Thinking (Re)Productively – June 2013

Social Marketing of Emergency Contraception: Are We Missing A Valuable Opportunity?

Elizabeth Westley, Tara Shochet

Globally, unmet need for family planning remains high, and in developed and developing countries alike, women and men face challenges accessing both accurate information about contraception and contraceptive supplies. Contraceptive social marketing programs offer creative, effective and successful strategies to provide reproductive health (RH) products and services around the world, particularly in developing countries. Yet, the peer-reviewed literature contains few evaluations of social marketing of contraceptives, and few evaluations of social marketing programs focused on emergency contraception (EC) exist.

The term social marketing has a host of meanings, but here, we refer to the selling or promotion of RH products by a nonprofit and nongovernmental organization (NGO), generally in the developing world. There are many different social marketing approaches and programs, and different generations of social marketing programs have widely varying capacities. Accordingly, the sale of RH products (such as condoms, oral contraceptives and other contraceptive products) can take a number of forms. Often, social marketing organizations register, import and distribute the product either through commercial outlets or through branded or franchised clinics, pharmacies or drug sellers or even through public sector providers. Social marketing organizations may also market a donor-supplied product, often overbranded with a different name and packaging than that supplied to the public sector. In some cases, a commercial partner distributes the product through commercial outlets while a social marketing NGO provides support such as advocacy with policy makers, advertising, training of providers and outreach to women. In general, social marketing organizations work through existing commercial and clinic channels, normalize contraceptive and other RH products by placing them on the shelf along with related health and household items and innovate in their branding, advertising and marketing. Social marketing agencies bring experience in RH and a passion for social good to commercial partners and products. With a special focus on the poor, social marketing programs sometimes subsidize a product in order to provide it at an affordable price.

In many ways, social marketing strategies are similar to the approaches used by pharmaceutical companies in the US and other developed countries. They may employ pharmaceutical detailers to support pharmacists and other drug vendors in selling their products and providing accurate health information and counseling to consumers; they may use direct-to-consumer advertising such as newspaper and television advertisements, billboards and celebrity endorsements; and they can also engage in interpersonal communication, with agents visiting communities and even homes to discuss health issues and products. Also like pharmaceutical companies, they typically have a significant investment in assuring the quality of their products and a deep knowledge of local regulatory and political environments. Unlike commercial agencies, they are often donor supported or subsidized, and their metric of success is measured not by financial profit but by lives saved, pregnancies averted or people served.¹ In addition, social marketing organizations are better able to withstand political pressures and to pursue courses that might be politically unpopular or that might not yield shareholder value. They can position and market their products and services with more culturally appropriate and/or edgy approaches, without a corporate image to protect. And, with a narrower range of products to promote, they are more able to innovate.

EC offers contraceptive protection when utilized after sex. Currently, several pills and intrauterine devices can be used postcoitally to provide EC. Here, we focus on levonorgestrel-alone emergency contraceptive pills (ECPs), now registered in over 140 countries. These ECPs are ideal candidates for over-the-counter pharmacy distribution, as they are safe for nonprescription use and are more effective the sooner they are used.^2,3 While ECPs have not been shown to be effective at reducing abortion and unintended pregnancy at the population level, they are undeniably effective for individual women. And as the only method that can be used after unprotected sex or when a barrier method has failed, ECPs play an important role in the contraceptive method mix. Women appreciate the privacy, speed and anonymity offered by pharmacy access of ECPs. Women are also willing to pay for ECPs, and in many markets, this product is priced similarly to a full month of oral contraceptive pills. Thus, ECPs are a good product for social marketing programs — but are social marketing agencies offering EC as part of their family planning method mix? The peer-reviewed literature offers virtually no evidence that ECPs have been successfully incorporated into social marketing family planning programs.

To better understand how this sector is expanding access to EC and to identify what steps could be taken to improve availability of ECPs, we conducted a survey of four international social marketing organizations with a strong focus on contraceptive products (DKT International, Marie Stopes International, Population Services International and ProSalud Interamericana). We contacted, via phone and email correspondence, senior management at the headquarters and/or field office level. We asked for a list of countries where each organization currently has programs; we then sought to identify which of these programs provide family planning services and/or EC products. We also inquired about barriers and facilitators to EC provision in each country program. We learned that while EC has great potential for success in this sector, the majority of social marketing programs that already provide at least one family planning product do not include ECPs. Of the 100 programs we documented that focus on family planning, only 33% of them have substantial EC programs.

Of the EC programs that do exist, many have achieved high sales volumes and have thus become self-supporting. In some cases, they have even subsidized other products and programs. In fact, data collected by DKT International shows sales of over 10 million packets of ECPs in 2011, a substantial increase over 2005, when only 3.3 million packets were sold.⁴ With such potential for success, why, then, are so many family planning social marketing programs still not providing EC? Our research showed that a variety of barriers are preventing social marketing organizations from moving forward with more extensive EC placement. A number of policy barriers inhibit family planning programs from offering EC. These include regulatory environments that make product registration challenging, court rulings that impact EC accessibility or sales, anti-EC influence by the Catholic Church and national governments that deem EC to be politically sensitive. Lack of donor funding is also limiting the ability of some organizations to introduce or promote EC in more countries. The Funders Network, which analyzes RH spending by US private foundations, estimated that grants supporting EC made up 0.2% of all RH-related funding in 2007 (the last year for which such data is available).⁵ In addition, some programs simply do not see EC as a priority, especially when funds for family planning programs are very limited. Finally, lack of knowledge about EC among the general population is a key barrier to EC sales in several countries; Demographic and Health Survey data show that the majority of women in developing countries are unaware of EC.⁶

Paradoxically, another barrier to the uptake of EC by social marketers in some countries may be the success of the commercial sector. As EC has become more available and accepted, the commercial sector has become increasingly involved in selling EC in a number of countries. In some cases, this reduces the need for social marketing and NGO programs to offer an ECP product. However, in these settings, the commercial sector may only be reaching more affluent clients, and social marketing programs still have an important role to play in reaching women with less ability to pay.

Some of the barriers identified above can be addressed through strategic efforts and simply take time to overcome. Indeed, a few of the country programs we spoke with indicated that they are in the process of adding EC to their mix of methods offered. Some of the barriers are large scale and should be addressed by governments and global partners: poor regulatory environments, extremely low awareness of family planning in general and EC in particular, and active hostility from those opposed to EC, such as the Catholic hierarchy, require coordinated and strategic approaches to overcome. Some donors may be concerned that no population-level effects (e.g., reduction in unintended pregnancy rates) have been seen in studies to date. One possibility for this lack of impact is that women do not use ECPs with every act of unprotected intercourse and they may be less likely to use them following the most risky incidents.⁷ However, ECPs have consistently been shown to be effective in preventing pregnancy on an individual level, and it is unclear that other user-dependent contraceptive methods could be shown to have a population-level impact either. ECPs fill a particular niche in the range of contraceptive options, and there may be some women who prefer this method and/or for whom other methods are not practical. A laser-like focus on population-level impact for each individual contraceptive method may overlook the benefit of family planning programs that provide a wide range of contraceptive methods, as well as the rights of women to choose from a range of methods across their life span and as their circumstances change. For these reasons, it is crucial that EC be part of the available array of contraceptives.

Even within challenging contexts, social marketing programs can play an important role in expanding access to EC. These programs can grow the entire market for family planning, create a cost-recovery model of ECPs and other products, manage registration and distribution of products with a focus on assuring quality and can create effective communications campaigns to enhance awareness and change norms and behaviors around sexual and reproductive health. They are in a unique position to address disparities in family planning access. In addition, with their focus on ECP access in pharmacies, social marketing programs support task shifting to address the world-wide shortage of health workers. Social marketing programs have the potential to reach women with affordable, quality emergency contraceptive products when and where they need them, and they can contribute substantially to women’s ability to access a range of contraceptive options.

References

1. Beato G. Sexually transmitted altruism. Stanford Soc Innov Rev. 2012;66–71
2. World Health Organization . Fact sheet on the safety of levonorgestrel-alone emergency contraceptive pills (LNG-ECPs).Geneva: World Health Organization; 2010;
3. World Health Organization. Emergency contraception: Fact sheet No.244. Geneva: World Health Organization; 2012.
4. 2011 and 2005 Contraceptive Social Marketing Statistics,
5. Funders Network on Population, Reproductive Health & Rights. Annual funding analysis #9: Highlights from the grants database, 1999–2007. Rockville, MD: Funders Network; October 2008. Accessed October 17, 2012.
6. Khan S, Mishra V, Arnold F, Abderrahim N. Contraceptive trends in developing countries. DHS comparative reports no. 16.Macro International Inc: Calverton (Md); 2007;
7. Raymond EG, Trussell J, Polis CB. Population effect of increased access to emergency contraceptive pills: a systematic review. Obstet Gynecol. 2007;109(1):181–188