Social Marketing Analysis for PSI Nepal

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Social Marketing Analysis for PSI Nepal

  1. 1. THE MARKET FORFAMILY PLANNING IN NEPAL Adrian BlairHarvard Business School Social Enterprise Summer Fellow July 2003 Page 1 of 111
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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