmarket.Non-users of contraception wishing to space or limit are said to have an “unmet need” forFP. Targeting new products at them does not entail taking share from any existingproviders. They want the benefits of FP, and are a large group (28% of MWRA11).Hence they are the most attractive target market.But this does not mean the job of converting unmet need to use is an easy one. It isimportant to bear in mind that “unmet need” does not equate to “unmet demand”(although no distinction is drawn in any of the studies to date in Nepal, and the terms areused synonymously).12 Somebody with unmet need is the result of a demographer’sequation subtracting one group (FP users) from another (spacers and limiters). They havenot necessarily expressed “demand” for FP. Desire for one of the benefits of somethingdoes not automatically entail demand for the product itself. Wanting in principle to travelto Pokhara does not imply demand for a plane ticket if you are ill, elderly, scared offlying, and work full time in Kathmandu.Because this distinction is not drawn, the tone in the literature on unmet need is often oneof mild bafflement at the irrational behaviour of people who “demand” something but donot use it. The question “why on earth don’t they use this thing they demand, even whenit’s free? (or, with VSC, even when they are paid!)” seems to lurk at the back of theauthor’s mind.In fact the subjects being studied have not always expressed “demand”, and as we shallsee generally have perfectly rational reasons for their non-use.Discontinuation rates10 CBS (2002); NDHS (2001)11 NDHS (2001)12 For example: Aryal (1997) p.91; Shrestha (1991) p.29; NDHS (2001) p.120 Page 11 of 111
  • 12. It is worth noting here that a significant minority in the unmet need category are previoususers who have discontinued. A recent study found the following one-yeardiscontinuation rates for each method:Table 1.1 - One-year discontinuation rates for temporary methods13 Method One-year discontinuation ratePill 38%Depo 30%IUCD 13%Norplant 3%Overall, around 1/3 of pill and Depo users discontinue each year.The picture is extremely mixed, however, at a district level. In some districts, accordingto the government’s Annual Report, discontinuation exceeds 100%. In others it isapparently negative.14 However, the government’s data on this varies so wildly bydistrict and method type that it is difficult to draw any firm conclusions, other than aboutthe quality of the data itself.Recommendation 3: Unmet needVariable 4: Age &Variable 5: Residence (urban / rural)These two variables are most revealing when analysed together. Chart 1.1 shows thelargest urban and rural groups by proportion of married women with an unmet need foreither spacing or limiting.Chart 1.1 - % of married women with unmet need1513 Pradhan et al (200314 DHS (2003). Eg. Pill dropouts as a % of current users in Dolpa district are 507%. Depo dropouts inMorang as a % of current users are -8%. This was calculated by assuming Dropouts in 2001-02 = Currentusers in Jul 01 + New Acceptors during 01-02 - Current users in Jul 02.15 NDHS (2001) Page 12 of 111
  • 13. 35 30 25 % with unmet 20 need 15 10 5 0 15-19 20-24 25-29 30-34 35-39 Age Urban spacers Rural spacers Urban limiters Rural limitersClearly young spacers in both urban and rural areas, and rural limiters aged 25-39, are thegroups whose needs are currently most underserved. However, the actual number ofindividuals in these groups is very different.Chart 1.2 illustrates the largest groups by absolute number. The two outstanding groups,numbering 0.29m and 0.43m respectively, are rural women aged 15-24 with an unmetneed for spacing, and rural women aged 25-39 with an unmet need for limiting.Chart 1.2 - Largest categories of married women with unmet need1616 CBS (2002); NDHS (2001). This analysis assumes that the proportion of women in these categoriesliving in urban areas is the same as that of the population as a whole (14.2%). Page 13 of 111
  • 14. 180 160 140 120 unmet need (000) Number with 100 80 60 40 20 15-19 20-24 25-29 30-34 35-39 Age Urban spacers Rural spacers Urban limiters Rural limitersChart 1.3 makes the point even more starkly, showing how over 90% of married womenaged 15-39 with unmet need live in rural areas.Chart 1.3 - Married women aged 15-39 with an unmet need for contraception17Total number = 987,91717 NDHS (2001); CBS (2002) Page 14 of 111
  • 15. Urban Spacing 5% Urban Limiting 4% Rural Limiting 51% Rural Spacing 40%This is also reflected in fertility and contraceptive usage rates for rural and urban areas.As table 1.2 shows, the urban fertility rate has now reached replacement level, whilstcontraceptive use is considerably higher than in rural areas.Table 1.2 - Fertility and contraceptive usage18 Urban RuralBirths per woman 2.1 4.4MWRA using a modernmethod 56% 33%In some urban areas the disparity is even higher than this suggests. In Kathmandu andBhaktapur for example, the CPR is over 75%. In neighbouring Lalitpur it is 69%.19The clear implication is that population growth in urban areas is not caused by high urbanfertility. It results primarily from rural-to-urban migration. And one of the prime causesof this (though there are many other causes of a trend that is to some extent inevitable asNepal’s economy develops) is overpopulation of rural areas caused by high rural fertility.Paradoxically, therefore, measures limiting rural fertility may yield a greater reduction inurban overcrowding than those targeted at urban residents.In summary, rural couples have an urgent need for limiting methods to help them achievetheir desired family size. Urban couples are now much closer to achieving this objective.18 NDHS (2001)19 DHS (2003) p. 64 Page 15 of 111
  • 16. However, a large proportion of urban youth - as Chart 1.1 showed - are failing almost tothe same degree as their rural counterparts to achieve the interval between births that theywant. And the younger the mother, the more acute the problem - 31% of births towomen aged 15-19 take place within 7-17 months of the preceding birth. This is threetimes higher than the equivalent figure for any other age group.20And this matters not just for the convenience of the mother. Infant mortality where themother is under the age of 20 is 108 per 1,000 live births - 60% higher than that of the20-29 age-group.21 There is no doubt that helping young mothers to space their birthswill save lives.Therefore young spacers in both urban and rural locations are an attractive target market;older limiters in rural areas are another.Recommendation 4: Age 15-24 (spacers); Age 25-39 (limiters)Recommendation 5: Rural and urban (spacers); Rural only (limiters)Variable 6: Level of education (none; primary; some secondary; SLC or above)Most women in Nepal receive little or no education. Despite huge improvement since theearly 1980s, the majority (57.5%) are still illiterate.22Table 1.3 shows (as demographic transition theory predicts) that the fertility rate declinessteeply as the level of a woman’s education increases. Although women with secondaryeducation or above still have an unmet need for spacing, their fertility rates are very closeto replacement level.Table 1.3 - MWRA by education level23 Unmet need for Unmet need No. of MWRA with Level of education % of MWRA Fertility rate spacing for limiting unmet needNone 72% 4.8 10% 19% 908,702Primary 15% 3.2 16% 13% 193,832Some secondary 10% 2.3 17% 8% 104,923SLC or above 4% 2.1 13% 7% 36,606Women with primary level education have the highest level of unmet need of all, at 29%.In contrast to women with no education, their unmet need is biased in favour of spacingrather than limiting. Just 2% of women with no education use contraception to space.2420 NDHS (2001) p. 6221 NDHS (2001)22 CBS (2002)23 CBS (2002); NDHS (2001)24 NDHS (2001) Page 16 of 111
  • 17. Women with an unmet need and primary education or no education are also the largestgroups in absolute terms, numbering 0.2m and 0.9m respectively. Putting all of thesefactors together, they appear to be the most attractive target markets.Recommendation 6: Primary education or no educationVariable 7: ParityNumber of living children is a vital determinant of need for FP products. Unmet need forspacing predominates at parities of 2 of below; limiting becomes much more importantat parities of 2 and above.Table 1.4 - Unmet need by parity25 Number of living Unmet need Unmet need for No. of MWRA with children for spacing limiting unmet need 0 23% 1% 126,627 1 28% 3% 217,718 2 13% 16% 264,579 3 5% 19% 205,669 4 3% 22% 172,270 5 1% 31% 258,142The absolute number of MWRA with unmet need at each parity is relatively even,although because as we have seen spacers and limiters overlap at parity 2, this is wherethe biggest number with unmet need are to be found (0.3m).Recommendation 7: 2 children or fewer (spacers); 2 children or more (limiters)Summary: Profile of target customersPutting each of the 7 recommendations above together yields two distinct potential targetgroups:Table 1.5 - Profile of target customer groups25 Pant (1997), revised 2003 to incorporate NDHS (2001) data; CBS (2002) Page 17 of 111
  • 18. Variable Target Group 1 Target Group 2Marital status Married and unmarried MarriedDesire for more children Spacer LimiterCurrent use of contraception Unmet need Unmet needAge 15-24 25-39Residence Urban and rural Rural onlyEducation level Primary or none Primary or noneParity 2 or below 2 or above2) Reasons for non-use of FP among target segmentsThis section aims to deepen our understanding of the decision making process of womenin the target segments above. We will do this by examining qualitative reasons forcurrent non-use of FP among the target groups, based around PSI’s BCC framework.Primary researchTo complement existing academic literature, PSI commissioned two brief studies ofunmet need in Nepal. Because, as we saw in Chart 1.3, over 90% of people with unmetneed are from rural areas, both studies focused on these communities. One involvedfocus groups with potential FP customers, the other interviews with providers.The methods used by both studies are described below.Primary research methodology - customer focus groupsThe study of customers (from here on referred to as IPED 2003) was carried out by atteam from the Institute for Population, Environment and Development (IPED),coordinated by Mr. Bidhan Acharya, an academic at Tribhuvan University.Focus group discussions were conducted in four VDCs in different parts of Nepal: • Dandabazaar VDC of Dhankuta district (eastern hill), a rural settlement of some 621 households of hill ethnic orign, around 90 minutes drive from Bhedetar on the Dharan-Dhankuta highway. • Aurabani VDC of Sunsari district (eastern terai), a poor rural area of 1,445 households. • Bharatpokhari VDC of Kaski district (western hill), a semi-urban area 13 Kms. south-east of Pokhara. 2,172 non-migrant mid-hill origin households. Page 18 of 111
  • 19. • Jutpani VDC of Chitwan district (central terai), a rural area in the north of the district 10 kms. from Ratnanagar. A majority of the population are migrants of hill origin. 2,557 households.26We decided to include men as well as women (although they are generally not includedin studies of unmet need), given the extent of their influence over FP decisions in Nepal.The aim in each VDC was to select two group of males and two of females, each groupapproximately matching the profile one of the target groups in Table 1.5 above. Thiswas done by asking six questions:Table 1.6 - Questions to select participants for focus group discussionsQuestion Possible answers Status GroupHow old are you? a. 15-24 Selected Not decided yet b. 25-39 Selected Not decided yet c. Others Discarded -Are you currently married? a. Yes Selected Not decided yet b. No Discarded -Are you (or Is your wife) pregnant? a. No Selected Not decided yet b. Yes Discarded - c. Don’t know Discarded -Are you using any kind of a. No Selected Not decided yetcontraceptive? b. Yes Discarded - c. Don’t know Discarded -(15-24) Do you want to delay your a. Yes Selected Selected for Group 1next birth? b. No Discarded -(Limiters are discarded)(25-39) Do you want to have no a. Yes Selected Selected for Group 2more children? b. No Discarded -(Spacers are discarded)On average 9 people took part in each focus group. There were a total of 142 participantsin 16 discussions across the four districts (79 females and 63 males).Primary research methodology - providersResearch among providers was carried out by four MBA students from KathmanduUniversity (from here on referred to as PSI 2003a).The aim was indirectly to get an insight into the decision making processes of a largenumber of customers (in a shorter period of time than it would take to approach themindividually), by talking to people who may have interacted with several hundred overthe course of their careers.26 All household numbers from CBS (2002) Page 19 of 111
  • 20. The research covered five districts, selected to provide some overlap with those of theconsumer researchers. These were: Baglung (western hill), Chitwan (central terai),Dhankuta (eastern hill), Kaski (western hill), and Parbat (western hill). Pairs of studentsspent one week in each area.Interviews were primarily with nurses, doctors, FCHVs, other health workers, and peopleproviding FP counseling services. The organisations they represented included HMG,NGOs such as FPAN and Aama Milan Kendra, and regular pharmacists. A total of 80provider interviews were carried out.PSI’s BCC FrameworkThe rest of this section integrates qualitative findings from both of the above studies withacademic research on unmet need in Nepal, and presents findings around PSI’s “bubbles”framework for BCC (illustrated below). All of the behaviour influences are dealt withhere except for “brand appeal”, which is covered in the next section (“Other Brands”).Chart 1.4 - PSI Behaviour Change Framework27 GOAL HEALTH STATUS QUALITY OF LIFE PURPOSE USE RISK-REDUCING BEHAVIOR NEED OUTPUTS OPPORTUNITY ABILITY MOTIVATION POPULATION CHARACTERISTICS ACTIVITIES PRODUCT PRICE PLACE PROMOTION Opportunity Ability Motivation Social Norms Affordability Awareness of and Support Severity Availability Behavior Personal Risk Awareness of Assessment Causes Outcome Awareness of Brand Appeal Self-Efficacy Expectations Health Problem27 PSI (2003)b Page 20 of 111
  • 21. Particular “bubbles” above take on a special importance in the Nepali context. As weshall see, perhaps the three most important in this market are “outcome expectations”(also known as “Solution Efficacy”), “social norms and support”, and “availability”.1. Opportunitya) AvailabilityTransportationThe most popular FP methods have to be delivered at a health facility. This creates aserious problem of transportation for most Nepalis.NDHS data reveals that the median time users of temporary methods spent travelling toobtain their method was 30 minutes.28 Even in remote areas it did not exceed 1 hour.However a revealing contrast arises between this and the data in Chart 1.5 showing thetime all women in Nepal (users and non-users) take to travel to a health facility.Chart 1.5 - Time taken by women to reach a health facility29 > 1 day 18% < 1 hour 25% 3-4 hours 32% 1-2 hours 25%28 NDHS (2001) p. 87. Surprisingly, this was 30 minutes both for users of condoms (available in retailoutlets and from FCHVs) as it was for injectables (only obtainable from health posts) - though just 20minutes for pills, presumably because of the large number distributed by FCHVs.29 S. Thapa and K.R. Pandey (1994) - Family Planning in Nepal: An update; Journal of Nepal MedicalAssociation 32: 131-143, quoted in Shakya (1999) Page 21 of 111
  • 22. If this study is to be believed, the median time to travel to a health facility is over 2 hours.For nearly 1/5 of women it takes over a day. So the average FP user can get to a healthfacility in half the time it takes the average woman. This implies that distance to a healthpost may be a significant barrier to use.This finding was supported by our primary research. “Availability” was much morecommonly cited as an important factor in FP decision-making by people living in remoteareas. People we surveyed in Pokhara, by contrast, rarely mentioned it, seeming to takeavailability of products for granted.Opening hoursTo compound the problem, many government health facilities have inconvenient openinghours. In Chitwan, we found the National Park Area had a single health post, where ahealth worker attends to patients daily from 10am to 2 pm. This made it difficult forpeople walking from far away to reach the health post before it closed.We also heard reports of government sub-health posts being found closed (sometimes fordays at a time) at times when they were theoretically open, because staff had got boredand gone to take a break in an urban area. It is difficult to tell how widespread thisproblem is however.Even if the health-post is open at the correct time, users in remote areas find it difficult tofind out exactly what the opening hours are supposed to be. They may end up walkingfor several hours, only to find that the weekly clinic does not open that day.FCHVsIn theory, FCHVs are a far more accessible channel, as they operate at a local level. Thisoften works well, though we found several people who viewed them with mistrust, andothers with outright derision. One FCHV in Parbat said some people feel FCHVs are justgiving out product because they have to fulfil their quota for the month.Mrs. Radha Poudel, Nursing Supervisor at the Western Regional Hospital in Pokhara,said that the work done by FCHVs is not properly assessed. Reports they file areapparently taken at face value, making it difficult to gauge their effectiveness. Peopleplanners assume to be using contraceptives may not actually be getting them.So, to summarise, availability is a major factor for some people, and a complete non-issue for others. This depends on where they live, the opening hours of the local healthfacility, how much time they have to spare, the effectiveness of their local FCHV, andother contextual factors such as the vagaries of the local bus timetable. Page 22 of 111
  • 23. 2. Abilitya) AffordabilityOur consumer focus groups found that price was one of the least important considerationsin making contraceptive choices. This may of course be because 80% of contraceptivesupply is still free distribution via government channels, so is not habitually factored intothe decision making process.The following sums up the priorities of most focus group participants: “If methods are found with no side effects we will use them whatever the price. Its a matter of personal health and the next generation.” [Numerous participants in all areas.]Limiters and people from urban areas in particular appear willing to pay for theircontraceptive needs. Many better-off people are unwilling to be seen waiting in line ingovernment hospitals for free products.Many health workers, FCHVs and district hospital employees believed people would bewilling to pay for VSCs. The Chitwan District Hospital even charges a minimum fee forVSC and claim no significant decrease in the number of patients due to charging. Thedestination of the money still officially paid to all VSC participants was not explained.A meeting with 27 FCHVs in Dhankuta revealed much more concern about issues suchas expired pills and inadequate hospital equipment. Price, they said, was of far lesserimportance if quality was maintained.The next section (“Other Brands”) discusses pricing for each separate product in moredetail.b) Self efficacyEmbarrassmentMany providers in our survey commented on the embarrassment people feel inapproaching them for contraceptives. “In my experience of 7 years in this field, only one female has come to buy contraceptives. Usually men come to buy for their wives as well.” [Mr. Arjun Kumar Shrestha, Kusma, Parbat] Page 23 of 111
  • 24. Mr. Arjun’s experience is revealing; many Nepalis are extremely reluctant to approach amember of the opposite sex about contraception. A surprising number of men in ourconsumer survey expressed a strong demand for Male CHVs for precisely this reason.A particular type of embarrassment was also mentioned by several consumers in relationto FCHVs. “The FCHV in my village is my aunt. I know the methods are available from her. I also need them. However, I cant talk about sex and those devices with her. I asked my wife to go to her, but she also does not like to ask for such devices from her. Once I had to ask my wife to ask one of her friends to consult the FCHV. These indirect ways are not always convenient.” [A Brahman man, Dhankuta] “My sister-in-law is an FCHV. I know she distributes condoms, but neither I, nor my wife can ask her for condoms. I have take them from outside.” [A Tamang man, Chitwan]c) Social norms and supportSpousal communication and approvalStudies throughout the world consistently reveal women’s perception of their husband’sattitude to FP to be one of the key predictors of use. Spousal communication is closelylink to this, as women who do not talk to their spouse often assume that he is opposed. AJohn Hopkins University study of IEC strategies to boost FP usage in Nepal found thatspousal communication and approval was the single most important predictor variable.30Amongst limiters, both of our surveys found spousal communication almost universal, asthe decision to stop having children is perceived as a momentous one.Amongst spacers, however, it appears to be less common. A recent survey of marriedurban youth found that 35% of men and 29% of women had never discussedcontraception with their spouse.31 The most commonly cited reason (given by 58% ofmen and women) was simply embarrassment. Spousal communication in this survey wasstrongly correlated with living standards and education levels (the level was much higherin Kathmandu than in other urban locales). This implies that there is likely to be evenless spousal communication amongst rural spacers.30 Storey (2000)31 Aryal (2002) Page 24 of 111
  • 25. This lack of communication is particularly disappointing given the widespread approvalby Nepali men of FP. In fact, in 87% of cases where a woman surveyed by the NDHSbelieved her husband was opposed to FP, he was actually in favour.32Where the husband disapproves of FP, or spousal communication has not taken place atall, secrecy is vital if a woman is to use FP. Many women find injectables, and (to alesser extent) pills useful for this purpose. But secrecy is not always possible. “My husband did not want me to use contraceptives nor did he use. He was so aggressive and completely against contraception. I did not want to have dispute in the family. I did not tell him, and used Sangini [injectible], but my deteriorating health revealed the use of method, for which my husband was furious with me. Out of six, two children died.” [A Magar woman, Kaski]Other relativesAlthough the husband-wife partnership is undoubtedly the most important influence onFP decisions, our two surveys revealed considerable anecdotal evidence about the partplayed by other relatives. “I did want to adopt a permanent surgical method to avert births when I had two daughters. My father ran after me to hit. He wanted to have at least one grand-son. My wife gave birth to one daughter more and finally to a son recently. Now I am prepared to adopt the permanent method.” [A Tamana man, Chitwan]Several young women in our focus groups had been influenced to have more children bytheir mothers and mother-in-laws. “My mother insisted me to have at least a child immediately after marriage. Therefore, I did not even think of using any method for spacing before the first child. She had advised me that a child makes my position strong and permanent in my family.” [A Dalit woman, Dhankuta]In many cases, however, FP is still considered an inappropriate topic of conversation foryoung people to have with their parents (in urban as well as rural areas).Women also commonly discuss FP with their sisters and sister-in-laws.Peer groups32 NDHS (2001) p.100 Page 25 of 111
  • 26. A surprising finding from our customer focus groups was the apparently minimalinfluencing role of peer groups. People did not openly acknowledge, or even to beconsciously aware of, influence from this source.The main influence of peer groups in fact appears to be a negative one. People do notgenerally mention their peers in the context of questions like “who influences yourdecisions regarding FP?”, but it is rare to find someone who cannot recall hearing aboutsomebody in their locality with a dreadful experience of side effects (see below).The pervasive influence of such stories shows the power peer groups could have if usedpositively. Many focus group participants commented after an hour or two of discussingFP with their village peers that they were now more likely to begin using. This is notsomething which government health personnel currently promote, and discussion groupsmay be a productive way to encourage use at a grassroots level.Health workersOur researchers in rural areas found health workers to be important FP influencers.FCHVs travel around their assigned areas (3 VDCs each), counseling women on theadvantages of family planning. Being local, FCHVs are generally trusted by the peoplethey meet.MCH workers also occasionally offer FP counseling to women coming for neo or post-natal care.Son preferenceOur researchers spoke to a Mrs. Chandrakala Rai, a senior FCHV in the region ofPakhribas. She told the story of a woman who had been abused by her husband eversince marriage. Desperate for a son, she so far had 3 daughters. After each birth, herhusband would throw her out of the house. On her eventual return, the man wouldproceed to get her pregnant again, in the hope of producing a son. Each time she boreanother girl, the cycle repeated itself. She is currently pregnant with her fourth child.Son preference arises for a multitude of reasons deeply embedded in Nepal’s culture.One of the most powerful relating to contraceptive use is a woman’s own self-interest.Her status within the household will be boosted by the birth of sons.Male son preference is often motivated by concern for their family’s wellbeing as well asmore symbolic reasons like continuation of the family name. In the words of onepolygamous rural man in Chitwan: Page 26 of 111
  • 27. “My [youngest] wife should not suffer because of my financial problems now, or because of my wishes. If I prevented her from having sons because of my current financial difficulties, then I would leave her with no recourse later, and with no means of support. This is traditional practice here. It came down from the time of our ancestors. If I did not allow at least one son to be born to each woman, I am certain to bathe in hell.”33Table 1.7 shows in detail the effect of son preference on contraceptive use. The data isbased on the principle of deriving a hypothetical level of contraceptive use in the absenceof any son preference. This hypothetical level is found by looking at the rate ofcontraceptive use of women with 1 boy at parity 1, 2 boys at parities 2 and 3, and 3 boysat parity 4. The final column states the net effect of son preference - ie. the % differencebetween actual use at a particular parity and expected use in the absence of sonpreference.Table 1.7 - Impact of son preference on contraceptive use34 Parity and no. of Contraceptive use without Actual contraceptive Effect of son sons son preference (%) use (%) preferenceAll 33 25 -24%Parity 0 3 3 0%Parity 1 0 14 11 -22% 1 14 14 0%Parity 2 0 44 17 -62% 1 44 27 -39% 2 44 44 0%Parity 3 0 49 6 -88% 1 49 29 -42% 2 49 49 0% 3 49 44 -11%Parity 4 0 46 14 -69% 1 46 22 -52% 2 46 43 -7% 3 46 46 0% 4 46 43 -8%33 Quoted in Stash (1999)34 Leone et al (2003). The study was based on data from the 1996 NDHS. Page 27 of 111
  • 28. For example, a woman at parity three with two sons and one daughter is assumed not toexhibit son preference. Usage of contraception amongst this group is 49%. So, in theabsence of son preference, we would expect 49% of women at parity 3 to be using. Infact, of women at parity 3 with no sons, contraceptive usage is just 6%. In other words,contraceptive use declines by 88% for these people as a result of son preference.The overall effect of son preference is that contraceptive prevalence in Nepal is some24% lower than it otherwise would be. The effect is particularly acute for couples atparities 2 and above with one son or no sons.A qualitative study of 98 couples with unmet need in Chitwan found that women wereparticularly susceptible to the influence of their husbands on this issue. Even womenwith a clear desire to bear no more children tended to give in to their husbands whenhaving more sons was at stake.35 The study included the following exchange between anewly married woman and her childless sister-in-law: Bride: People around here, in this village, if you don’t have babies, they say, “Get rid of her! She won’t have children!” Sister-in-law (laughing): Oh, that’s what they say! Bride: [They say,] “He’ll bring another wife. He’ll bring her to the house, and you two wives will fight.” That’s why women try to have their babies fast. Do you understand?” Sister-in-law: This one will have a son soon; really, she will. Bride: If I say I will have a baby 2 or 3 years from now, they’ll say, “Bring another wife! This one is no good! She is spoiled! She won’t have any sons! Send her running!” That is what they’ll say.ReligionOur research overall found that religion is no longer a major barrier to the spread of FP inNepal. However, certain traditional beliefs were still encountered.Some Brahmins, for example, apparently believe that VSC prevents a person fromreaching heaven. In Dhankuta, our researchers learned about a tribe of Rais whomaintain traditional beliefs forbidding any form of FP. Despite this, some of theirwomen apparently sneak into district hospitals to get their injectibles every three months.3. Motivation35 Stash (1999) Page 28 of 111
  • 29. a) Awareness of problem, causes and severityNepalis appreciate in abstract the difficulties associated with having a large family. Theyobviously realise too the mechanism by which a large family comes to exist. But theyoften do not regard the problem as being acute enough to tackle now, today.In particular, there is reluctance to experience economic loss today for the sake of someabstract, long-term benefit. This economic loss is not confined to the charges (if any) forFP products. More significant is the opportunity cost - what people think they will haveto forego in order to adopt FP.Many people in rural areas need to undertake long hours of strenuous manual work eachday in order to survive. This makes the side effects of contraception far more costly thanjust physical unpleasantness. If there is a risk of missing a day in the field then thepotential cost of FP use is extremely high. And there is little confidence in thewillingness of government providers to take care of women should such problems arise.This is appears to be supported by other research into unmet need.36b) Personal risk assessmentThe most common reason for low personal risk assessment is that the woman’s husbandis an absent migrant worker. This is becoming increasingly common in Nepal, as moremen travel to India and the Middle East to earn a living.This results in a serious dilemma for many women. Because of their low personal riskassessment, they see little point in the hassle and side effects of chemical methods. Ourresearchers also found that their husbands generally oppose use during their absence,fearing this may incite their wife to promiscuity (apparently not an entirely baseless fear -our team heard several stories of pregnancies during a husband’s absence).But if the woman chooses for these reasons not to use, then she risks pregnancy on herhusband’s return (assuming, as is likely, they do not condoms).Most women in this position appear to opt for non-use. Temporary methods are eithertoo much hassle (pills), or protect them (and hence expose them to side effects) for anunnecessarily long period (3-month injectable, IUD, Norplant).c) Solution efficacy36 eg. Stash (1999) - “The perceived potential for sizeable indirect costs associated with illness and loss ofwork served as major explanations for unmet need.” Page 29 of 111
  • 30. Side effectsSide effects were the overwhelming reason for non-use amongst our consumer focusgroup participants. Even young never-users had generally already heard about the badexperiences of their older peers.It is important we do not dismiss stories about side effects as groundless rumour forsocial marketers to dispel heroically. Many of the most pervasive are well grounded inmedical reality. “I had used Sangini (the injectible) for four years. I had not menstruated during the period of use. I discontinued using this method some six months ago. I am not even menstruating yet. This is not just my story. There are a number of sisters facing this problem in my village.” [A Tharu woman, Sunsari] “My friend had used injectible for spacing just after the marriage, but she did not conceive even after she discontinued the method. We don’t know the reason in details, but we fear that using injectibles and oral pills might result in sterility among women. Therefore, many women in my village do not approve such methods.” [A Magar woman, Chitwan. Echoed by several other participants.]Both stories show the potentially devastating effects not of injectable contraceptives, butof inadequate counselling.The first woman should have been warned in advance about the potential consequencesof Sangini for her menstrual cycle, and offered an alternative method when the problemsfailed to stabilise after the first few weeks. She should never have had to continuesuffering for four years, before giving up completely.The second story again shows the distress caused by lack of information about a perfectlynormal consequence of injectable use (a period of infertility up to 9 months after the lastinjection is expected, and women have a right to know this in advance). Had the womanbeen told about this, she would presumably either have opted for another method, or notbeen distressed when the problem arose. Instead, the idea that Sangini causes infertilityspread throughout her community. The fear then naturally began to extend to otherchemical methods.This is the mechanism by which side effects have come to be the biggest single reason forunmet need. Inadequate screening and counselling leads to side effects that are moresevere, or more prolonged, or less expected or understood than they need to be. Andwomen working with friends in the fields of Nepal do not suffer in silence. The storyspreads, and contraception rapidly becomes something to be feared. Page 30 of 111
  • 31. This is what leads to the widespread phenomenon of clustering of particular methods insmall geographical areas. Sharon Stash (1999) mapped contraceptive use in 3 villagesites, and found distinct clusters of households where sterilisation, injectables, orcomplete non-use was the order of the day. As we shall see in the “Other Brands”section, similar patterns occur at a macro level, different districts opting for a surprisinglydiverse mixture of methods.Of course, not all stories of side effects are grounded in reality. A popular (and, for men,convenient) misconception in Nepal is that vasectomies cause several days of weakness.The “No Scalpel Vasectomy” (NSV) method now used in Nepal very rarely has thiseffect, yet still this is the most commonly cited reason for non-use. “I had severe side effects from pills and injectibles. My husband is a wage labourer and I did not want him to go for a vasectomy because of a fear that he might be weak after the operation. Therefore, I wanted to shift to permanent method myself; but my husband suspected that if I have that method adopted I might sleep with others in the village and he refused. I don’t know what to do. Is there any method that makes my life easier?” [A Tamang woman, Chitwan]37Such beliefs cause understandable frustration to providers. In Dhankuta, Ms.Bal KumariTamang of the district hospital complained that some women blame all their medicalproblems on contraceptives. She apparently finds it difficult to convince women thattheir ailments are caused by anything other than contraceptives.38Nonetheless, no IEC campaign should attempt to tackle the effects (fear of side effects)without addressing the cause (inadequate counselling). To do so would be to risk acatastrophic loss of credibility. Supply-side improvements are the most important singlestep that can be taken towards removing side effects as a barrier to take-up and continueduse of contraception in Nepal.Range of products availablePredictably enough, women in our focus groups complained that in addition to all theirother burdens they were also expected to assume responsibility for contraception. Thesurprising finding was the number of men (in separate focus groups) who agreed, andcomplained that there were not more male methods. “My wife is suffering from side effects of injectibles. I have only one child and wanted a vasectomy, but my wife wants to have at least one more. Using a condom is clumsy. Once a chicken found it and played in37 IPED (2003)38 PSI (2003)a Page 31 of 111
  • 32. the yard in front of parents and others. Storage and disposal of condoms is also problematic. My wifes body is not ready for further use of pills and injectibles. Instead, I am ready to use if male oral pills are available in the market.” [A Brahman man in Kaski]39C. Ranking of key influencing factorsIt may be interesting to learn about the extraordinary diversity of factors influencingdecisions of people with unmet need, but it can also be confusing. Marketers need notonly to understand the full range of influences on customers, but also how differentfactors directly related to marketing mix decisions stack up in order of importance.So in addition to qualitative focus group discussions and individual interviews, ourresearchers introduced a quantitative element. Customers and providers were given fiveseparate sets of playing cards. Each set contained cards relating to one of five categoriesof interest to social marketers (reasons for non-use, influencers, marketing mix, productattributes, and place). Each individual card was labelled with one factor relating to aparticular category. Subjects were then asked to rank the cards in order of preference,omitting any they did not feel were relevant.Table 1.8 summarises all of the findings from this exercise. It lists factors in order ofimportance, judged by their aggregate score. This was calculated by assigning 1 point toa first preference, ½ a point to a 2nd preference, 1/3 of a point to a 3rd preference, etc., andadding the points to derive a single composite figure reflecting both the number of timesa particular factor was mentioned and the rank it was assigned.Alongside the aggregate score from consumer focus groups, the table also gives theprovider score (provider opinions of consumer preferences, not providers’ personalopinions), and a breakdown of the aggregate consumer score into male and femalespacers and limiters. To make the results clearer, and because of the small sample size,only the top 3 preferences of each such subgroup have been given. To give an idea of therelative importance of the top 3 preferences, the actual score for each subgroup is given,rather than a simple 1-3 ranking.Table 1.8 - Summary of customer preference ranking4039 IPED (2003)40 IPED (2003); PSI (2003)a Page 32 of 111
  • 33. All Female Male Female Category Factor All consumers Male spacers providers spacers limiters limiters Fear of side effects 66 51 7 21 15 24 Spouse disapproves 24 41 9 Low risk of pregnancy 24 15 9 6 No suitable product 23 21 10 Want more children 22 12 7 7 Reasons for Lack of knowledge 18 55 8 non-use Risk of losing child 11 19 6 Unaware of true cost 6 20 Embarrassment 5 33 Religious prohibition 4 17 No friends use 2 21 Husband or wife 90 91 15 21 25 30 Self 42 - 13 14 9 6 Mother-in-law 13 25 6 5 Influencers Other relatives 9 22 2 Health workers 9 55 Friends / peers 6 55 4 Product is effective 101 77 19 28 25 29 Marketing Trusted source 62 48 15 17 15 15 mix Easily accessible 51 70 9 19 10 13 Reasonably priced 28 37 Few side effects 90 52 12 33 18 27 Easy to use 82 79 19 24 20 Product Reliability / quality 68 53 19 19 20 attributes Prevents disease 67 39 24 24 Attractive image 12 24 FCHVs 98 55 14 33 23 29 Gvt. health post 82 85 18 21 19 24 Place Pharmacy 45 54 10 13 10 13 General store 29 20Reasons for non-useAs expected, fear of side effects tops the ranking by some distance. But some revealingdifferences emerge between the various sub-groups.Providers are acutely aware of consumer ignorance, and rank lack of knowledge as beingthe most important reason for non-use. Male spacers, however, were the only consumergroup to include this in their top 3.Side effects are important to all 4 consumer sub-groups, but their relative importance isfar greater for women than for men - presumably because they tend to be the ones whoactually endure the side effects. Male spacers, for whom condoms are the only option,were the only sub-group not to rank side effects as their top reason for non-use. Page 33 of 111
  • 34. Surprisingly, the only sub-group to give a top-3 ranking to spousal disapproval was malelimiters. These turned out to be men who wanted their wives to have minilap operations,but whose wives were not keen on the idea.Both spacer groups included “want more children” in their top 3. In the light of previousstudies, this result was to be expected. One such study found that 47% of women with anunmet need for spacing gave desire for more children as their primary reason for non-use(the same study found fear of side effects to be the overwhelming reason for unmet needfor limiting).41This may be linked to the history of FP in Nepal. Even as recently as 1996, 80% of FPusers had been sterilised. Many people still appear to equate “contraception” with“sterilisation”. Even among people using temporary methods, the vast majority are usingto limit rather than to space (88% of Norplant and IUD users, 74% of Depo users, and77% of OC users are using to limit, according to a recent survey42). The standard patternof contraceptive use is still to begin only when desired parity has been reached.InfluencersThe spouse emerged as by far the most important influencer on FP decisions overall. Theonly other relative playing a significant role was the mother-in-law, though theirinfluence appears to extend only to women.Providers considered themselves and peer groups to be important influencers, though fewcustomers mentioned these.Marketing mixA fairly clear picture emerged across customer groups on the most important elements ofthe marketing mix. Top by some distance was an effective product, followed by a trustedsource. Price for all groups was considered the least important factor.The only divergence was that female spacers appeared relatively more concerned aboutaccessibility than the 3 other groups. This may be because many in this age range (15-24) are nursing young children, and so find it hard to travel long distances.Product attributesClear differences emerged here between the sexes.41 Aryal (1997)42 Pradhan et al (2003) Page 34 of 111
  • 35. Men, perhaps aware of difficulties with the only temporary method available to them(condoms) cited ease of use as the most important attribute, followed closely byreliability.By contrast, women were most concerned that a product carried few side effects. Asurprisingly high proportion of female spacers and limiters also ranked prevention ofdisease as a key attribute.PlaceFCHVs and government health posts were the most popular choices of contraceptivesource, though the enthusiasm of males, and in particular young males, for FCHVs wasmore limited, perhaps because of the embarrassment factor we encountered in our focusgroups.A stark contrast emerges between this data on where non-users would like to get theircontraception, and where people who do use actually obtain supplies. FCHVs in practiceaccount for just 1.7% of all contraceptive supply.43 This suggests that if FCHVdistribution were to be scaled up, non-users may start to use, as a source more to theirliking became available.43 NDHS (2001) Page 35 of 111
  • 36. Part Two - Other BrandsThe aim of this section is to identify areas in which the largest groups of people with anunmet need for FP identified in Part One - 15-24 year old spacers and 25-39 year oldrural limiters - are currently being inadequately provided for.It is possible, for example, that products currently available in the market do not have theblend of attributes target customers require, or are not available in certain areas ordistribution outlets, or priced unrealistically. Equally, it is important to identify areaswhere provision is already more than adequate.The section has three main parts:1. Trend in use of different product categories2. Geographical “Gaps” in the market3. Detailed information on each product type, including: 1. Strengths and weaknesses 2. Sales levels and market share for each major brand 3. The price charged by each major brand 4. Key distribution channels used by each brand 5. The current positioning strategy of each brandThe product categories covered are: • VSC • 3-Month Injectables • Pills • Condoms • IUD • Norplant • Pregnancy test kits.In the light of this information, any current or emerging “gaps” in the market - areaswhere the needs of the major target segments are not being adequately met - shouldbecome clear.1. Trend in use of different product categories Page 36 of 111
  • 37. This section aims to give a high-level account of the relative popularity of differentmethod types available in Nepal, and recent trends in their usage rates.60% of all modern method users in Nepal are people who have been sterilised. Thehistoric domination of FP by permanent methods (in part because of money paid by thegovernment to clients and providers - see below) has over time led to the relative neglectof people who want to space: ¾ of their overall need is unmet, whilst the equivalentfigure for limiters is less than 1/3. 44Chart 2.1 shows the current split between all modern method users.Chart 2.1 - Breakdown of FP users by method45 IUD, 1% Norplant, 2% Condom, 8% Female VSC, Injectables, 24% 42% Pill, 5% Male VSC, 18%But the dominance of sterilisation is rapidly being eroded - a trend that has acceleratedmarkedly over the last decade. In 1991, over 80% of all modern method users had beensterilised; now, as we have seen, the proportion is much smaller.Chart 2.2 shows the changing method mix since the 1976 Nepal Fertility Survey.44 Pant (1997), updated with figures from NDHS (2001)45 NDHS (2001) Page 37 of 111
  • 38. Chart 2.2 - method mix in Nepal, 1976-2001 46 Method mix 18 Female 16 VSC 14 % non-pregnant MWRA 12 Injectables 10 8 Male VSC 6 4 Condom Pill 2 Norplant IUD 0 1976 1981 1986 1991 1996 2001Future intentionsThe 2001 NDHS asked married women non-users to specify which method, if any, theyintended to take up in future. Table 2.1 shows the answers to this question given by thetwo target age groups highlighted in Part One, split out by ecological zone.Table 2.1 - % of non-using MWRA intending to use47 Mountain Hill Terai 15-24 25-49 Total 15-24 25-49 Total 15-24 25-49 TotalFemale Sterilization 15 9 12 19 19 19 50 43 47Male Sterilization 12 7 9 14 14 14 3 4 3Injections 37 48 43 26 30 28 24 27 25Pill 12 12 12 8 10 9 6 9 7Condom 1 1 1 2 2 2 1 2 1Norplant 5 4 5 4 3 4 2 4 3IUD 1 1 1 2 1 1 1 1 1Other / dont know 18 19 18 26 21 23 13 11 12Total 100 100 100 100 100 100 100 100 10046 1976 Nepal Fertility Survey; 1981 Nepal Contraceptive Prevalence Survey; 1986 & 1991 Nepal Fertilityand Family Planning Survey; 1996 Nepal Family Health Survey; 2001 NDHS; all quoted in MOPE (2002)47 NDHS (2001). Note that these figures understate the likely future popularity of condoms, as the sampledrespondents were women only. Page 38 of 111
  • 39. This shows that the trend towards injectables is likely to continue - they are a morepopular method for future use than even female sterilisation in hill and, particularly,mountain regions. Mountain regions also look set to overturn their traditional preferencefor male over female sterilisation.The aversion to vasectomies in the terai looks set to continue, with female sterilisation amore popular method for future use than any other, though injectables are not far behind.This shows considerable growth potential for injectables in the terai, where currently lessthan 9% of MWRA use depo.ConclusionsClearly the main reason for the erosion of share of VSC has been the rapid rise since thelate 1980s of the 3-month injectable. None of the other 4 temporary methods available inNepal have shown anything like the same surge in popularity - around 1998, injectablesovertook male VSC as Nepal’s second most popular method.At the same time, whilst vasectomies have stagnated since the late 1980s, there has beena consistent increase in the proportion of MWRA relying on the most popular method ofall, female VSC.Non-users’ intended methods for future use suggest the dominance of female sterilisationand depo are set to continue.2. Geographical gaps in the marketThis section identifies districts offering the greatest untapped opportunity for new FPproducts. To do this, we will take three factors into account: • Proportion of MWRA currently using a modern temporary method • Proportion of MWRA belonging to a couple practising VSC (male or female) • Addressable market size.Why are these factors important?The proportion of MWRA currently using contraception indicates the size andeffectiveness of ongoing FP programmes in each district48. By separating temporary andpermanent methods we also see the method type that has so far been focused on by theseprogrammes.48 It is not the whole story however. A district (such as Kathmandu) containing an exceptionally largeproportion of people with a demographic profile lending itself to high FP use will have a higher proportionof users. This means the district must have a large FP programme, but does not necessarily give anindication of its effectiveness. Page 39 of 111
  • 40. A high proportion of MWRA currently using suggests that customers most amenable toFP are already being provided for. This is likely to make winning new users morechallenging than in a district where the proportion of current users is low. So, otherthings being equal, it is better to target a programme at a district with a lower proportionof current users, even if the number of non-users is the same in both districts.For a social marketing organisation aiming to grow the user base than win share fromexisting providers, the addressable market for FP in a given district comprises all MWRAwho are not currently using a modern method. Economies of scale make this animportant variable for potential providers. Given the costs involved in setting up a newprogramme in a particular district, as many potential clients as possible should lie withineasy reach. A district may have a tiny proportion of current users, but if only 1,000people live there it is difficult to justify the cost involved in setting up a programme.Chart 2.3 illustrates these three factors for each of Nepal’s 75 districts:Chart 2.3 - Underserved districts in Nepal, July 200249 (area of each bubble is proportional to addressable market size) 50% Kathmandu Dhankuta 40% Kapilvastu % MWRA using temporary Baglung 30% Kaski Chitawan 20% 10% 0% 0% 5% 10% 15% 20% 25% 30% 35% 40% % MWRA using VSC Terai Hill MountainThe most attractive districts on the chart are represented by large bubbles in the bottomleft-hand corner50 - in other words, big addressable markets with currently very small FP49 DHS (2003): CBS (2002) Page 40 of 111
  • 41. programmes. Table 2.1 lists the 16 districts in the bottom left-hand corner in order ofbubble size (ie. number of non-using MWRA).Table 2.2: Nepal’s most attractive districts for FP? Temporary / MWRA using no District Region Ecological Zone VSC / MWRA MWRA methodKapilvastu Western Terai 10% 9% 77,857Gulmi Western Hill 14% 8% 46,635Achham Far-Western Hill 5% 7% 41,406Baitadi Far-Western Hill 7% 7% 39,715Arghakhanchi Western Hill 13% 7% 34,046Rolpa Mid-Western Hill 7% 11% 34,016Doti Far-Western Hill 9% 13% 33,279Khotang Eastern Hill 6% 11% 32,811Bajhang Far-Western Mountain 8% 5% 30,823Jajarkot Mid-Western Hill 9% 8% 22,874Darchula Far-Western Mountain 8% 4% 22,354Dadeldhura Far-Western Hill 12% 12% 18,946Bajura Far-Western Mountain 9% 7% 16,793Humla Mid-Western Mountain 10% 9% 6,004Mugu Mid-Western Mountain 11% 7% 4,945Dolpa Mid-Western Mountain 9% 8% 3,393Total 465,897But there are several problems with this list. Most are mid and far-western hill andmountain districts, which may pose problems with distribution due to harsh terrain orMaoists. More serious still is the fact that their addressable markets are relatively small(an average of 29,000 MWRA non-users per district).A better approach is to focus on districts with a high population of non-using MWRA andan exceptionally low proportion of either temporary or VSC users - in other wordsdistricts lying below the horizontal line in Chart 2.1, or to the left of the vertical line.Table 2.2 lists the top ten of 37 districts in the former category (below the horizontal linein Chart 2.1), and Table 2.3 lists districts to the left of the vertical line - ie. districts withan exceptionally low proportion of VSC users.Table 2.3 - districts with an exceptionally low proportion of temporary users50 The definition of “bottom left-hand corner” used here is to the left of the vertical line and below thehorizontal line - ie. less than 15% of MWRA use VSC and less than 15% use temporary methods. Theexact position of the two lines is arbitrary. Page 41 of 111
  • 42. Temporary / MWRA using no District Region Ecological Zone VSC / MWRA MWRA methodBara Central Terai 22% 4% 84,476Sarlahi Central Terai 29% 6% 84,387Rautahat Central Terai 22% 4% 83,055Mahottari Central Terai 28% 2% 79,924Siraha Eastern Terai 26% 9% 78,368Dhanusha Central Terai 36% 6% 78,206Kapilvastu Western Terai 10% 9% 77,857Nawalparasi Western Terai 28% 10% 73,774Saptari Eastern Terai 29% 10% 72,015Parsa Central Terai 32% 7% 62,814Total top 10 774,876Total other (27 districts) 954,352Overall total 1,729,228Table 2.4 - districts with an exceptionally low proportion of permanent users Temporary / MWRA using no District Region Ecological Zone VSC / MWRA MWRA methodKapilvastu Western Terai 10.0% 9.1% 77,857Gulmi Western Hill 14.4% 7.6% 46,635Dhading Central Hill 11.9% 16.5% 46,234Achham Far-Western Hill 5.2% 7.2% 41,406Baitadi Far-Western Hill 7.4% 7.4% 39,715Udayapur Eastern Hill 14.6% 16.0% 36,833Arghakhanchi Western Hill 12.7% 6.8% 34,046Rolpa Mid-Western Hill 7.3% 11.2% 34,016Doti Far-Western Hill 8.6% 13.0% 33,279Khotang Eastern Hill 6.4% 11.2% 32,811Total top 10 422,832Total other (21 districts) 384,012Overall total 806,844A similar approach can be used for each individual method. In Salyan district, forexample, 34% of MWRA use Depo, so any new introduction of a 3-month injectablethere would probably steal share from existing providers. It makes more sense to targetdistricts where an exceptionally low proportion currently use a particular method, butwhere there is also a large absolute number of MWRA non-users.So Table 2.5 runs through each temporary method, and for each identifies the ten districtsin Nepal where the lowest proportion of MWRA are using that particular method.Districts are again listed in descending order of MWRA non-users.Table 2.5 - Districts for with the lowest proportion of MWRA using each temporary method5151 DHS (2003); CBS (2002) Page 42 of 111
  • 43. Users of each Number of MWRA Rank District Region Ecological Zone method using no method Condoms Condom users / MWRA 1 Bara Central Terai 1.2% 84,476 2 Rautahat Central Terai 1.0% 83,055 3 Mahottari Central Terai 0.4% 79,924 4 Kathmandu Central Hill 1.0% 78,178 5 Gorkha Western Hill 1.1% 39,425 6 Sindhuli Central Hill 0.7% 36,668 7 Sindhupalchok Central Mountain 1.2% 34,143 8 Lalitpur Central Hill 1.0% 23,523 9 Jajarkot Mid-Western Hill 1.0% 22,874 10 Bhaktapur Central Hill 0.8% 12,940 Depo Depo users / MWRA 1 Bara Central Terai 2.5% 84,476 2 Sarlahi Central Terai 3.0% 84,387 3 Rautahat Central Terai 2.2% 83,055 4 Mahottari Central Terai 1.6% 79,924 5 Syangja Western Hill 2.9% 45,791 6 Arghakhanchi Western Hill 3.2% 34,046 7 Bajhang Far-Western Mountain 2.8% 30,823 8 Darchula Far-Western Mountain 1.1% 22,354 9 Jumla Mid-Western Mountain 3.7% 10,603 10 Dolpa Mid-Western Mountain 3.5% 3,393 Pill Pill users / MWRA 1 Bara Central Terai 0.5% 84,476 2 Mahottari Central Terai 0.3% 79,924 3 Siraha Eastern Terai 0.6% 78,368 4 Dhanusha Central Terai 0.4% 78,206 5 Nawalparasi Western Terai 0.7% 73,774 6 Parsa Central Terai 0.3% 62,814 7 Tanahun Western Hill 0.1% 47,705 8 Ramechhap Central Hill 0.8% 27,826 9 Jumla Mid-Western Mountain 0.5% 10,603 10 Mugu Mid-Western Mountain 0.6% 4,945 IUD + Norplant IUD + Norplant users / MWRA 1 Bara Central Terai 0.0% 84,476 2 Bajhang Far-Western Mountain 0.0% 30,823 3 Parbat Western Hill 0.0% 24,121 4 Jajarkot Mid-Western Hill 0.0% 22,874 5 Darchula Far-Western Mountain 0.0% 22,354 6 Bajura Far-Western Mountain 0.0% 16,793 7 Jumla Mid-Western Mountain 0.0% 10,603 8 Humla Mid-Western Mountain 0.0% 6,004 9 Mugu Mid-Western Mountain 0.0% 4,945 10 Dolpa Mid-Western Mountain 0.0% 3,393Table 2.6 gives more analysis of which specific districts are the most attractive for eachproduct. It shows the number of districts in which the proportion of MWRA using eachmethod falls within a particular range, and the absolute number of MWRA non-usersliving in all of these districts. For female VSC, for example, although there are 20districts where over 15% of MWRA are current users, there are another 21 where lessthan 1% of MWRA use. This information should help in selecting specific districts forspecific programmes promoting specific methods. Page 43 of 111
  • 44. Table 2.6 - Distribution of districts by % MWRA using each method52 % MWRA using each Condom Depo Pill IUD+Norplant Male VSC Female VSC method Number of districts <1% 5 0 17 51 4 21 1% - 2% 33 2 24 15 4 5 2% - 5% 29 22 24 6 10 7 5% - 10% 7 18 8 2 32 14 10% - 15% 1 16 2 1 18 8 > 15% 0 17 0 0 7 20 How many MWRA currently using no method live in the above districts? <1% 290,765 0 846,794 1,830,505 312,851 421,581 1% - 2% 1,378,202 102,278 904,109 552,346 329,160 109,051 2% - 5% 932,496 945,180 751,323 231,698 545,464 182,949 5% - 10% 132,777 658,478 189,721 55,310 992,703 464,230 10% - 15% 13,797 626,429 56,090 78,178 446,565 326,741 > 15% 0 415,672 0 0 121,294 1,243,485ConclusionsThis presents two stark alternative geographical target markets.The most distinctive feature of the tables is that all of the 10 biggest53 districts with anexceptionally low proportion of temporary method users are in the Terai, and all but oneof those with an exceptionally low proportion of permanent users are in Hill areas.When we drill down into each individual temporary method, three district names seem tocrop up again and again: Bara, Rautahat, Mahottari. These and other large terai districtsare potentially a very attractive market for temporary methods, targeted primarily atwomen with an unmet need for limiting, as an alternative to sterilisation.Likewise, large hill districts where access to VSC has so far been limited are an attractivetarget market for minilap and NSV services.3. Detailed information on each product type52 DHS (2003); CBS (2002)53 “Biggest” here meaning “having the highest number of MWRA non-users of any method” Page 44 of 111
  • 45. 3.1 Voluntary Surgical Contraception (VSC)a) Strengths and weaknessesIn the Nepali context, VSC has several important strengths. For the consumer it requires- unlike temporary methods - only a few days of inconvenience in return for a lifetime ofcoverage. For providers, it requires seeing each individual only once, and has none of thesupply problems associated with moving physical product across Nepal’s unreliable roadnetwork.However, male VSC can be an unreliable method, particularly if clients are not told aboutthe need to use condoms for several weeks after the operation, during which there is stilla significant risk of pregnancy. Female VSC (now almost always “minilap” in Nepal, themore expensive “laposcropy” method having been phased out by the government) isalmost 100% reliable, but side effects are more common.As we saw in Part One, misconceptions about side effects are also very common. Thepopular belief that NSV (the main male method used in Nepal) leads to several days ofweakness means provision of VSC in Nepal is highly seasonal. Very few people get theoperation done in the busy summer months where the agricultural workload is heavy.There are also concerns about the risk of infection in hot weather. The vast majority waituntil winter for their operation.b) Sales levels and market shareFor each product type we will contrast two alternative forms of measurement: The “top-down” approach of the NDHS, derived from surveying consumers, and the “bottom-up”approach of adding up distribution figures claimed or forecasted by the various providers.“Top-down”Despite the boom in the NGO sector since the early 1990s, HMG is still responsible foraround 80% of VSC provision for both sexes. Chart 3.1 shows the split by channel andprovider.Chart 2.4 - Market share of providers of VSC54 Female Male54 NDHS 2001 Page 45 of 111
  • 46. Providers of Male VSC Providers of Female VSC Other Government Other 15% hospital, clinic 13% FPAN 28% FPAN Government 7% 5% hospital, clinic 41% Mobile camp Mobile camp 41% 50%“Other” here includes other NGOs, private clinics, other types of government healthcentre, and 4.4% of male respondents who did not know who had given them theirvasectomy. It also includes an 6% of female respondents classified as none of the above;these could be women who got the operation abroad, or may simply be a balancing figureinserted to make the numbers sum to 100%.“Bottom-up”Table 2.7 shows results of the alternative approach of adding up each provider’sstatistics. In the absence of data on “other” providers, a 5% share for each method hasbeen assumed.Table 2.7 - Reported number of operations carried out by VSC providers, 1998-20025555 DHS (2002); DHS (2003); NDHS (2001); Data provided directly by FPAN, 8 July 2003. Wheregovernment data is in Nepali years an average has been taken to convert to western calendar years. Eg.calendar year 2000 = average of 2056/57 and 2057/58 Page 46 of 111
  • 47. Method Provider 1998 1999 2000 2001 2002Male VSC Government 18,456 19,615 21,834 21,354 19,813 market share 79% 82% 83% 84% 85% FPAN 3,837 3,303 3,093 2,802 2,383 market share 16% 14% 12% 11% 10% Other (estimate) 1,115 1,146 1,246 1,208 1,110 Total 23,408 24,063 26,173 25,363 23,306Female VSC Government 45,976 47,726 50,340 51,172 51,139 market share 89% 89% 91% 93% 93% FPAN 3,205 3,493 2,188 953 1,093 market share 6% 6% 4% 2% 2% Other (estimate) 2,459 2,561 2,626 2,606 2,612 Total 51,640 53,779 55,154 54,731 54,844All VSC Market size 75,048 77,843 81,327 80,095 78,149 Annual growth 0.1% 3.7% 4.5% -1.5% -2.4%LessonsThe main message from table 3.1 is the marked decline of the importance of the FPAN asa provider of VSC over recent years. Its female VSC provision had fallen by 2002 to lessthan a third of 1998 levels, whilst its share of vasectomy operations (traditionally an areaof focus for FPAN) was heading inexorably towards single figures. FPAN now runsVSC in just three clinics in Nepal, each in urban areas (in Kathmandu, Chitawan, andSunsari districts). It has not run any mobile VSC camps since 1998.56Comparison with the top-down data suggests the FPANs share may in fact be marginallyhigher in female VSC and marginally lower in male, though it is difficult to see why theNDHS numbers would be overstating government provision for one method andunderstating it for the other.Either way, the message from both data sets is that for good or ill the government is leftwith a virtual monopoly in both methods, and the trend towards government dominance56 Interview with Dr. Giridhari Sharma Paudel, Programme Manager, FPAN, 4 July 2003 Page 47 of 111
  • 48. is set to continue, particularly in the light of FPANs current funding difficulties (seesection 3).VSC is the only method where very distinct differences exist between Nepal’s threeecological zones. Chart 2.5 shows how male VSC is the dominant method in mountainregions, whilst female VSC is almost the only permanent method of choice in the terai.Chart 2.5 - Male vs. female VSC by ecological zone57 30.0% 25.0% 20.0% % MWRA Female VSC 15.0% 22.3% 7.8% Male VSC 2.1% 10.0% 5.0% 11.0% 9.8% 3.9% 0.0% Mountain Hill TeraiCurrent VSC programmes are clearly operating on a far larger scale in the lowland areasof Nepal. There may also be cultural biases in different ecological zones that favourfemale VSC over male in the terai, and the reverse in mountain regions.The trend over time in VSC has been somewhat erratic. Table 2.8 shows the growth rateof all VSC operations from 1999-2002.Table 2.8 - growth rate in VSC operations by ecological zone5857 CBS (2002); DHS (2003). The chart includes government operations only.58 DHS (2002); DHS (2003) Page 48 of 111
  • 49. 1999-00 2000-01 2001-02Mountain 8% 4% -2%Hill 6% 4% -1%Terai 6% 10% 3%Nepal total 6% 8% 2%Supply rather than demand is the main driver of this. The government was pushing VSCaggressively in 1999-2000, whilst sluggish economic performance and the Maoistinsurgency restricted the programme in 2001-02, particularly in hill and mountainregions.b) PriceThe “price” for VSC in Nepal has traditionally been negative - in other words, people getpaid.The MOH began providing financial incentives in 1979, when it introduced a payment ofRs. 68 per client, to be split between the different categories of service provider involved(doctors, nurses, field workers).In addition, the MOH paid Rs. 100 directly to each client, as compensation for lost worktime and travel expenses. These compensatory payments were stopped on anexperimental basis from 1991 in a minority of districts, but reintroduced in 1994.59MSI charge a nominal amount for VSC, but they operate in predominantly urban areaswith a wealthier local population. FPAN have experimented with charges for temporarymethods, but have not yet done so for VSC.c) Distribution channelsVSC is provided through static sites (providing year-round or seasonal service athospitals and clinics), and mobile outreach sites (“camps”, providing services in schools,health posts or other local buildings not normally used for clinical services). Chart 3.1showed the relative market share of each channel.Despite occasional claims to the contrary, camps appear to provide a comparable qualityof service to static sites. There is no significant variation between channels in rates ofsterilisation regret following treatment, implying that no more women wereinappropriately sterilised through camps than through static treatment. And side effects59 Thapa and Friedman 1998 Page 49 of 111
  • 50. were a more common cause of regret for patients treated at static sites, implying that thequality of the operations was at least as high at camps60.But this does not mean the quality of either channel is satisfactory. Just 12% of femaleVSC clients were informed by the provider of other methods that could be used, and 83%were not told what to do if they experienced side effects (far higher than thecorresponding figure for temporary methods) 61. This is particularly worrying given thatside effects outweigh by far any other reason for sterilisation regret.There also appears to be large variation in quality of service by region and by provider.Sterilisation regret varies from 0% in the Western Mountain region to 15% in theneighbouring Western Hill (nearly twice the national average). With providers, 36% ofMarie Stopes clients and 25% of government clients were not informed that sterilisationwas permanent, whereas 100% of ADRA clients were given this critical information.62d) Brand positioning strategyThe concept of a “brand” may initially appear to be less applicable to VSC than, say, to acondom, as no physical product is given to the consumer. But in many respects it oughtto be even more important. A complex service is being provided, full of potentialhazards and anxiety for the consumer. Traditionally, brands have most value at preciselysuch times, when customers are at their most worried (eg. the reassuring effect of lookingout of an aeroplane window and seeing “Rolls Royce” or “General Electric” on theengine).Our researchers in Pokhara found that urban residents from the middle and upper classesgenerally opted to pay for VSC from private hospitals; some had even travelled as far asKathmandu to get a better perceived quality of treatment.63 This illustrates the importanceof brand image, as the same government doctors often provide services in private clinics.It may also be connected with status - many such people feel that getting an operation forfree is degrading and will inevitably be of poor quality.Yet the nature of the service in Nepal means VSC has never been treated as a “brand”.The government dominates provision, and promotes “Sibir” (camp) dates nationally overthe radio, and locally via leaflets and posters. But the most important means of informingpeople remains word of mouth, using FCHVs, ward chairmen, and other localinfluencers.This is certainly an effective way to get people in rural areas to use services, but it doesentail a loss of control by the government over the way VSC services are presented to thelocal community. One FCHV may present VSC in a very different light to her60 Thapa and Friedman 199861 NDHS (2001)62 NDHS (2001) p.8963 PSI (2003a) Page 50 of 111
  • 51. counterpart in a neighbouring ward, preventing any kind of consistent “brand image”from forming.The camp mechanism by its nature positions VSC as something highly seasonal. 93% ofcamp clients receive the service between mid-December and mid-March, the time ofhighest demand due to lower agricultural workloads during winter, and a widespreadbelief that infections spread less in the colder months64. The corresponding figure forstatic sites is 78%, implying that some of the winter peak in camp’s demand is duesimply to the fact that that is when they tend to be there, so is supply as well as demand-driven.3.2 Injectable contraceptivesa) Strengths and weaknesses65 Strengths WeaknessesLow failure rate Irregular and prolonged bleeding is common and expected in the first 3 to 6 months of use.Reversible (with delay in return to fertility) Other side effects, including amenorrhea, weight gain, headaches, nauseaDoes not interfere with intercourse No protection against STDs or HIV/AIDSOffers privacy to women whose husbands or Delayed return to fertility after last injection (up to 9 months)families are opposed to useDoes not affect breastfeedingBeneficial non-contraceptive health effectsIn addition to the above, an important reason for the high prevalence of Depo thatemerged in some of our focus groups was the fact that it is promoted moreenthusiastically by some providers.66 The reason for this is not clear. Providers arecertainly not given a financial incentive for administering Depo, as they are with VSC.The most important of the above weaknesses in Nepal is side effects. Focus groupscarried out in 2001 amongst 84 participants in the Kathmandu Valley found that of 23Depo users, only 3 had not experienced side effects. Women found the disturbance totheir menstrual cycles particularly distressing; for some, their periods stoppedcompletely; others had periods more twice per month.67b) Sales levels and market share64 Thapa and Friedman 199865 Based on Population Information Program, Center for Communication Programs, The Johns HopkinsSchool of Public Health ( accessed 14 July 200366 This is supported by Bajracharya (2001)67 Bajracharya (2001) Page 51 of 111
  • 52. “Top-down”Chart 2.6 shows the share of each main provider implied by consumer survey data. 68Chart 2.6 - Share of each major provider of injectablesTotal market size = 1,509,052 vials (in 2001) Private sector, traditional (CRS) 8% Other, including friends Other NGO 1% 1% FPAN 4% Government 86%As with VSC, provision is overwhelmingly government-dominated, though HMGs shareis gradually being eroded by CRS. CRS distribution increased by 70% from 1999 to2002, whilst the government expanded its user numbers by just 38% over the sameperiod.“Bottom-up”Table 2.9 shows each provider’s forecast according to their own internal data.Table 2.9 - Actual and forecast number of depo vials per provider, 2001-20056968 NDHS (2001); CBS (2002)69 LMD (2003); CRS forecasts provided 8 July 2003; FPAN forecasts provided 4 July 2003; Data for MSIand Red Cross based on 2001-02 actuals reported in MOH (2003), and in the absence of other data assumedto increase in line with government provision. Page 52 of 111
  • 53. Provider 2001 2002 2003 2004 2005Government 1,343,017 1,545,666 1,526,988 1,710,226 1,881,249 market share 73% 76% 74% 74% 74%CRS 160,664 173,114 198,239 238,567 287,098 market share 9% 8% 10% 10% 11%FPAN 324,196 309,608 328,794 345,234 362,495 market share 18% 15% 16% 15% 14%MSI 3,224 3,710 3,666 4,106 4,516 market share 0.2% 0.2% 0.2% 0.2% 0.2%Red Cross 6,356 7,315 7,227 8,094 8,903 market share 0.3% 0.4% 0.3% 0.4% 0.3%Total 1,837,457 2,039,413 2,064,913 2,306,226 2,544,261Annual growth 11% 1% 12% 10%Top-down / bottom up divergenceThe figures overall imply total “leakage” in the system of over 328,000 vials. In otherwords, the number of vials in use implied by the NDHS survey data (1.5m) was less thanthe number obtained by adding each provider’s total (1.8m) by about 22%. For whateverreason, many units leaving central warehouses do not end up being administered byproviders.A summary of divergences between usage and provider sales reports is given below.Table 2.10 - Divergence between usage and sales by pill provider, 2001 Usage implied by Reported 2001 Divergence / Provider Excess reported 2001 NDHS sales reported salesGovernment 1,296,488 1,343,017 46,529 3%FPAN 63,317 324,196 260,879 80%CRS 116,081 160,664 44,583 28%All suppliers 1,509,052 1,837,457 328,405 18%The top-down figures ascribe a much higher share to the government and a lower share toFPAN than the data from each provider would suggest. Assuming both sets of data arereliable, this may mean that consumers who had received their injectables from FPANwere under the mistaken impression they had been provided by the government. Page 53 of 111
  • 54. LessonsWith the exception of a blip in 2003 caused by an unexplained drop in governmentprovision, strong double-digit growth in depo usage looks set to continue.b) PriceThe biggest supplier to charge for Depo-Provera is CRS, under its “Sangini” brand.Table 2.11 shows the price paid per vial at each stage of the distribution process.Table 2.11 - Pricing of Sangini supplied by CRS70 (all prices in NRs.) Distributor Wholesaler Retailer ConsumerCost per unit 17 19 20 30% margin 10% 5% 50% -Retailer margins are clearly generous, and in practice may be even more so than this datafrom CRS suggests as clinics may disguise the real price for the product with consultancyfees and other additional charges.FPAN recently began charging a nominal fee on a trial basis in selected urban clinics.This involved charging Rs. 10 for a Depo injection. Despite the misgivings of local staff,initial results have apparently been very positive, with a drop in demand of just 5%.71An FPAN pricing study in 2001 recommended a fee of NRs. 20-30 per vial, varyingacross districts to take into account local conditions such as average income.72 An earlierstudy conducted in 1999 surveyed 300 FPAN and United Mission clinic clients in thePalpa district (western hill). This found an average willingness to pay of Rs.25 per shotof Depo (although 20% of clients surveyed said they were not prepared to payanything).73The story on the ground with FPAN appears slightly different. Our researchers foundFPAN staff in rural areas had been informed that from 2004 onwards a nominal fee of Rs.0.10 per condom and Rs. 3 for a 3-month injectible would be introduced. Staff wereapprehensive about customer reactions to this, given that government health posts willalmost certainly still be providing free of charge.70 Data supplied by CRS 16 July 200371 Interview with Dr. Giridhari Sharma Paudel, Programme Manager, FPAN, 4 July 200372 FPAN (2001b)73 Prasai (1999) Page 54 of 111
  • 55. MSI charge Rs. 30 per vial (and operate mainly in urban areas) 74. The government doesnot charge consumers for its supplies.c) Distribution channelsHMGChart 2.7 illustrates government distribution of injectables by outlet type.Chart 2.7 - % of government provision distributed via each channel75 FCHV , 2% Government hospital, PHC outreach clinic, clinic, 9% 3% PHC/Health centre , 11% Health post , 18% Sub-health post , 57%A surprisingly low proportion of injectables are distributed via FCHVs, indicating thattraining on a wide scale in administering Depo has yet to take place (the same appears tobe true of FPAN, who do not distribute Depo via their RHFV network - see below).FPANTable 2.12 shows the individual districts covered by FPAN, the second largest providerof injectables after HMG. These figures show FPAN’s distribution to be focused on hilland terai districts, but evenly spread between the five development regions.74 FPAN (2001b)75 NDHS (2001) Page 55 of 111
  • 56. Table 2.12 - Districts covered by FPAN in order of number VDCs served76 Number of VDCs District Region Ecological zone covered by FPANSindhupalchok Central Mountain 41Morang Eastern Terai 40Palpa Western Hill 35Bhojpur Eastern Hill 27Sunsari Eastern Terai 27Bardiya Mid-Western Terai 23Banke Mid-Western Terai 22Nawalparasi Western Terai 21Jhapa Eastern Terai 20Kailali Far-Western Terai 20Kanchanpur Far-Western Terai 19Kavrepalanchowk Central Hill 19Dhanusha Central Terai 18Rupandehi Western Terai 17Achham Far-Western Hill 16Dang Mid-Western Terai 16Dhankuta Eastern Hill 15Arghakhanchi Western Hill 14Kaski Western Hill 14Surkhet Mid-Western Hill 14Chitawan Central Terai 13Sarlahi Central Terai 13Baglung Western Hill 12Doti Far-Western Hill 12Makawanpur Central Hill 12Saptari Eastern Terai 12Ilam Eastern Hill 10Dailekh Mid-Western Hill 9Tanahun Western Hill 2FPAN only distributes Depo through its clinics - it does not do so through its network ofRHFVs.CRSCRS distributes Sangini mainly to private pharmacists and clinics in urban areas. Twothird-parties lie between CRS and the retailer: a distributor, operating across “Zones”spanning multiple districts, and a wholesaler, acting at a more local level, ferryingproduct from distributors to individual retail outlets.76 DHS (2003) p. 309 Page 56 of 111
  • 57. d) Brand positioning strategyCRS is the only supplier to have an explicit brand positioning strategy. Its currentpositioning statement is:“Sangini, three monthly injectable contraceptive that is convenient, reliable, affordableand professionally administered.”77The following target group analysis was also supplied by CRS: Target Group Variables General Lifestyle Age group: 18-30 (Primarily women who want to Personality Characteristics: Conservative, come off the pill and as yet are not ready for long Assertive, Practical, Conscientious and term contraception like IUDs and Norplant). Careful. Outlook: Urban (Cities & towns where Sangini is Level of Exposure to Mass Media : Low to available). Medium Education: secondary plus Husband Wife Communication on FP: high Income: Disposable income from husbands Purchasing Habit: Consistent Occupation : Working woman/House-wife Family Affiliation: Strong, responsible and loyal (both to offspring and husband) Family Structure: With or without children Social Pressure/Conformity: High Married women Source of Information: Peers/Radio Purchase of Method: Self, as she needs to visit the certified outlet for the injection.3.3 Oral contraceptivesa) Strengths and weaknesses78 Strengths Weaknesses99% effective if used properly Require daily use - easy to miss a pillReversible (with rapid return to fertility) Common side effects, including nausea, heavy bleeding, and mood swings. Usually settle after 2-3 months77 Supplied by CRS, 16 July 200378 Based on Population Information Program, Center for Communication Programs, The Johns HopkinsSchool of Public Health (, FHI( and Family Planning Queensland(!factsheets&brochures/fs-ch-cocp.htm) accessed 18 July 2003 Page 57 of 111
  • 58. Does not interfere with intercourse No protection against STDs or HIV/AIDSBeneficial non-contraceptive effects, including Require regular re-supplymore regular periods and protection from ameniaand ectopic pregnancyOne of the key strengths of OCs in Nepal (highlighted in a 2001 focus groups study) istheir lack of effect of menstruation (a key defect of Depo - see above).79 Side effects arealso apparently less of a problem (in general) than with Depo.The three most prominent reasons for non-use of pills found in the same focus groupstudy were: • Difficulty in use, given the need to take daily • Worry about side effects • The fact that health workers recommended Depob) Sales levels and market share“Top-down”Chart 2.8 shows the share of each main provider implied by consumer surveys carried outof for the 2001 NDHS. 80Chart 2.8 - Share of each major provider of pillsTotal implied market size = 1,075,741 cycles (in 2001)79 Bajracharya (2001)80 NDHS (2001); CBS (2002) Page 58 of 111
  • 59. Nepal Red Cross Private sector, non- Other, including 2% traditional friends 2% 6% Private sector, traditional (CRS) 30% Government 54% Other NGO 1% FPAN 5%The market is considerably more fragmented than either VSC or injectables. Thegovernment is nowhere near as dominant, accounting for just over half of all supply.“Bottom-up”Table 2.13 shows each provider’s forecast according to their own internal data.Table 2.13 - Actual and forecast number of pill cycles per provider, 2001-20058181 LMD (2003); CRS forecasts provided 8 July 2003; FPAN forecasts provided 4 July 2003; Data for RedCross based on 2001-02 actuals reported in MOH (2003), and in the absence of other data assumed toincrease in line with government provision. “Other” is assumed to be a constant 5% of the market, in theabsence of other information. Page 59 of 111
  • 60. Provider 2001 2002 2003 2004 2005Government 936,869 995,634 1,035,937 1,139,531 1,230,693 market share 44% 44% 42% 42% 42%Nilocon White (CRS) 358,667 398,282 440,416 511,615 544,903 market share 17% 17% 18% 19% 19%Sunaulo Gulaf (CRS) 297,673 351,734 410,379 459,691 481,428 market share 14% 15% 17% 17% 17%FPAN 467,269 438,648 483,474 507,648 533,030 market share 22% 19% 20% 19% 18%Nepal Red Cross 15,000 15,941 16,586 18,245 19,704 market share 0.7% 0.7% 0.7% 0.7% 0.7%Other 88,140 91,628 97,991 107,940 115,431 market share 4% 4% 4% 4% 4%Total 2,148,618 2,275,926 2,468,197 2,726,425 2,905,485Annual growth 6% 8% 10% 7%Additional brandsTable 2.14 shows results of a brief survey carried out by PSI in May 2003 in pharmaciesin Kathmandu, Lalitpur and Bhaktapur. This revealed several other brands for which nopublished information is available. These presumably account for a large part of the“other” category revealed in the NDHS survey data above. All are Indian imports.Table 2.14 - Additional oral contraceptive brands available in the Kathmandu Valley82Brand Name Manufactured by Made inFemilonTM desogestrel and Organon, India LTD. Indiaethinylestradiol tablets Kolkata 700014Novelon desogestrel and Organon, India LTD. Indiaethinylestradiol tablets Kolkata 700014Ovral*L Wyeth Lederie Limited, India MumbaiTrriqrilar® German Remedies Limited, India82 In-person pharmacy visits by PSI, May 13-14 2003 Page 60 of 111
  • 61. MumbaiDuoluton L German Remedies Limited, India MumbaiRodhak Subhash Ayurvedic Store India Nawada (Bihar)Top-down / bottom up divergenceThere is a startling difference between the market size of over 2m cycles implied by these“bottom-up” numbers and the implied market size from the 2001 NDHS of just 1mcycles. If this data is correct, then providers claim to be supplying 1m more cycles thanwomen are actually using. The breakdown of this between different providers is shownbelow:Table 2.15 - Divergence between usage and sales by pill provider, 2001 Usage implied by Divergence / Provider Reported 2001 sales Excess reported 2001 NDHS reported salesGovernment 594,403 936,869 342,466 37%FPAN 51,687 467,269 415,582 89%CRS 324,122 656,340 332,217 51%All suppliers 1,075,741 2,148,618 1,072,877 50%As was the case with injectables, the biggest divergence between sales and usage was forFPAN, whose excess amounted to 89% of their reported sales.LessonsProviders are clearly optimistic about future prospects for pills. After sluggish growth in2002, their projections are collectively forecasting growth to hit 10% by 2004. This,however, is a consistent view amongst providers, so if correct no significant change inmarket share will occur for any player over the coming years.The nationwide market shares above are more representative of rural than of urban areas.CRS share is likely to be considerably higher in the latter, as this is where their outlets areconcentrated. CRS claims a 51% share for its Nilocon White brand in urban areas.83b) Price83 CRS (2002) p. 19 Page 61 of 111
  • 62. CRS supplies pills to private sector clinics and drug stores under its “Nilocon White” and“Sunaulo Gulaf” brands. Table 2.16 shows the price paid per cycle at each stage of thedistribution process for each brand.Table 2.16 - Pricing of pills supplied by CRS84 (all prices in NRs.) Distributor Wholesaler Retailer ConsumerNilocon White 7.1 7.8 9.2 12.0% margin 10% 18% 31% -Sunaulo Gulaf 4.6 5.0 6.0 8.0% margin 10% 20% 33% -As with Sangini, retailer margins are the most generous, though the difference with pillsis less pronounced. This makes sense given that lower costs are involved inadministering pills than injectables (eg. less highly trained staff are required). Marginsare approximately the same for each of CRS’s two brands.FPAN included oral contraceptives in its urban clinic pricing trial (see above), chargingRs. 5 per cycle. 85 Except for trial clinics, it does not currently charge for pills. The2001 FPAN pricing study recommended a fee of NRs. 10 per cycle. 86 Particularly in thelight of their current funding difficulties, is likely that FPAN will gradually extendcharging throughout its network of clinics.Government supplies are free to consumers.c) Distribution channelsFrom a distribution standpoint, pills occupy an awkward halfway position between theFMCG-style ease of condoms (where all distributors have to do is physically connect theproduct with the user) and each of the other temporary methods (all requiring qualifiedmedical help to administer).Pills are easy to give out and to use, but still have potential for serious side-effects, whichusers should be counselled in dealing with at the point of distribution. But manyproviders appear to ignore this part of their job. Pill customers are in general much lesswell informed than users of any other temporary method. Just 51% are told about theexistence of side effects, and 52% are not informed what to do should they experienceside effects.8784 Data supplied by CRS 16 July 200385 Interview with Dr. Giridhari Sharma Paudel, Programme Manager, FPAN, 4 July 200386 FPAN (2001b)87 NDHS (2001) Page 62 of 111
  • 63. HMGChart 2.9 illustrates government distribution of pills by outlet type.Chart 2.9 - % of government provision distributed via each channel88 Government hospital, clinic, 17% FCHV , 21% PHC/Health centre , 6% Health post , 13% Sub-health post , 42%Pills appear to be much more readily available than Depo - a considerably wider range ofgovernment outlets distributes them. In particular, FCHV’s - who play no role in Depodistribution - distribute over 1/5 of all government-supplied pills.As with so much in Nepal, however, the role of FCHVs varies enormously by district. In11 districts FCHVs distribute over 40% of government pills (as high as 63% in Bajura),whereas in 20 others they provide less than 10% (right down to zero in Solukhumbu).Moreover, this variation appears entirely arbitrary - there is no meaningful correlationwhatsoever between this and any other known district-level variable.FPANSee table 2.12 above for details of districts where FPAN operates. In contrast to Depo,RHFVs play a major role in FPAN’s oral contraceptive distribution. Around 80% ofFPAN’s pills are distributed via this channel.89 FPAN, in other words, relies far moreheavily on its RHFVs than the government does on its FCHVs.88 NDHS (2001)89 Interview with Dr. Giridhari Sharma Paudel, Programme Manager, FPAN, 4 July 2003 Page 63 of 111
  • 64. CRSCRS distributes Nilocon White mainly to private pharmacists and clinics in urban areas.Sunaulo Gulaf is provided to similar outlets in rural areas. Distribution works in thesame way as with Sangini - product flows from CRS to a distributor spanning multipledistricts, and proceeds to a wholesaler who distributes to individual retailers.d) Brand positioning strategyAs with Sangini, CRS is the only supplier to have an explicit brand positioning strategy.Its current positioning statements are:“Nilocon White is a reliable and safe contraceptive pill for the busy and conscious [sic]woman”and“Sunaulo Gulaf is a proven yet affordable temporary family-planning contraceptive for agolden future.”90The following target group analyses are also being used by CRS:Nilocon White Target Group Variables General Lifestyle Age group : 20-29 Personality Characteristics: Extrovert, relatively independent, influenced by peers Outlook : Urban Oriented Level of Exposure to Mass Media : Medium to High Education : Secondary plus Husband Wife Communication on FP : high Income : Disposable income from Purchasing Habit: Normal & consistent husband/self Occupation : Working Family Affiliation: Strong, responsible and loyal (both to woman/House-wife offspring and husband)90 Provided by CRS, 16 July 2003 Page 64 of 111
  • 65. Family Status : Nucleus Social Pressure/Conformity: Medium to low from in-laws. Conformation: Low. Source of Information: TV, FM stations, Newspapers, Household Magazines. Method of Purchase: Husbands/Self, Maids, and helpers. Target Groups § Urban oriented house-wife § Working womanSunaulo Gulaf Target Group Variables General Lifestyle Age group: 16-24 Personality Characteristics: Obedient, simple, hard working and thrifty. Outlook: Rural oriented Level of Exposure to Mass Media: Low except for Radio Education: Illiterate/ basic. Husband Wife Communication on FP: Low Income: Dependant on the family Purchasing Habit: Special Occasions like Haat-bazaars Occupation: Agriculture / House- Family Affiliation: Strong, responsible and loyal (both to wife / Manual / Non wage earner. family and husband). Family Status: Joint/Extended Social Pressure/Conformity: Very High from In- laws/Husband/Family members. Source of Information: Peers/FCHV Purchase of Method: Husbands/Father- in- law Target Groups § Rural oriented house-wife § Agricultural and menial working woman3.4 Condomsa) Strengths and weaknesses91 Strengths WeaknessesDouble protection (pregnancy and HIV/AIDS) Often used inconsistently or incorrectlyNo side effects Reduce male pleasure91 FHI - accessed 18 July 2003 Page 65 of 111
  • 66. Easy to discontinue - immediate return to fertility Require regular resupply Higher failure rate than any other modern method Require proper storage Not controlled by the woman - male co-operation is requiredDespite the benefits, a lot of evidence points to the lack of suitability of condoms for FPpurposes.A 1997 study of 160 women obtaining induced abortions in a Kathmandu clinic foundthat condoms were the most commonly used method to have failed - 15% of the womenhad used condoms prior to pregnancy.92 Research carried out in the early 1990s by FHIamong 150 Nepali couples using 750 condoms found that 7.5% of couples reportedcondom failure (4% due to breakage and 3.5% slippage).93b) Sales levels and market share“Top-down”Chart 2.10 shows market shares at a provider level implied by the 2001 NDHS. 94Chart 2.10 - Share of each major provider of condomsTotal implied market size = 24,144,241 pieces (in 2001)92 Thapa (2001)93 Steiner (1994)94 NDHS (2001); CBS (2002) Page 66 of 111
  • 67. Nepal Red Private sector, non- Cross traditional (SMD) 1% 5% Other, including friends 7% Government Private sector, 46% traditional (CRS) 38% FPAN Other NGO 2% 1%There is, however, considerable uncertainty regarding these numbers. Firstly, the NDHSsampled only married men and women of reproductive age. The above figure willtherefore be an underestimate, as condoms used by unmarried people will not beincluded.Secondly, reported condom use among married women in the 2001 NDHS was 2.9%; theequivalent figure for married men was 6.3%. Which of these figures we believe makes ahuge difference to our estimated market size - the female figure implies a market of just15.6m pieces , whilst the male figure suggests some 32.7m pieces (assuming the standardconversion factor of 1 married user = 120 pieces per year).The NDHS authors speculated that the difference may have arisen because: • men were using with women other than their wife • men may have been embarrassed to admit they did not practice FP • women may have under-reported out of shyness.They concluded that “women’s reports may be closer to actual use.”95 The NDHS alsosampled a much larger number of women (8,885 compared to just 2,353 men), meaningdata from them will be more representative.Whatever the explanation, the implied market size from men’s reports looks like a seriousoverestimate when compared to the “bottom up” figure for 2001 of 32.2m (see below). Iftrue, it would imply that more condoms are being used than sold, and that condoms are95 NDHS 2001 p. 71 Page 67 of 111
  • 68. being distributed around Nepal in their millions by the government and private sectorwith no wastage.Equally, the 15.6m figure implied by women’s reports suggests that more condoms arebeing lost than sold. This may be closer to the truth, but the overall picture isinconclusive. The figure of 24.1m pieces given in the chart above is an average fromusing both of the controversial numbers.Either way, supply is clearly more fragmented than with any other method - condoms arethe only method where the government’s share of use is under 50%.“Bottom-up”Table 2.17 shows each provider’s current and forecast sales according to their owninternal data.Table 2.17 - Actual and forecast number of pieces per provider, 2001-20059696 LMD (2003); CRS data provided by CRS 8 July 2003; FPAN data provided 4 July 2003; SMD internaldata provided 8 and 16 July 2003; Interview with Mr. Rajeeb Satyal, Managing Director of SMD, 16 July2003; “Other” is assumed to be a constant 3% of the remainder of the market, in the absence of otherinformation; PSI estimates where data unavailable. Page 68 of 111
  • 69. Provider 2001 2002 2003 2004 2005Government 15,120,775 14,095,911 13,874,953 15,123,699 16,484,832 market share 47% 42% 35% 34% 34%FPAN 5,942,721 5,339,594 6,110,307 6,415,822 6,736,613 market share 18% 16% 15% 14% 14%Dhaal (CRS) 5,404,059 6,975,970 8,506,405 9,618,546 10,170,696 market share 17% 21% 21% 21% 21%Panther (CRS) 4,185,595 4,666,144 4,687,898 4,855,891 5,023,884 market share 13% 14% 12% 11% 10%Number One (CRS) 0 0 1,980,885 3,448,447 3,935,124 market share 0% 0% 5% 8% 8%Dhaal (SMD) 411,504 879,996 70,000 63,000 56,700 market share 1.3% 2.6% 0.2% 0.1% 0.1%Panther (SMD) 117,660 347,990 30,000 27,000 24,300 market share 0.4% 1.0% 0.1% 0.1% 0.1%Number One (SMD) 0 0 3,000,000 3,967,500 4,364,250 market share 0% 0% 8% 9% 9%Karma Sutra (SMD) 52,932 178,782 187,721 197,107 206,963 market share 0.2% 0.5% 0.5% 0.4% 0.4%IFC Dotted (SMD) 45,000 93,273 97,937 102,833 107,975 market share 0.1% 0.3% 0.2% 0.2% 0.2%Other 938,407 977,330 1,156,383 1,314,595 1,413,340 market share 3% 3% 3% 3% 3%Total 32,218,653 33,554,989 39,702,488 45,134,440 48,524,677Annual growth 4% 18% 14% 8%Top-down / bottom up divergenceThe divergence between provider and NDHS numbers is subject to a large margin oferror given the uncertainty discussed above as to which NDHS numbers to use. Using anaverage between the two controversial figures, the breakdown of supply betweendifferent providers is shown below:Table 2.18 - Divergence between usage and reported sales by condom provider, 2001 Page 69 of 111
  • 70. Usage implied Reported 2001 Divergence / Provider Excess reported by 2001 NDHS sales reported salesGovernment 11,119,376 15,120,775 4,001,399 26%FPAN 434,162 5,942,721 5,508,559 93%CRS 9,189,766 9,589,654 399,888 4%All suppliers 24,144,241 32,218,653 8,074,412 25%Again, the divergence is greatest by far for FPAN - their excess over usage reported inthe NDHS was 93% of their reported supply.Current share by brandChart 2.11 illustrates the market share of each major brand in 2003Chart 2.11 - Share of each major condom brand, 2003 Other Number One 4% 13% Panther 12% Unbranded (HMG and FPAN) 49% Dhaal 22%Current share by providerChart 2.12 illustrates the market share of each major provider in 2003Chart 2.12 - Share of each major condom provider, 2003 Page 70 of 111
  • 71. Other SMD 3% 9% Government 35% CRS 38% FPAN 15%Additional brandsThe brief PSI pharmacy survey carried out in May 2003 in the Kathmandu valleyrevealed several other specialty brands for which no published information is available.These originate in South Korea and Malaysia. They presumably account for part of the“other” category given in the NDHS survey data.“Jodi” is a brand launched by MSI in November 2002. It is aimed at people who wantsome of the benefits of “Karma Sutra” condoms (interesting flavours, texture, etc.) buthave a lower ability to pay. Jodi is available through non-traditional as well as traditionaloutlets.Table 2.19 - Additional condom brands available in the Kathmandu Valley97Brand Name Description Manufactured by Made inSkin Less Skin Unique Vibra-Ribbed Dotted Dongkuk Techco Rubber Malaysia Fitting, vanilla Flavour Industries Sdn.Bhd. 10200, Penang, MalaysiaJodi Dotted coloured lubricated Marketed by Marie ?Premium condoms electronically tested condoms Stopes services Pvt.Ltd. KathmanduBlack Cobra Dotted electronically tested CRL in collaboration Korea condoms with Greenmate97 In-person pharmacy visits by PSI, May 13-14 2003 Page 71 of 111
  • 72. Corp.Korea Marketed by Apex VentureBull (dotted, banana, strawberry Electronically tested condoms CUPID Rubber Ltd South Koreaand apple) A-68. M IDC Sinnar, Malegaon, Nashik 422103 in collaboration with Greenmate Corp, South KoreaWild Cat Electronically tested condoms Dongkuk Trading Co. KoreaLatex Prophylactics Ltd, Seoul, KoreaLessonsThe data implies that the introduction of Number One condoms in 2003 has had a mixedeffect. Overall market growth in 2003 is forecast to be 18% - a significant increase over4% growth last year. This implies that the promotional activity for Number One has, asintended, helped to grow the overall market. However, at the same time cmbined shareof Dhaal and Panther is forecast to fall from 38% in 2002 to 33% in 2003. The sharetaken by HMG is also expected to fall. Some of this decline will have been due to theintroduction of Number One.b) PricePrices at each stage of distribution were obtained from each of the main private sectordistributors, CRS and SMD. CRS uses two intermediaries: a distributor at “Zone” level,covering multiple districts; and district-level wholesaler. SMD distributes directly tolocal retailers using its own salesforce.Table 2.20 - Pricing of condoms supplied by CRS98 (all prices in NRs. per piece) Distributor Wholesaler Retailer ConsumerPanther 1.3 1.4 1.6 2.0% margin 10% 14% 25% -Dhaal 0.5 0.5 0.6 0.8% margin 10% 19% 33% -Number One 0.6 0.6 0.8 1.0% margin 8% 17% 33% -Table 2.21 - Pricing of condoms supplied by SMD99 (all prices in NRs. per piece)98 Data supplied by CRS 16 July 2003 Page 72 of 111
  • 73. Retailer ConsumerNumber One 0.8 1.0% margin 33% -Dhaal 1.3 1.7% margin 33% -Panther 2.7 3.3% margin 25% -Karma Sutra Premium 6.4 7.5% margin 16% -Karma Sutra Sport 6.9 8.0% margin 16% -Karma Sutra Extra Pleasure 9.2 10.7% margin 16% -IFC 4.5 6.4% margin 42% -Despite the absence of intermediaries, SMD’s retailers pay more for their supplies thanthose of CRS (although they end up with the same margin thanks to higher prices). Thisis because SMD distributes to “non-traditional” outlets, whereas CRS supplies privatepharmacies and clinics. Consumer willingness to pay appears to be higher in the non-traditional sector.“Price discrimination” (charging different prices to different clients according to theirability to pay) does not appear to be widespread. Only 6% of traditional and non-traditional outlets surveyed in October 2002 claimed to practice this.100 However, thereis anecdotal evidence that many retailers do not charge prices specified by retailers,particularly when products are subsidised. The full extent of this problem is unknown.Government and FPAN supplies are free to consumers.c) Distribution channelsHMGChart 2.13 illustrates government distribution of condoms by outlet type.99 Data supplied by SMD 8 July 2003100 CEDA (2002) Page 73 of 111
  • 74. Chart 2.13 - % of government provision distributed via each channel101 Government hospital, clinic, 10% FCHV , 20% PHC/Health centre , 6% Health post , 17% Sub-health post , 46%The government appears to distribute condoms in much the same way as pills - overallshares of each channel are very similar. Given the difficulty for most people in ruralareas of reaching a health post, this is clearly inadequate. It is not realistic to expect usersto walk long distances every time they need a new condom.As was the case with pills, the proportion of government supplies distributed by FCHVsvaries haphazardly from district to district. Overall however, as Chart 2.14 shows,FCHVs do not see condom distribution and pill distribution as alternatives. In areaswhere they play an important role in the distribution of one, they also tend to hand out alot of the other (though, as always, there are exceptions).Chart 2.14 - Correlation for each district between FCHV condom and pill distribution101 NDHS (2001) Page 74 of 111
  • 75. 70% 60% % pills distributed by FCHVs 50% 40% 30% 20% 10% 0% 0% 2% 4% 6% 8% 10% 12% 14% % condoms distributed by FCHVsFCHVs are an acceptable channel for women, but as our customer research showed,many men are reluctant to approach a woman for contraceptives. So many men in ruralareas face the choice between embarrassing themselves in this way, or walking a longdistance, and all for the sake of a device which reduces their eventual pleasure. It ishardly surprising that so many opt for non-use or non-government distribution.FPANSee table 2.12 above for details of districts where FPAN operates. As with pills, around80% of FPAN’s condoms are distributed via its network of RHFVs.102 From a maleperspective, these present the same embarrassment problem as FCHVs.CRS and SMDTable 2.22 shows the number of outlets of each type currently covered by CRS.Table 2.22 - Types of distribution outlet covered by CRS103102 Interview with Dr. Giridhari Sharma Paudel, Programme Manager, FPAN, 4 July 2003103 Provided by CRS, 16 July 2003 Page 75 of 111
  • 76. Outlet type NumberTraditional 7,790 Distributing Sangini 6,535 Not distributing Sangini 1,255Non-medical 5,009Private doctors 136Female pill-distributors 400Total 13,335Their coverage of non-medical outlets is surprisingly high, given their reputation as adistributor to traditional outlets.As of May 2003, SMD covered 5,002 non-traditional outlets. Table 2.23 breaks thisdown into different outlet types.Table 2.23 - Types of distribution outlet covered by SMD104 Type of shop NumberGrocery 1,968Cigarette / pan shop 1,201Bar / restaurant / tea shop 637Hotels / guest houses 178Other 1,018Total 5,002Overall, it is difficult to assess the coverage of CRS and SMD because of uncertaintyover the actual number of outlets in Nepal. There are apparently 4,000 registeredpharmacies in the whole of Nepal;105 yet a census of retail outlets conducted just twomonths after this figure was obtained found 7,917 in rural areas alone.106 The samecensus estimated 123,503 non-traditional outlets in rural Nepal.Depending on which number we believe, the 7,790 medical outlets covered by CRScould mean the whole country is covered twice over, or (presumably as most of the 7,790are in urban areas) that large parts of rural Nepal have been left out.104 SMD-PSI Final Database and Report, 4 June 2003. Data correct as of 15 May 2003.105 CEDA (2002) p.5106 ORG-MARG (2002) Page 76 of 111
  • 77. Table 2.24 - showing the proportion of outlets of each type stocking condoms - suggeststhe latter may be closer to the truth.Table 2.24 - Proportion of retail outlets selling condoms107 % Currently selling Type of shop condomsMedical shop 95%Food 17%Beauty / cosmetics 2%Betel leaf & tea 4%Night life venues 1%Mobile shop 13%Wholesalers 12%All rural 17%All urban 19%Total 18%Clearly, distribution to non-traditional outlets still has a long way to go. Given theinadequacy of government channels and the small number of pharmacies in rural areas,this must be stepped up if the number of males using condoms for FP is to increase.d) Brand positioning strategyOf the two leading condom brands, Dhaal is targeted at poor rural consumers; Pantheraims for more affluent, urban customers. CRS supplied the following positioningstatements:Dhaal DeluxePositioning statement: “Dhaal Deluxe is Nepal’s traditional and trusted brand of choice for faithful, family orientated, rural married couples demanding a high quality and affordable family planning condom.”Target Group Analysis: Target Group Variables General Lifestyle Age group : 18-35 of C/D/E of social Personality Traits: Handsome / hard working /107 CEDA (2002) p.23 Page 77 of 111
  • 78. economic personable / modern outlook / caring to wife / perfect father / perfect Nepali family man / has more in life than peers. Seen as a media for advice from peers who want what he wants. Outlook : modern oriented Level of Exposure to Mass Media: Low except radio Education: Lower than secondary Husband Wife Communication on FP : Low Income: Monthly household income Purchasing Habit: Non-impulsive, introvert, infrequent, 2,000Rs. thrifty Occupation: Manual worker/ blue Family Affiliation: Strong, responsible, loyal collar Family Status: Joint family Social Pressure/Conformity: High from elders Mobility: Generally static Source of Information: Radio, health workers, peers Method of Purchase: SelfPantherPositioning statement: “Panther is the condom brand of choice for upwardly mobile, educated, adventurous male pleasure seeker.”Target Group Analysis: Target Group Variables General Lifestyle Age group: 25-35 yrs of B/C of Personality traits: Handsome / hard working / enjoys social economic socializing with friends / role model to subordinates / leader of the pack / successful / strong / handsome / sexy / sexual / ladies-man Outlook: Urban Oriented Level of exposure to media: FM/TV/Magazine Education: Secondary plus Husband wife communication: NA Income: Extra money for all kind of Purchasing habit: careless impulsive buying/regulated by pleasure peers Occupation: Manual/trade/ Family affiliation: Indifferent factory/service Family status: Nuclear family Social pressure/conformity: low but highly influenced by peers Mobility: Generally static Source of information: peers Method of Purchase: self Target Group § Working urban men and women looking for pre-marital and or extra-marital sexual contact § College students § BusinessmenNumber OnePositioning statement: Page 78 of 111
  • 79. “Number 1 is the condom brand of choice for both urban and rural youth who have just begun to engage in sexual activity. The “modern” affordably priced, widely available youth condom brand aims to link current high-risk sexual behaviour to the future health, dreams and aspirations of the target consumer.”Target Market: Just beginning to experiment with intimate relations. Tuned into a variety of mass media channels and attentive to what is considered “trendy”. Easily influenced by peers. Rebellious streak against what they consider to be conformity.3.5 IUDa) Strengths and weaknessesA host of misconceptions surround IUD use in Nepal. Common fears repeatedlymentioned by consumers in several studies include: • Fear of the IUD coming out whilst urinating • Fear of it going too far inside and getting stuck • Fear of cancer should the device enter the womb.Infections are apparently common among rural IUD users, because of poor standards ofhygiene.108 It may be more suitable for urban areas as a result.b) Sales levels and market shareIUD is a much more popular method in many other LDCs, where it is seen as aconvenient, low-cost option, than in Nepal, where use is still extremely rare.The “top down” method works slightly differently for IUD and implants, due to thedifficulty of estimating the number of products supplied each year from the share of totalusers given by the NDHS survey data. Chart 2.15 therefore illustrates the share of userstaken by each provider. The share of product is likely to be roughly in line with this. 109Chart 2.15 - Share of each major provider of IUDTotal market size = 35,174 current users (in 2001)108 Interview with Dr. Kiran, Director of FP at ADRA, 19 July 2003109 NDHS (2001); CBS (2002) Page 79 of 111
  • 80. Private sector, traditional (CRS) Other 19% 6% Other NGO 3% Government 63% FPAN 9%Private clinics plays a significant role in IUD supply. Anecdotal evidence suggests thatthis is because of the popularity of IUD in urban areas as an alternative to sterilisation,where there is ability to pay for private treatment.“Bottom-up”Table 2.25 shows each provider’s forecast according to their own internal data.Table 2.25 - Actual and forecast number of IUDs per provider, 2001-2005110110 LMD (2003); CRS forecasts provided 8 July 2003; FPAN forecasts provided 4 July 2003; Data for MSIbased on 2001-02 actuals reported in MOH (2003), and in the absence of other data assumed to increaseannually at 3%. “Other” assumed to be 5% of total, in absence of other data. Page 80 of 111
  • 81. Provider 2001 2002 2003 2004 2005Government 8,997 6,998 8,533 9,386 10,043 market share 72% 67% 68% 67% 66%CRS 1,137 1,227 1,577 1,918 2,333 market share 9% 12% 12% 14% 15%FPAN 509 402 509 534 561 market share 4% 4% 4% 4% 4%MSI 1,336 1,376 1,417 1,460 1,504 market share 11% 13% 11% 10% 10%Other 599 500 602 665 722 market share 5% 5% 5% 5% 5%Total 12,578 10,503 12,638 13,963 15,163Annual growth -16% 20% 10% 9%Top-down / bottom up divergenceThe figures imply that government reporting of IUD provision is broadly accurate. CRS“bottom-up” share is considerably lower than top-down private-sector share, suggestingwidespread provision in private urban clinics of devices not distributed by CRS. Foronce, FPAN’s reported provision is significantly below that implied by the top-downfigures. If both data sets are accurate, some users receiving government IUDs apparentlybelieved they were being treated by FPAN.LessonsAn unexplained drop in government provision led to 16% decline in the market size in2002. Strong growth in 2003 will see provision returning to 2001 levels, and continuedgrowth of 9-10% is forecast over the coming years. IUD therefore looks set to continueas a niche product, with a small share of the overall contraceptive market in Nepal.c) PriceA study by FPAN found the following pricing of different IUD providers:Table 2.26 - Price of IUD insertion from different providers111111 FPAN (2001)b Page 81 of 111
  • 82. Charge for IUDOrganisation insertion (Rs.)FPAN 5Government 10MSI 100Private hospital / clinic / 100-300nursing homeThe FPAN and government charges above are registration fees at clinics, payable on aper consultation basis. The IUD itself is free. It seems there is significant willingness topay amongst more affluent women, though many buying from private clinics will havebeen from urban areas. MSI also operates primarily in urban localities. The averageconsumer willingness to pay for IUD insertion found in the same FPAN survey was Rs.58, though this varied considerably by district.Figures for pricing of IUDs across wholesalers and distributors were not readily availablefrom CRS.c) Distribution channelsChannels to the consumer are critical for an effective IUD programme. The mostimportant function of providers is the screening of potential candidates. Many women inrural Nepal are anaemic for example, and it is essential that they are screened out prior toacceptance for IUD. Side-effects management following insertion is also vital. All toooften, both of these functions are lacking.HMGAs Chart 2.16 shows, district-level government hospitals and primary health care centresdominate IUD insertion.Chart 2.16 - Share of total government distribution of IUDs accounted for by each channel112112 NDHS (2001) Page 82 of 111
  • 83. Other, 6% PHC/Health centre, 23% Government hospital, clinic, 71%The problem this creates is that IUD services are very difficult for the majority of peopleto access. There is, on average, only one government hospital and two PHCCs perdistrict (though as with so many things, at a district level the number of PHCCs varieswidely, from 7 in Kathmandu to none at all in several mountain districts).Another problem with this is the nature of government hospitals themselves. Theyprovide a far lower quality of service than any other government outlet (with theexception of mobile sterilisation camps) when measured by the proportion of customersinformed about side effects. 77% of customers at government hospitals are not told whatto do if they experience side effects.113 And customers themselves clearly regard this asbeing a serious issue: a detailed study on clinic facilities in Kathmandu in 2002 foundthat “being told all the benefits and risks to all the clients” was considered the mostimportant of all elements of a clinic’s service (cited by 94% of respondents).114With injectables and pills this was less of a problem, as only a minority of governmentprovision took place through hospitals (most was through sub-health posts). But for amethod where hospitals account for 71% of government distribution, the absence ofproper information for customers is worrying to say the least.By way of contrast, a more recent study found the quality of information on side effectsgiven to IUD clients to be the highest of any temporary method (93% of acceptors wereapparently informed what to do in the event of complications).115 But this may simplyreflect increasing numbers opting for the private sector because awareness of the low113 NDHS (2001)114 Das (2002)115 Pradhan et al (2003) Page 83 of 111
  • 84. quality of government provision is spreading. The data available is ultimatelyinconclusive.The same survey uncovered a poor quality of service when users ask for the IUD to beremoved. 1/5 of removers failed to have the device taken out following their firstrequest, usually simply because the provider did not want to. These people had to returnand make the request a second time.116 This was no doubt a particular frustration formost clients given typical travel times to government hospitals and PHCCs.Other providersCRS distributes to private clinics. MSI and FPAN provide IUD insertion at their ownclinics. MSI has primarily urban coverage, FPAN a mixture of rural and urban areas.c) Brand positioningCRS did not make any brand positioning work for IUD available. Little promotionaleffort seems to be made by anyone in favour of the method. As a result, it has (at 55%)the lowest level of awareness among women of any method apart from vaginal foamingtablets.1173.6 Implantsa) Strengths and weaknessesNorplant has had a controversial history in richer countries. In the late 1990s, around 400women started a lawsuit against Norplant manufacturers, claiming to have suffered fromhair loss, mood swings and "endless” periods. The primary distributor was eventuallyforced to withdraw from the UK market in October 1999.In the Nepali context, the fact that Norplant lasts such a long time (up to 5 years) isclearly positive given the predominance of demand for limiting rather than spacing.However, pain in the arm, weakness, and blood discharge were commonly citedweaknesses.118Norplant is also by far the most costly method to supply - around $25 per unit. Adding tothe expense is the fact that insertion requires a qualified staff nurse. Staff nurses trained116 Pradhan et al (2003)117 NDHS (2001)118 Bajracharya (2001) Page 84 of 111
  • 85. in Norplant insertion are not available at most health posts and sub-health posts, addingto the accessibility problem.b) Sales levels and market shareChart 2.17 illustrates the share of users taken by each provider. The share of physicalproducts is likely to be roughly in line with this.Chart 2.17 - Market share of Norplant providers119 Other NGO Other 7% 6% Government ADRA 51% 27% FPAN 9%Although this data comes from the most recent NDHS, it is not credible. ADRA at thetime of the survey ran only one static clinic (in Banepa), and 10 mobile clinic sessionsper month in different parts of the surrounding Kavre district.120 It is difficult to believethat this district alone accounted for over ¼ of Nepal’s Norplant insertions (althoughADRA’s programme there is having some success - 5% of MWRA in Kavre useNorplant, compared to just 0.8% in Nepal as a whole).121119 NDHS (2001)120 Interview with Dr. Kiran, Director of FP services at ADRA, 19 July 2003.121 DHS (2003) Page 85 of 111
  • 86. The chart above is certainly not representative of the current situation, as ADRA havenow stopped providing Norplant due to lack of supply (it is the most costly temporarymethod on a per-unit basis). Their focus is now on IUD.122“Bottom-up”Table 2.27 shows each provider’s forecast according to their own internal data.Table 2.27 - Actual and forecast number of Norplant units supplied per provider, 2001-2005123Provider 2001 2002 2003 2004 2005Government 8,441 5,168 9,569 10,526 11,263 market share 63% 59% 65% 65% 65%CRS 522 431 377 674 707 market share 4% 5% 3% 4% 4%FPAN 2,246 1,653 2,273 2,387 2,506 market share 17% 19% 16% 15% 14%Other 2,242 1,450 2,444 2,717 2,895 market share 17% 17% 17% 17% 17%Total 13,451 8,702 14,663 16,304 17,371Annual growth -35% 69% 11% 7%The share of CRS is extremely small, though they are forecasting it virtually to doubleover the next two years. FPAN’s forecast may be optimistic, given the cost of themethod and their current funding difficulties. Government supply is erratic, droppingsteeply from 2001 to 2002, before rebounding in 2003. ADRA does not appear in thetable, for reasons explained above.c) PriceThe FPAN pricing study found huge variety between different Norplant providers:Table 2.28 - Price of Norplant insertion from different providers124122 Interview with Dr. Kiran, Director of FP services at ADRA, 19 July 2003.123 LMD (2003); CRS forecasts provided 8 July 2003; FPAN forecasts provided 4 July 2003; “Other” isassumed to be 20% of total, in absence of other data.124 FPAN (2001)b Page 86 of 111
  • 87. Charge for IUDOrganisation insertion (Rs.)FPAN 5Government 10MSI 600Private hospital / clinic / 350-700nursing homeAs with IUD, the FPAN and government charges are registration fees. Willingness topay among affluent urban women using private clinics seems to be considerable. 11% ofMWRA in Kathmandu are now using either IUD or Norplant, in most cases as analternative to sterilisation.125The average consumer willingness to pay for Norplant insertion found in the FPANsurvey was Rs. 50, though as with IUD it varied considerably by district (from Rs. 22 inSunsari to Rs. 67 in Chitwan).Figures for pricing of IUDs were not readily available from CRS.c) Distribution channelsPost-insertion follow-up is a critical function of implant providers. Some Norplantacceptors apparently leave the rods in place far beyond the standard 5-year period ofeffectiveness. This is cause for concern given that the average use duration of implants inother countries is 3.8 years.126HMGGovernment provision of Norplant is more diverse than that of IUD, though stilldominated by district-level hospitals and clinics.Chart 2.18 - Sources of government Norplant insertions127125 DHS (2003); CBS (2002)126 UNFPA 1997, p. 12127 NDHS (2001) Page 87 of 111
  • 88. PHC outreach clinic Sub-health post 4% 4% Health post 3% PHC/Health centre, 23% Government hospital, clinic 73%Clearly very few health posts and sub-health posts offer Norplant - a crucial step if usageis to be expanded significantly beyond urban and semi-urban locales. And the dominanceof government hospitals exposes Norplant users to all the hassles suffered by their IUDcounterparts and discussed above. In fact, the proportion of women having to requestremoval more than once was, at 28%, even higher for Norplant than for IUD.128Other providersAnecdotal evidence, alongside the numbers above, supports the view that there is a trendtowards the private sector for Norplant and IUD services, particularly in urban areas. Thebenefits of doing so are stark - customers at private clinics are almost three times as likelyas those using a government hospital to be told what to do if they experience sideeffects.129d) Brand positioningThe situation with Norplant appears to be much the same as IUD. Little active promotionis going on through the media. Whatever there is is being done at grassroots level. No“brand positioning” statements for Norplant were found.128 Pradhan et al (2003)129 NDHS (2001). 23% are informed in a government hospital, 59% in a private clinic. Though this ofcourse means that even in the private sector 41% are not being told about side effects. Currently the bestprovider in Nepal by this measure is ADRA (89% told about side effects). Page 88 of 111
  • 89. Despite this, awareness of implants - at 80% for women and 72% for men - issignificantly higher than that of IUD.1303.7 Pregnancy Test KitsRationaleAnswers to a number of simple questions usually confirm that a woman is not pregnant.If a woman’s answers fail to prove this conclusively, a pregnancy test needs to beperformed before any modern FP method aside from condoms can be used.Availability in NepalA recent study in the Kathmandu valley found that 58% of drug stores and 90% of privateclinics performed pregnancy tests.131 However, phone-calls to selected providersrevealed a degree of frustration that people go to hospitals and clinics for the servicedespite being perfectly capable of performing it themselves at home.We also carried out brief primary research into availability of self-test kits. These werewidely available in major urban centres. A gynecologist informed us that rural areaslacked demand, supply, and awareness, though distributors we contacted in Kathmandusaid they sent supplies all over Nepal.Hospitals and clinics appear to be the major buyers of the kits. They purchase wholesaleat around Rs. 25, and provide for clients in return for a service fee. At the Blue Crossnursing home in Tripureshwar the fee for this extremely simple service was Rs. 200.They claimed to have considerable demand at this price. Most of their customers aremarried couples.There is a widespread lack of awareness among clients that they can buy from apharmacist and carry out the tests themselves. Those that do know may also not trustthemselves to read the instructions properly and administer the test correctly.Brands and pricingResearch in Kathmandu revealed a range of brands available, at a wide variety of prices.Table 2.29 - Pregnancy test kits available from selected outlets in Kathmandu132130 NDHS (2001)131 Das (2002)132 Primary research carried out 23 July 2003 Page 89 of 111
  • 90. Country of origin if Provider Brand Price (Rs.) knownNGO / ClinicsModel Hospital Elisa 180Sarwanga clinic Acon and Tulip India (Tulip) 220Life care nursing home Streak 75Medicare nursing home Acon 150Valley nursing home Elisa 200United nursing home Elisa 200FPAN Acon 125PharmacistsGanga medical hall Unbranded 75Hada medical hall Blue Cross India 110Ishwor medical hall Precheck Korea 75Medico enterprises Organol 65Nepal drug store Blue Cross India 60Pabitra Pharma Quickcheck 65Shyam Medico Acon 45Other brands we heard about included “Rapid Test” (made in USA), “Clue”,“Gravicheck”, “Graviscreen”, and “Insight”. Despite the range available however, mostoutlets only stock one brand. Test kits are not something the consumer shops around for,and brand loyalty is low. Page 90 of 111
  • 91. Part Three - Social Marketing Programme PotentialThis section briefly profiles organisations involved in social marketing of contraceptivesin Nepal, and evaluates the price of contraceptive supplies for different methods.1. Key organisationsa) Population Services International (PSI)PSI is one of the world’s largest social marketing organisations, based in WashingtonD.C. It is supported in Nepal by USAID.PSI’s major product in Nepal to date is the Number One condom. It followed this up inJune 2003 with the launch of the Sun Quality Health Clinics franchise network.b) Family Planning Association of Nepal (FPAN)FPAN aims to improve the accessibility and quality of FP services it provides, focusingon people with unmet need. It is planning to conduct surveys to identify currently under-served groups, and develop new and cost-effective delivery mechanisms to address theirneeds. It will also continue to provide IEC for its FP services133.FPAN is the oldest organisation in Nepal working in the FP. From its inception in 1958its focus was on IEC work in the Kathmandu valley. Expansion beyond the valley beganfrom 1972. They now run approximately 850 clinics, open once a week (at least one inevery VDC in which they operate). The clinics are managed by a local VDC Co-operation Committee, typically comprising 7 - 10 volunteers.To complement the work of the clinics, 3 RHFV’s are employed in every VDC (eachcovering 3 Wards), distributing condoms and pills. FPAN claims that because theirRHFV’s are paid, they are in general more effective than the government’s unpaidFCHV’s.FPAN is an affiliate of the IPPF, who provide its commodities along with KfW. USAID,formerly a major supplier, stopped working with FPAN in 2002 after FPAN’s decisionnot to comply with the US government’s Mexico City Policy on abortion. This has led toa commodity shortage for FPAN, exacerbated by KfW’s decision to stop direct deliveriesto FPAN and instead donate via HMG (FPAN now receive 10% of whatever suppliesKfW gives to HMG).134133 FPAN 2001134 Interview with Dr. Giridhari Sharma Paudel, Programme Manager, FPAN, 4 July 2003 Page 91 of 111
  • 92. In theory, FPAN is managed my its members, although political influence plays animportant - and by some accounts, negative - role.135c) Contraceptive Retail Sales Company (CRS)CRS began business in 1978, marketing contraceptives through a variety of distributionchannels. Its scope extends throughout Nepal, and it covers an increasing number ofsales outlets.A tension exists between its aims of making enough revenue to cover operating expensesand continuing (at great cost) to expand coverage in remote areas.Problem of low-quality imported products sold by CRS-trained pharmacists.CRS is owned by 14 permanent shareholders, including representatives from the MOH,Royal Nepal Airlines, and various private-sector enterprises.d) Social Marketing and Distribution (SMD)SMD is Nepal’s major distributor of condoms to non-traditional outlets. It employs 25district-level field staff recruiting new outlets.e) Sunaulo Parivar Nepal (SPN - part of MSI partnership)Established 1994, SPN provides SRH services with a focus on marginalised, underservedcommunities. It has static centres in 14 districts spanning all 5 development regions,though the vast majority (11 of 14) of the centres are in the Terai.In addition to its health centres, SPN runs outreach clinics, offering temporary methodsmainly to hill regions. It also runs a network of Community Health Promoters (CHPs),employed to distribute pills, injectables and condoms at a local level.CHPs play an important role in promoting SPN’s mobile VSC camps, which beganoperating in 1996. Camps promote the full range of temporary methods alongside VSC,and run mainly during winter (after the planting and harvesting season).SPN launched its own “Jodi” condom brand in November 2002, and charges a nominalfee for all services. It also works with schools to arrange visits for pupils to clinics, anddeliver lessons on SRH.SPN is a partner of MSI, a London-based INGO with local partners in 36 countries.Donors include the EU, the UNFPA, and DFID.135 For example, UNFPA 1997 p. 33 Page 92 of 111
  • 93. f) Nepal Family Health Programme (NFHP)Launched in April 2002, incorporating JSI, EngenderHealth (formerly the Association forVoluntary Surgical Contracteption), JHPIEGO, and the JHU Centre for CommunicationsProgrammes. The NFHP provides financial assistance, training, and supervision togovernment health facilities and local NGO partners.The programme aims to ensure that a basic package of FP and MCH services is availablein 17 districts throughout Nepal, including district hospitals, primary health centers,health posts, and FCHVs.g) Nepal Fertility Care Centre (NFCC)A group of doctors affiliated with the NFCC currently provide FP services in their privateclinics, charging clients a service fee. Also works with CRS in motivating more private-sector practitioners to begin FP provision.2. Cost of MethodsTable 3.1 summarises the relative value-for-money of different methods, from thesuppliers’ perspective.Table 3.1 - Cost at source of each temporary method136 Total cost Cost per Cost per Method Supplier Units in 2003 CYPs ($) unit ($) CYP ($)Condom KfW 18,000,000 150,000 370,980 0.02 2.47Injectable KfW 850,000 212,500 612,000 0.72 2.88Pills DFID 700,109 58,342 230,616 0.33 3.95IUD DFID 3,046 15,230 5,128 1.68 0.34Norplant DFID 3,579 17,895 91,265 25.50 5.10This seems not to have a significant causal relationship to actual projections of use overthe coming years. IUD, by far the best value in cost per CYP terms, is set to remain atvery low usage levels. A possible exception to this is Norplant, whose extremely highcost is discouraging future supply.A potentially more serious issue for social marketers considering broadening theirmethod provision is the cost of staff training. 17 days are required, for example, to trainsomebody who is already a qualified doctor to administer NSVs.137 Detailed research136 MOH (2002)137 Interview with Dr. Kiran, Director of FP at ADRA, 19 July 2003 Page 93 of 111
  • 94. into this is beyond the scope of this study, but the costs of training sufficient people toadminister VSC and other popular methods such as Depo will be significant. Page 94 of 111
  • 95. Part Four - ContextThis section describes four important parts of the context of FP programmes in Nepal:1. Basic country data2. Indirect influences on fertility and FP3. Quantitative analysis of direct causes of fertility decline4. A note on government policy and planning.1. Country Data138Country size 147,181 sq km Age structure %GNP(GDP)/capita $233 (2002) 0-10 26.2Languages Nepali; Maithali; Bhojpuri; Tharu; 10-14 13.1 Avadhi; c. 15 othersReligions Hindu (81%); Buddhist (11%); 15-19 10.5 Muslim (4%)Literacy rate-male 65.1% 20-24 8.9Literacy rate-female 42.5% 25-29 7.6Life expectancy 60.8 (male); 61 (female) 30-34 6.7Fertility rate 4.1 35-39 5.8Total Population 23.1m 40-44 4.8 % urban vs. rural 14.2% urban; 85.8% rural 45- 49 4.1 % and # male vs. female 50+ 9.1Infant Mortality Rate 64 per ‘000 live birthsMaternal Mortality Rate 539 per 100,0002. Indirect influences on fertility and FPAge at first marriageTable 4.1 shows how the mean age at first marriage has crept slowly upwards since the1960s.Table 4.1 - Mean age at first marriage in Nepal, 1961-2001139138 EIU (2003)a; MOPE (2002)139 MOPE (2002) Page 95 of 111
  • 96. 1961 1971 1981 1991 2001Male 19.5 20.8 20.7 21.4 23.6Female 15.4 16.8 17.2 18.1 20.3HMG is now trying to speed the process, with Parliament before its dissolution passing abill to increase the legal age at marriage for both men and women to 20 years. Despitethis, the slow pace of progress is likely to continue.EducationEducation and urban residence are two of the key variables associated with a higher ageat marriage and increased contraceptive use.HMG spends about 8% of the development budget on education, and remains thedominant provider (84% of primary and secondary school students are enrolled atgovernment schools).140 Progress in female literacy has been rapid, with the literateproportion increasing from 25% in 1991 to 42.5% in 2001.However, the primary school enrolment rate is still very low, at just 68% (compared tothe “Millennium Development Goal” of 100%). A group of donors (including the WorldBank, ADB, and EU) recently created a fund aiming to increase the enrolment rate to80% by 2004, through the Basic and Primary Education Project (II). The success of thisinitiative will have a substantial indirect impact on the FP programme.UrbanisationThe proportion of Nepalis living in urban areas has increased rapidly, from just 6.4% in1981 to 14.2% by 2001. By comparison to other Asian nations, however, this is stillextremely low (the Asian average is 37%, implying that Nepal still has a long way to go).The urbanisation process is progressing faster in the Terai than in hill and mountainareas, due mainly to better infra-structure and higher levels of economic activity.Maoist InsurgencyThe Maoists claim that, in a third of Nepal’s 75 districts, the government’s autonomy isrestricted to the district HQ. This precise claim is hard to verify, but there is significantanecdotal evidence indicating that Maoists have hampered the work of government140 EIU (2003) Page 96 of 111
  • 97. health-posts and sub-health-posts in many areas. Personnel may have fled from remoteareas into urban centres, leaving facilities closed.The knock-on effect for contraceptive distribution, given the important role played in thisby sub-health-posts in particular, is obvious. Closure of health-posts may also be causinguntold problems for clients requiring counselling for side effects, or IUD / Norplantremoval.The Maoists have also caused significant disruption to Nepal’s education system, whichmay hamper progress towards the government’s aim of increasing primary schoolenrolment (a crucial driver of FP use).InfrastructureIn March 2001, Nepal had just 4,593 km of paved roads. Most rural areas are thereforeonly accessible via unpaved roads, many of which get washed away during the rainyseason. This leads to the government practice of only supplying district-levelcontraceptive supply warehouses on an annual basis, during the dry season when roadsare passable.Many district Headquarters are still not accessible year-round by road. Even if the the10th 5-year plan targets are met, there will still be 5 district HQs without road access by2007. The 2003 budget announced plans to connect the district HQs of five remotewestern districts (Darchula, Bajhang, Kalikot and Jajarkot) by July 2004.141EconomyAfter a dismal year in 2001, when the economy shrank by 0.6%, growth picked up in2002 to 3.9%, and is forecast to accelerate to 5% and 5.2% in 2003 and 2004respectively.142 Nepal’s imminent accession to the WTO will open up the economy tomore imports, particularly from India.3. Direct causes of TFR declineThis section aims to show FP in the context of other factors directly leading to a declinein Nepal’s TFR.Table 4.2 illustrates how two of the key determinants of the TFR (nuptiality - ie. theproportion of women married in each age group; and marital fertility - the number ofchildren married couples produce) varied by age group and ecological zone between theperiods covered by the 1996 NFHS and 2001 NDHS.141 Annual Budget for Fiscal Year 2003/04, quoted in Kathmandu Post, 18 July 2003 p.8142 ADB forecasts, quoted in EIU (2003)b Page 97 of 111
  • 98. Table 4.2 - Decomposition of change in TFR, 1996-2001143 Marital Net effect on Nuptiality fertility TFRMountain 15-29 -0.03 -0.01 -0.03 30-49 0.03 -0.35 -0.32 Total 0.00 -0.35 -0.35Hill 15-29 0.05 -0.12 -0.07 30-49 0.05 -0.16 -0.11 Total 0.10 -0.28 -0.18Terai 15-29 -0.20 0.11 -0.09 30-49 -0.01 -0.19 -0.20 Total -0.21 -0.08 -0.29Nepal total 15-29 -0.08 0.01 -0.07 30-49 0.02 -0.21 -0.19 Total -0.07 -0.20 -0.27Two lessons are immediately apparent. First, the overwhelming factor reducing TFRover the period was a decline in marital fertility. The only group for whom decliningnuptiality was the overriding cause was young people in the terai.Second, the decline in marital fertility was much greater for older couples than foryounger ones, particularly in the mountain and terai regions. Decomposing the declinesin marital fertility further, Retherford and Thapa found that about 4/5 of the decline wasdue to changes in population composition, the key elements of which were “time elapsedsince first cohabitation” and “whether sterilised at the start of the 5-year period precedingthe survey”. The remaining 1/5 was unexplained, and is probably due mainly totemporary FP measures.4. A note on government policy and planningThe government is responsible for 80% of FP provision in Nepal. It therefore becomesan important part of the context for FP social marketers to take account of.143 Retherford (2002) Page 98 of 111
  • 99. A brief historyNepal’s first (1955-1960) and second (1960-1965) Five Year Plans did not include anyexplicit population policy. Although the FPAN had begun work as early as 1958 (seeabove), Nepal’s FP programme did not gain official endorsement until 1965, when the3rd 5-Year Plan (1965-1970) discussed the negative consequences of rapid populationgrowth. The Family Planning and Maternal and Child Health Project was alsoestablished during this period (1968). The Fourth Plan (1970-75) included populationcontrol as a major objective, but stopped short of setting detailed quantitative targetsbeyond a general aim of limiting population to 16-22 million.In 1983, during the period of the Fifth Five Year Plan (1975-80), the NationalCommission on Population outlined the “National Population Strategy.” This set anambitious target of reducing the TFR from the prevailing level of 6 per woman to 2.5 bythe year 2000, implying a CPR of over 60%144. By contrast, shortly afterwards theUnited Nations predicted a TFR for Nepal of 4.6 by 2000145, which in the event provedmore accurate - the actual TFR in 2001 was 4.1146.In 1997, more long-term targets were set in the 20-year Second Long-Term Health Plan(1997-2017), sometimes referred to as the National Health Policy. The documentdisappointed some by the lack of attention it paid to RH. One MOH representative said:“I thought we had drafted a chapter on RH for the Second Long-Term Health Plan; I amsurprised that it does not appear in the final document”147. The few RH-related targetsthat were set for 2017 were more modest than those the 1983 strategy had set to beachieved in 2000, including a TFR of 3.05, and a CPR of 58%.In summary, government targets have been set regularly, but achieved only rarely. Whenthey have been achieved, the targets have been beaten by such a wide margin as to callinto question the original reasoning behind them. Table 4.3 summarises this track record,from the mid-1960s to the mid-90s.Table 4.3 - Government FP targets, 1965-95148 Target FP % of target Five-year plan Period Acceptors Achievement achievedThird 1965-70 103,403 44,488 43%Fourth 1970-75 312,000 363,437 116%Fith 1975-80 132,000 801,580 607%Sixth 1980-85 900,000 1,370,401 152%Seventh 1985-90 2,925,000 1,673,757 57%Eighth 1990-95 1,239,600 1,056,442 85%144 Thapa and Tsui 1990145 United Nations 1986146 NDHS 2001147 Agarwal 1997 p.7148 Pradhan (1997) Page 99 of 111
  • 100. What this means for social marketersOne lesson from the above for social marketers is that the approach of trying to impose agrand top-down target on a market as complex as that of FP in Nepal rarely works. Thedanger of this mentality is that the service gets distorted towards the target. If the targetis a high number of VSC operations for example, providers are motivated to increasethroughput of new clients, but have little incentive to take proper care of previous clientsexperiencing complications.There must surely be a link between the top-down, target-driven approach of thegovernment and the inadequacy of screening, counselling and follow-up at a grassrootslevel. This has ultimately been counter-productive even from the target-setter’s point ofview. Over time, as we have seen, it has led to the high levels of anxiety about sideeffects which are now one of the major barriers to expansion of the FP programme. Page 100 of 111
  • 101. Part Five - Conclusion and RecommendationsThis final part summarises the target market recommendation, and outlines theimplications of this study for the FP marketing mix in Nepal.It comprises four sections: 1. Target market recommendation 2. Recommended districts 3. Suggestions for further work 4. Suggestions for the marketing mix.1. Target market recommendationWhich people should be targeted, and how?Part One proposed two broad target groups for new FP products, each a differentcombination seven key demographic variables. Group 1 comprised 15-24 year olds withan unmet need for spacing; group 2 consisted of married rural 25-39 year olds with anunmet need for limiting.The other 6 are important, but “Spacing / Limiting” is the crucial variable that dividesthese two groups. And accepting this means accepting that the way contraception ismarketed in Nepal needs to change in a quite fundamental way.In so far as marketing activity for FP has taken place at all in Nepal, it has focused so faron defining people into crude demographic boxes. So Nilocon White is for affluenturban people, whereas Sunaulo Gulaf is for their poor rural counterparts. Panther is forthe affluent, Dhaal for the poor; Government provision is for the poor; private clinics arefor the rich. But price, as we consistently saw, is not the thing that concerns theconsumer most.When the “spacing / limiting” line is drawn, it is often unhelpfully done in the context ofproduct choices - “spacing products” are for spacers; “limiting products” are for limiters.As we have seen, this is highly misleading, as most “spacing products” are in fact used bylimiters.This way of thinking must change. The market should no longer be segmented by pricepoints, or product types. Nepal needs distinct families of brands of the same product Page 101 of 111
  • 102. types, one focused entirely on spacers, the other on limiters. Let us briefly remindourselves why.What matters to spacers?Spacers are young, and often anxious about the world of childbearing they have recentlyentered. They are under intense social pressure from relatives to have children, fast, assoon as possible after marriage. They are aware of contraception, and can name methods,but have little detailed knowledge of the full range available and how each productworks. They have probably heard stories about side effects on the grapevine. Many areunder the impression that FP is not there for them; it is only for people who want no morechildren, and will not help with their desire to delay their next birth. Many will neverhave discussed FP with their spouse or partner. Awareness of the far higher level of riska mother is taking by giving birth at a young age is low.This is inevitably something of a caricature, but carries with it a host of implications forthe marketer. These people need a very particular type of brand. One which reassuresthem in the face of anxiety and uncertainty; one which is on their side and understandsthe awkwardness of their situation, helping them to learn more about what FP can do forthem; one which captures something of the rebellious streak they may have to have toresist social pressure to reproduce fast, and pluck up the courage to raise such ahazardous topic with their other half. One which makes FP something ok and almostfashionable for teenagers to discuss.Contrast all of this with the story for limiters.What matters to limiters?Limiters are older people, who have already been through the ups and downs of severalchildbirths. Husband and wife together are now grappling with a major life decision -whether to stop childbearing completely, and perhaps irreversibly. They will never haveany more sons to provide for them in old age than are already there. They may in factend up with fewer, as some of their existing children may die. Moreover, they mustdecide which of them is going to take the risk of the debilitating side effects they haveheard so much about from their friends over the years stifling their ability to work.Whose economic value is worth less? Why not have this difficult conversation tomorrowinstead?Again, a very particular type of brand is needed - one more down-to-earth and focused onpracticality than that aimed at spacers. Limiters are further down the path leading fromawareness to action than their spacing counterparts. If anything they know too much.They need to be convinced that something has changed, things are now different, theterrible things you may have heard in the past are unlikely to be the case for you. Theservice will be readily available - you won’t need to travel for a day leaving your three Page 102 of 111
  • 103. children behind only to find that the clinic is closed. And when you get service, thechances of things going wrong afterwards are now much lower. Even if something doesgo wrong, you will be properly looked after. And afterwards you will be secure in theknowledge that you will not have to suffer the pain and cost associated with morechildren. You may be able to afford a better education for the ones you already have.Which of the above should be targeted?In the long-term, satisfying both of the above groups is necessary if unmet need in Nepalis to be significantly reduced. But in the short-term it is the needs of Group 1 - youngspacers - that are most urgent. Over 90% of all contraception in Nepal is still used forlimiting, not for spacing. 149 Table 5.1 shows the proportion of all need for spacing andlimiting that is unmet, for married women of each age group.Table 5.1 - Current proportion of total need that is unmet150 Age % with unmet % with unmet need % need for spacing % need for limiting group need for spacing for limiting that is unmet that is unmet 15-19 33 2 76 64 20-24 24 9 73 39 25-29 11 21 78 36 30-34 4 23 71 31 35-39 1 23 69 29 40-44 0 21 100 28 45-49 0 12 0 22This makes it very clear that the current FP programme is doing a much better job ofmeeting the needs of limiters than of spacers. Over 70% of need for spacing is unmet, forall age groups from 15-34 (though it is important to remember that the problem is mostacute for 15-24s, where the absolute number with unmet need for spacing is very high).With limiting, as soon as the absolute number in need becomes significant (around theage of 25), around 2/3 of overall need is being met.So, in summary, the top priority in Nepal is for a single brand covering multipletemporary methods, targeted specifically at people aged 15-24 with an unmet need forspacing. In time, a brand is needed, again covering multiple products - including bothtemporary methods and VSC - targeted at 25-39 year old limiters. Both brands must havea marketing mix tailored closely to the precise needs, attitudes, and lifestyles of theirrespective target markets.149 NDHS (2001) p.120. 39.3% of MWRA are using contraception; 35.5% to limit and 3.8% to space.150 Pant (1997), updated with NDHS (2001) data Page 103 of 111
  • 104. 2. Recommended districtsFP in Nepal is highly resistant to generalisation. Trends often appear obvious fromgovernment data (especially when segmented - often misleadingly - by developmentregion), but at a district level there are usually stark exceptions to any rule that can bedevised.For example, in the Mid-Western region female sterilisation is almost twice as popular asany other method. So it may seem superfluous to offer this here rather than an alternativemethod. Yet in Mugu, Kalikot, and Dolpa - all Mid-Western districts - no femalesterilisation programme yet exists. 151 Planning at a district level is therefore critical toensuring programmes are appropriate for local conditions.Part Two highlighted the ten most attractive districts for promoting new temporary andpermanent methods. These are places where the proportion of MWRA using eachmethod is exceptionally low, and the potential target market (ie. the current number ofMWRA non-users) is large. Using this method, it illustrated the “top ten” districts foreach specific product type.Four terai districts in particular stood out as being exceptionally attractive: Bara,Rautahat, and Mahottari (all in the central development region) for temporary methods;and Kapilvastu (in the western region) for both temporary and permanent methods. Over0.3m MWRA non-users live in these districts, and the prevalence of temporary methodsis under 10% in each.This gives an indication of the most attractive target districts, but note that is not the fullstory. A town where nobody wears shoes is either the best or the worst place in the worldto open a shoe shop; it all depends on the customer. There may be clear district-specificreasons for the unpopularity of particular methods, which it would be too much of achallenge for social marketing to overcome. The extremely low prevalence of Male VSCin the terai in general may be a case in point. Men in this area appear exceptionallyreluctant to use.Detailed, district-specific customer research was beyond the scope of this study, butneeds to be done in each district prior to the launch of new products.3. Suggestions for further workBrand positioning of existing products151 NDHS (2001) p. 72; DHS (2003). Maoist problems aside, one reason for this is the unbalanced patternformed by the patchwork of I/NGOs throughout Nepal. For example, six I/NGOs sampled between themhad FP programmes covering a total of 81 districts. Yet 32 of Nepal’s 75 districts remained untouched byany of them. Up to 4 of the 6 coexisted in many districts. Page 104 of 111
  • 105. As well as informing marketing mix decisions for new products, this study should helpre-positioning of what is already in the market. Positioning statements should highlightthe critical benefit of a particular product to a tightly defined target group. Except forthat of Number One, none of the current positioning statements really do this. This willhelp focus future marketing activity on what really matters to customers.Research on women’s attitude to periodsHormonal methods affect menstruation in different ways, but we do not know preciselyhow this affects Nepali women’s method preferences. Are levels of anxiety higher, forexample, for methods making periods more irregular than for methods which stop periodsaltogether?Attitude of consumers in target districtsAs outlined above, more needs to be known about the needs of more locally definedtarget markets before a new product is launched into a particular district. This shouldinclude the experience of other I/NGOs currently providing FP services there.Cost of training providersA shortage of trained providers has held back widespread availability of government-supplied FP products, particularly Depo. The costs and other difficulties associated withfinding sufficient trained providers needs to be explored in more detail before decisionsto expand into particular new methods are taken.4. Suggestions for the marketing mixProductDiversity is crucial here. If one word springs to mind in trying to sum up what has beenlearned about FP in Nepal, it is “fragmentation”. Sangini, for example, is perfect forsome women who need secrecy and a long-lasting method; it is terrible for many otherswho suffer from its side effects and don’t have time to walk to a provider.So more products to better address the needs of particular niches are needed. A one-month injectable may be useful for women who want to start using, but suffer side effectsfrom the progestin-only 3-month injectable. Or for women whose husbands are absentfor long periods, and for whom 3 months of coverage is superfluous. Or for current pill Page 105 of 111
  • 106. users who want a method that affects their bodies in the same way but gives them moresecrecy and freedom from the daily chore of taking a pill.PriceGenerally, this is of lesser importance compared to other elements of the marketing mix.But one interesting finding from FPAN’s pricing study was the enormous variation inconsumer willingness to pay across districts.152 Having a universal, all-Nepal price maytherefore be a bad idea, and give retailers an incentive to take pricing into their ownhands. Pricing should, as far as possible, be set according to income level and ability topay in specific areas. More affluent areas will then help support poorer ones, ensuringprogramme sustainability.PlaceImproving distribution and quality of customer care is, as we have seen, absolutelycritical if the stigma of inconvenience and side effects is to be removed from FP in Nepal.A few specific suggestions: • The “Sun Quality Health Clinic” franchise network should be expanded rapidly to rural areas with urgent levels of unmet need for spacing, probably in the districts recommended in Part Two. • Different promotional strategies should be adopted by providers for each of the two key target groups (spacers and limiters). They each have a distinct set of concerns, which a “one size fits all” approach to marketing by providers like Sun will not address. • The expansion of SMD’s condom distribution to non-traditional outlets should be continued. This is crucial given the inadequacy for this of government channels such as FCHVs. • The model of ADRA, currently doing a better job than any other provider in informing clients properly about what to do in the event of side effects, deserves close study.153 • A guarantee could be given to customers, promising proper care to people experiencing side-effects, to address fears of loss of income through weakness152 FPAN (2001)b153 NDHS (2001) p.89 Page 106 of 111
  • 107. • The FCHV model in general works well, particularly with pills. But very few are trained to administer injectables. Greater availability of injectables at a local level through FCHVs would increase take-up.PromotionThe problem of unmet need in Nepal is not one that will ever be solved by a single large-scale intervention. Rather, particular barriers for particular people in particular areasneed to be identified and overcome with targeted measures.Types of promotion must be varied, not limited to media advertisements. The model ofsmall single-sex focus group discussions in rural areas should be investigated further,particularly for spacers, many of whom are not currently talking about FP with friends orrelatives.Promotional activities must also bear in mind the different needs of subgroups below theheadline spacer / limiter categories.Major sub-groups uncovered in our customer research included: • Women not using because of side effects • Mothers of young children unwilling to travel long distances to obtain contraception • Wives of migrant workers, needing condoms or possibly one-injectables • Women whose husbands disapprove of use, or who are prevented for religious reasons, and therefore require secrecy • Couples at parity 2 or above with 1 son or no sons • Unmarried girls, afraid to carry condoms • Men who think VSC will make them weakSingle-issue, single-district campaigns may be the best way to address such a diversity ofbarriers to use. For example, do men in Dhanusha district in the central terai (where just1% of couples use male VSC) realise that it involves no scalpel, and has fewer sideeffects than the “minilap” female VSC operation? One campaign could set out to addressjust this issue. Page 107 of 111
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