The importance of socio-economic context for social marketing models for improving reproductive health: Evidence from 555 years of program experience

0 Chemonics International , Washington, D.C. , USA 1 Department of International Health and Development, School of Public Health and Tropical Medicine, Tulane University , 1440 Canal Street, Suite 2200, New Orleans, LA 70112 , USA Background: Over the past two decades, social marketing programs have become an important element of the national family planning and HIV prevention strategy in several developing countries. As yet, there has not been any comprehensive empirical assessment to determine which of several social marketing models is most effective for a given socio-economic context. Such an assessment is urgently needed to inform the design of future social marketing programs, and to avoid that programs are designed using an ineffective model. Methods: This study addresses this issue using a database of annual statistics about reproductive health oriented social marketing programs in over 70 countries. In total, the database covers 555 years of program experience with social marketing programs that distribute and promote the use of oral contraceptives and condoms. Specifically, our analysis assesses to what extent the model used by different reproductive health social marketing programs has varied across different socioeconomic contexts. We then use random effects regression to test in which socio-economic context each of the models is most successful at increasing use of socially marketed oral contraceptives and condoms. Results: The results show that there has been a tendency to design reproductive health social marketing program with a management structure that matches the local context. However, the evidence also shows that this has not always been the case. While socio-economic context clearly influences the effectiveness of some of the social marketing models, program maturity and the size of the target population appear equally important. Conclusions: To maximize the effectiveness of future social marketing programs, it is essential that more effort is devoted to ensuring that such programs are designed using the model or approach that is most suitable for the local context. - Background In many developing countries, social marketing program have become an essential component, if not the main component, of the national family planning and HIV prevention strategy. Social marketing programs in reproductive health all aim to improve reproductive health of the target population by using commercial approaches to promote healthy behaviors and/or to expand access to essential products and services. While improving reproductive health of the target population is the ultimate aim, donors recognize the potential of social marketing programs to build the sustainable delivery of reproductive health and family planning products and services in developing countries. Different types of social marketing models have been used to achieve these objectives. Social marketing programs have often been classified as either using the non-governmental organization (NGO) model (sometimes also referred to as the social marketing organization model) or the manufacturer's model . [1-3]. The NGO model typically focuses on achieving the largest possible health impact among the target population. Hence, the NGO model typically heavily subsidizes products. By contrast, the manufacturer's model was specifically developed in response to the need not only to improve reproductive health, but also to do so in a financially sustainable manner. Programs under the manufacturer's model are treated as temporary interventions with a realistic exit strategy. Such programs typically use experts to provide temporary technical assistance to existing private sector companies, which eventually are expected to continue the program without subsidies. Although the two models are defined largely by the type of management and financial structure, they often also differ in terms of branding, pricing, distribution, and other factors. Moreover, context-specific variations on these two models are common, and some programs use hybrid approaches that integrate features from each of the two broader models [4]. While many social marketing variants have proven successful, it is generally assumed that the manufacturer's model is more feasible in middle-income countries with a fairly well developed commercial infrastructure, while NGO models are more appropriate in lower-income countries with less less-developed commercial infrastructure [4]. Although scattered case studies support these assumptions, as yet there has not been any comprehensive empirical assessment of the socio-economic context in which each model works best. This paper analyzes a comprehensive database of annual social marketing statistics. The database is unique in that it includes annual data on social marketing programs in reproductive health in over 70 countries, which cumulatively represent 555 years of experience with social marketing programs. We analyze these data to provide empirical information on the extent to which different social marketing models have been used in different socio-economic contexts, and to identify the socio-economic context in which each model is most effective. Our analysis is restricted to programs that social market condoms or oral contraceptives. As only limited data on the features of social marketing programs are routinely collected, we focus on differences in management structure. In many countries, social marketing programs are an essential component of the national family planning and HIV prevention programs. At present, large-scale social marketing programs for reproductive health are in operation in over 60 countries worldwide. A growing body of evidence shows that social marketing programs can make an important contribution to the reproductive health of the target population [5-19]. In 2002, social marketing programs in 69 countries sold almost 1.6 billion condoms [20] accounting for more than half of all condoms available from public sources. Total sales of condoms, pills, vaginal foaming tablets and IUDs amounted to over 28 million couple-years of protection (a measure of the number of couples that could be protected from pregnancy for one year). In these countries (excluding China and Russia) social marketing sales of temporary methods of contraception excluding condoms accounted for almost 10 percent of all use [21]. Social marketing tends to be a cost-effective approach to achieving widespread access to health products and services [22,23]. It uses private sector incentives and organizations to achieve efficiency and revenues from sales offset some of the program costs. The total cost of $6 per coupleyear of protection compares favorably with costs to implement public sector family planning programs, which are around $1520 per couple-year of protection [24-27]. Some programs may eventually become self-sustaining and graduate from donor assistance altogether. Some social marketing programs in low- (...truncated)