A case study from Reducing Poverty, Sustaining Growth--What Works, What Doesn't, and Why A Global Exchange for Scaling Up Success Scaling Up Poverty Reduction: A Global Learning Process and Conference Shanghai, May 25­27, 2004 Role of Social Marketing in HIV/AIDS Prevention in Cameroon Authors: Dr. Birgit Niebuhr, Theresa Gruber-Tapsoba, MIM, Msc Motzstr.22, D-10777 Berlin, Germany, Association Camerounaise pour le phone: +49-30-2117380 MarketingSocial (ACMS) e-mail: niebuhr.berlin@t-online.de BP 14025, Yaoundé, Cameroun, phone:+237-221-0920 / +237-793-8383, e-mail: tgtabpsoba@his.com Dipoko Degrando Dr. Kai Gesing, MScCHDC Association Camerounaise pour le KfW Development Bank Marketing Social(ACMS) Palmengartenstr. 5-9, BP 14025, Yaoundé, Cameroun, D-60325 Frankfurt, Germany phone:+237-220-9224 / +237-793-6610, phone: +49-69-7431-4172 e-mail: dipoko_degrando@yahoo.fr e-mail: kai.gesing@kfw.de Implementing Agency in Camaroon: Association Camerounaise pour le Marketing Social (ACMS), BP 14025, Yaoundé, Cameroun, phone:+237-221-9419, e-mail: tgtabpsoba@his.com The findings, interpretations, and conclusions expressed here are those of the author(s) and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank cannot guarantee the accuracy of the data included in this work. Copyright © 2004. The International Bank for Reconstruction and Development / THE WORLD BANK All rights reserved. The material in this work is copyrighted. No part of this work may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or inclusion in any information storage and retrieval system, without the prior written permission of the World Bank. The World Bank encourages dissemination of its work and will normally grant permission promptly. ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON Executive Summary The HIV/AIDS epidemic is becoming the single biggest obstacle to reducing poverty and to achieving the Millennium Development Goals (MDG). While HIV/AIDS is not strictly a "disease of poverty"--since it affects people at all income levels--HIV infections disproportionately affect the poor and illiterate, with young women topping the list. The impact of HIV/AIDS is unique, because the disease hits adults in the prime of their lives, thus depriving families, communities and entire nations of their most productive citizens. Cameroon already has more than its fair share of ill health to cope with--indeed, health indicators are now worse than they were 10 years ago. The additional burden caused by the HIV epidemic is worsening and promoting the spread of poverty. It is reversing human development, exacerbating gender inequalities, eroding government capacity to provide essential services and reducing labor productivity. HIV/AIDS thus has far-reaching ramifications for MDG attainment and related national poverty targets. The Programme de Marketing Social au Cameroun (PMSC), implemented by the Association Camerounaise pour le Marketing Social (ACMS) since 1996 and financed by German Development Cooperation (KfW--Kreditanstalt für Wiederaufbau) since 2001, took up the challenge of reducing rates of HIV infection in 1989 by selling high-quality condoms at a subsidized price through private-sector channels. The ACMS has achieved high governmental recognition, is credited with a dramatic increase in condom use and is recognized for its effective behavior change campaigns. PMSC was faced with the challenge of developing information and sensitization campaigns in a country characterized by multi-ethnicity, religious pluralism and remarkable socio-economic disparities in the various regions. Differences in acceptance of condom use are clearly shown by the provincial breakdown of per-capita condom consumption, which ranges from 3.4 condoms in more urbanized predominantly Christian areas to 0.3 condoms in northern regions with a lower socio-economic standing and Muslim population groups. The project is creative in meeting the challenge by giving special attention (e.g., radio broadcastings for youth) to areas with a low rate of acceptance. Creation of ACMS institution was supported by an international NGO, Population Services International (PSI). PSI provides financial oversight, training, quality control and international exchange of best practices through formal representation on the ACMS board. This is complemented with representation by local independent board members who have no direct commercial interest in program activities. There are now five Cameroonian board members who act as antennae in the larger community and have helped the ACMS avert problems and take advantage of opportunities. The fact that the ACMS is a true local institution increases opportunities and eligibility for donor funding. Severely restricted by funding and limited by poor economic conditions from 1989 to 1995, the ACMS has been innovative with regard to its operations. Relying heavily on existing 1 CASE STUDIES IN SCALING UP POVERTY REDUCTION resources of the commercial sector, the ACMS has established a cost-efficient distribution system, maintained a lean organizational structure, and increased cost recovery. It has been creative in mobilizing funds to address the most vulnerable groups with targeted messages, and research has provided evidence of behavior change resulting from these interventions. Complementary efforts by KfW focus on supporting social change and mobilization of vulnerable groups, including young women and people living with HIV/AIDS (PLWHA), thereby promoting an integrated approach to HIV/AIDS control. The ACMS's success has contributed to Cameroon's growing recognition of the potential contribution of the private sector for the achievement of social goals. This is seen as a necessary prerequisite for scaling up poverty reduction. PMSC started its activities three years after the first case of HIV/AIDS was declared in Cameroon. At that time, PMSC condom promotion activities were regarded by many as being of a purely commercial nature. Expensive condom brands were available in pharmacies and were predominantly used for contraceptive purposes. Although the Ministry of Health had agreed to the widespread distribution of condoms--officially considered to be a pharmaceutical product-- by PMSC, a formal agreement with the ministry was not signed until 1992. PMSC worked hard in the following years to earn acceptance and gain recognition by the ministry, the National AIDS Control Committee (NACC), and other governmental bodies created for the fight against HIV/AIDS. ACMS sought close cooperation with the public sector as well as with a variety of NGOs. This was facilitated during the period 1996­2003 when it was funded within the framework of the regional USAID project Santé Familiale et Prévention du SIDA (SFPS). This multifaceted effort strengthened the capacity of public-sector health facilities and promoted acceptance of family planning and HIV prevention through community mobilization and social marketing. At present, ACMS regularly supports small NGOs in their AIDS awareness activities, primarily through the donation of educational condom samplers. It also works more closely with larger NGOs such as CLAP (an NGO for commercial sex workers), the Cameroonian Family Planning Organization (CAMNAFAW), and the Society for Women and AIDS in Africa (SWAA), mostly in connection with sensitization events. During the program's lifetime, changes in scale have been many and multifaceted. The program enlarged its conceptual approach by starting a social franchising project, ProFam, that aims to improve reproductive health-service delivery in private clinics. With that, ACMS made a qualitative jump from a product- and awareness-oriented organization to one that is concerned with actual clinical service delivery. Presently 64 clinicians from 25 private clinics have been trained in family planning counseling, outreach, and client orientation and began providing services in December 2003. This will expand into priority areas such as management of sexually transmitted infections and HIV counseling and testing. There have been quantitative changes in the programs regarding office outlets, staffing and--most of all--condom distribution. From the outset, the program has targeted nationwide distribution, relying initially on just three independent sales managers. By 2001, the number had 2 ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON risen to one manager for each province plus one for a key tourist town. Thus, the project has been able to address both distribution and communication needs more effectively. Early attempts to involve NGOs in the creation of sales networks by giving them appropriate training did not prove sustainable, as commercial sales were not part of these NGOs' mandate. New ways in which NGOs can be more involved with the project are still being identified. There are plans to explore working with them on a short term basis to open new sales points. One focus for impact assessment concerns whether condoms have been made more acceptable. Although the program started its activities in the midst of the socioeconomic crisis, ACMS has been able to ensure increases in annual condom sales from the very beginning, except the year following the price increase. This is even more remarkable given the sociocultural climate at a time when HIV was not in evidence and therefore not perceived as a threat. In addition, a number of social and religious sectors of the population opposed the promotion of condom use and reacted in a very hostile manner to the project's sensitization measures. Since 2001 ACMS has conducted substantial baseline research. Research findings have been used to identify specific features of various target groups and their misconceptions about condom use, and to address identified issues with skillfully targeted messages. The impact of these messages will be measured in two years' time. The comparison of baseline and follow-up studies of the 100 percent Jeune project, funded by the Gates Foundation, reveals that progress has been made in key areas. Condom use has increased with regular partners; youth report improved self-efficacy in terms of purchasing and correct usage of condoms; young women have been empowered, as demonstrated by their increased rates of condom purchase and use and their ability to discuss and negotiate condom use with their partners; parental support for condom use has increased; and there is less stigma attached to condom use, sexual negotiation and HIV in general. Another focus for impact assessment concerns influence on policies and governance. The program has witnessed profound changes over the last 15 years in terms of national policy formulation, international and public support, and presidential commitment to HIV/AIDS control and its efforts. PMSC/ACMS is mentioned as one of the key elements and main partners in the "Strategic plan of action for the fight against HIV/AIDS in Cameroon (2000­05)" and is the principal partner of the National AIDS Control Committee for condom distribution. The growing recognition in Cameroon of the potential contribution of the private sector for the achievement of social goals has been stimulated by the success of the social marketing program. In general, the understanding that ministries or the public sector should finance and deliver all services is disappearing in favor of a more pluralistic, multi-stakeholder approach. There is now increasing support for ProFam, the family planning franchising model of ACMS. Along the same line, KfW is piloting a co-operative health insurance scheme and is drawing on the experience of PMSC for its marketing. A third focus for impact assessment concerns whether ACMS has been able to contribute to poverty reduction and thereby to the achievement of the MDG and the pursuit of the broader country poverty reduction strategy (PSRC). Increasing condom sales, in combination with 3 CASE STUDIES IN SCALING UP POVERTY REDUCTION preliminary research results concerning behavioral change, provide convincing evidence that the program definitely contributes to poverty reduction in terms of opportunity, empowerment, and risk reduction. ACMS arguments to convince wholesalers to sell condoms have evolved with time. Wholesalers needed first to be convinced that it was legal to sell condoms in retail outlets, since they feared harassment by the forces of law and order. They thought condoms could only be sold in pharmacies and were skeptical as to whether consumers would buy from them. Once these concerns were addressed, ACMS used commercial arguments, helping wholesalers understand that by selling condoms they would earn the same profit margin as for any other consumer product they carry. ACMS assured them that promotion would stimulate demand for the product, and advised them how to merchandise condoms and assist condom clients. Presently, the message is conveyed that while earning a fair profit margin for a well-promoted product, wholesalers are helping Cameroonians to fight HIV/AIDS. This social aspect has proved highly motivating. The approach of ACMS--marketing condoms in conjunction with promotion and sensitization campaigns--is complemented by the KfW's Youth and Adolescent Reproductive Health Project. This project also aims to prevent HIV transmission but focuses on social transformation and mobilization of vulnerable groups as well as model development for improved self perception, social roles and responsible behavior. To ensure that strategies reflect the realities of the epidemic as experienced by PLWHA, the project supports their organizational network in order to address the prevailing stigma and denial surrounding the HIV/AIDS epidemic--a major obstacle for effective prevention. The relationship between poverty, gender, and vulnerability to HIV/AIDS is addressed by a component supporting teenage mothers through "aunties" who offer advice legitimized by their own life experience. Together, these KfW approaches encompass the spectrum of preventive measures. Financial, geographic, sociocultural, and cognitive access to condoms are preconditions for prevention, while promotion of civil spirit, courage, the ability to communicate, and community development help to overcome taboos and stigmatization still connected with sexuality and HIV/AIDS, making condom use more sustainable. Without both approaches the HIV/AIDS epidemic cannot be overcome. Lessons learned ACMS experience suggests that--at the bottom line--consumers and the private sector are willing to invest in their own health as well as in public health objectives if given the opportunity and offered affordable and high-quality alternatives. Other lessons from this example of NGO involvement in the broad range of poverty reduction activities include: · Think "public health" and "private sector" at the same time. · Remain focused on measurable health impact. 4 ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON · Stay in touch with customers/stakeholders and keep asking questions (via research, focus group research, visiting wholesalers, service providers, pharmacies, and so on). · Develop a strong partnership with the Ministry of Health but maintain autonomy and support views with facts. · Build a strong partnership with other stakeholders, share your experiences and promote complementarity in action among them. · Remain open to learn from others both in country as well as internationally. Implementation Process While HIV/AIDS is not strictly a 'disease of poverty' - since it affects people at all income levels - HIV infections disproportionately affect the poor and illiterate, with young women topping the list. The impact of HIV/AIDS is unique, because the disease hits adults in the prime of their lives, thus depriving families, communities and entire nations of their most productive citizens. Cameroon already has more than its fair share of ill health to cope with ­ indeed, health indicators are now worse than they were 10 years ago. The additional burden caused by the HIV epidemic is worsening and promoting the spread of poverty. It is reversing human development, exacerbating gender inequalities, eroding government capacity to provide essential services and reducing labor productivity. HIV/AIDS thus has far-reaching ramifications for MDG attainment and related national poverty targets. Very early in the epidemic, in 1989, 'Programme de Marketing Social au Cameroun (PMSC)', took on the challenge of reducing HIV transmission and unwanted pregnancies by making high quality condoms and hormonal contraceptives available through private-sector channels. The non-governmental `Association Camerounaise de Marketing Sociale' (ACMS) was set up by an international NGO, Population Services International (PSI), in 1996 after an initial US-funded start-up phase of seven years. Since 2001, ACMS's HIV/AIDS-specific activities have been financed by German Development Co-operation supporting the Ministry of Health of Cameroon. The success the program has enjoyed is remarkable given two factors that hindered its acceptance at the start: The socio-economic crisis and the socio cultural climate with regard to HIV. 1. When PMSC began in 1989, Cameroon was in the midst of a severe economic crisis. While the country had enjoyed more than two decades of steady economic growth up till 1985, revenues suddenly went into a sharp decline, leading to a 40 % fall in per-capita consumption and a reduction in investment by almost two thirds of GDP. In an attempt to bring government spending into line with decreased revenues, civil-service wages were cut by 50% in 1993, severely reducing the population's purchasing power. The downward trend was reversed in 1995 and economic growth subsequently leveled off at over 4% per year. Improved macro-economic performance and higher per-capita incomes (about 2% per annum 5 CASE STUDIES IN SCALING UP POVERTY REDUCTION since 1996) have been achieved thanks to steady economic development and political stability over the past years. However, social conditions deteriorated substantially during the years of crisis, adversely affecting the provision of social services in particular, and economic recovery has done little so far to reverse this trend. 2. PMSC started its activities three years after the first case of HIV/AIDS was declared in Cameroon. At that time, PMSC condom promotion activities were regarded by many as being of a purely commercial nature. Expensive condom brands were available in pharmacies and were predominantly used - if at all - for contraceptive purposes. Although the MoH had agreed to the widespread distribution of condoms ­ officially considered to be a pharmaceutical product ­ by PMSC, a formal agreement with the Ministry was not signed until 1992. PMSC worked hard in the following years to earn acceptance and gain recognition by the MoH, the National AIDS Control Committee (NACC) and other governmental bodies created for the fight against HIV/AIDS. In its Poverty Reduction Strategy Paper (PRSP, 2003), the government expresses its commitment to do all it can to implement its 2000-2005 AIDS strategy. ACMS objectives are fully consistent with governmental strategies, including the development of communication and outreach campaigns, particularly for young people, women and rural populations; the promotion both male and female condom use among target populations; and the development of effective partnerships between different groups of society. ACMS has always sought close cooperation with the public sector as well as with a variety of NGOs. This was facilitated during the period 1996-2003 when it was funded within the framework of the regional USAID project "Santé Familiale et Prévention du SIDA (SFPS)". This multi-faceted effort strengthened the capacity of public sector health facilities and promoted acceptance of family planning and HIV prevention through community mobilization and social marketing. At present, ACMS regularly supports small NGOs in their AIDS awareness activities, primarily through the donation of educational condom samplers. It also works more closely with larger NGOs such as CLAP (an NGO for commercial sex workers), the Cameroonian Family Planning Organization (CAMNAFAW), and the Society for Women and AIDS in Africa (SWAA), mostly in connection with sensitization events. Early attempts to involve NGOs in the creation of sales networks by giving them appropriate training did not prove sustainable as commercial sales were not part of these NGOs' mandate. New ways in which NGOs can be more involved with the project are still being identified. There are plans to explore working with them on a short term basis to open new sales points. And ACMS cooperates with youth organizations in order to enlarge the network of peer educators and thus promote the efficient sensitization of young people. Such cooperation is presently intensified with other efforts supported by German DC, like the 'Youth and Adolescent Reproductive Health Project' addressing young people and PLWHA in the process of identity building and social change in order to strengthen support for the vulnerable. PMSC/ACMS has constantly adapted throughout its existence in response to institutional growth, market mechanisms or consumer beliefs and orientation. However, no fundamental changes occurred during the program's lifetime 6 ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON Changes in scale have been many and are multifaceted in nature1. First of all, they concern the increasing variety of ACMS products for health and prevention. The program further enlarged its conceptual approach by starting a social franchising project "ProFam", which aims to improve reproductive health-service delivery in private clinics. With that, ACMS made a qualitative jump from a product- and awareness-oriented organization to one that is concerned with actual clinical service delivery. Presently 64 clinicians from 25 private clinics have been trained in family planning counseling, outreach and client orientation and began providing services in December 2003. This will expand into priority areas such as management of sexually transmitted infections and HIV counseling and testing. There have been quantitative changes in the programs regarding office outlets, staffing and - most of all - condom distribution. From the outset, the program has targeted nation-wide distribution, relying initially on just three independent sales managers. By 2001, the number had risen to one manager for each province plus one for a key tourist town. Thus, the project has been able to address both distribution and communication needs more effectively. During the period 1989-1993, sales increased annually between 50 and 100 percent. These increases stabilized at around 10% per annum with a notable spurt in 1997. The jump in sales resulted from wholesaler anticipation of a price increase, which went into effect during the final quarter of 1997. Consequently 1998 sales lagged while stockpiles were sold. The upward trend was reestablished in 1999 at around 15 to 20% per annum. Since 2001 - the start of German DC funding ­ private sector condom sales of Prudence Plus have continued this trend, increasing from 14.5 million in 2001 to 18.9 million in 20032. Impact Analysis ACMS's results thus far have been in line with the initial objectives. Quantitative targets for condom sales set for each year have been achieved or exceeded. Specific targets related to attitudinal or behavioral change have not been defined, however, a number of key indicators are measured through regular quantitative research studies of high risk target groups. Achievements are evident when a comparison of baseline and follow-up studies of the '100% Jeune' (100% Youth) project reveals that progress has been made regarding condom use. · A first focus for impact assessment concerns whether condoms have been made more acceptable. Although the program started its activities in the midst of the socio-economic crisis, ACMS has been able to ensure increases in annual condom sales from the very beginning, except the year following the price increase. This is even more remarkable given the socio-cultural climate at a time when HIV was not in evidence and therefore not perceived as a threat. In addition, a number of social and religious sectors of the population 1see annex 1 2see annex 2 7 CASE STUDIES IN SCALING UP POVERTY REDUCTION outspokenly opposed the promotion of condom use and reacted in a very hostile manner to the project's sensitization measures. ACMS work is research based - a prerequisite for the development of messages and marketing strategies that are tailored to the target groups. Since 2001 the program has conducted substantial baseline research. Research findings have been used to identify specific features of various target groups and their misconceptions about condom use, and address identified issues with skillfully targeted messages. The impact of these messages will be measured in two years' time. The comparison of baseline and follow-up studies of the '100% Jeune' project reveals that progress has been made in key areas: Condom use has increased with regular partners; youth report improved self-efficacy in terms of purchasing and correct usage of condoms; young women have been empowered, as demonstrated by their increased rates of condom purchase and use, and their ability to discuss and negotiate condom use with their partners; parental support for condom use has increased; and there is less stigma attached to condom use, sexual negotiation and HIV in general. · A second focus for impact assessment concerns whether condoms have been made geographically and financially more accessible as measured by market share, stimulation of the overall condom market, reduced distribution costs and increasing cost recovery while remaining affordable to the poor3. ACMS has proven effective on all accounts. · A third focal area concerns the efficient use of resources in terms of the distribution system through wholesalers, competitive sub-contracting of communication and research activities4. · A fourth focus for impact assessment concerns influence on policies and governance. The program has witnessed profound changes over the last 15 years in terms of national policy formulation, international and public support, and presidential commitment to HIV/AIDS control and its efforts. PMSC/ACMS is mentioned as one of the key elements and main partners in the "Strategic plan of action for the fight against HIV/AIDS in Cameroon (2000- 2005)" and is the principal partner of the National AIDS Control Committee for condom distribution. The larger potential of social marketing, and the specific contributions of ACMS, have become well recognized by the government. Their particular appreciation was best expressed years ago by a former Director of Primary Health who described the PMSC as 'the public sector's bridge to the private sector'. The growing recognition in Cameroon of the potential contribution of the private sector for the achievement of social goals has certainly been stimulated by the success of the social marketing program. In general, the understanding that ministries or the public sector should finance and deliver all services is disappearing in favor of a more pluralistic `multi-stakeholder' approach. This is reflected in the ongoing debate in the Ministry of Health about contracting out services to private providers. There is now increasing support for "ProFam", the family planning franchising model of ACMS. Along the same line, German DC is 3see annex 3 4see annex 4 8 ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON piloting a co-operative health insurance scheme and is drawing on the experience of PMSC for its marketing. A sign of the high level of recognition the ACMS enjoys is the offer it has received to work as an NACC subcontractor for the free distribution of government condom supplies. Of central concern to the ACMS is the potential conflict between this activity and its private-sector condom sales. The NACC and other institutions have occasionally regarded the ACMS as a local condom supplier, requesting large amounts of condoms on short notice without forward planning, and potentially jeopardizing the careful procurement planning required to meet the needs of its private sector sales network. Although the revenues would benefit the ACMS, the institution has focused on what is best in terms of sustainable public health interventions, conscious of the fact that its own funding is not stable. The ACMS is working with government authorities both to develop a longer term vision and to ensure that the government's central purchasing unit for essential medicines remains the primary source of condoms for public sector activities. It is anticipated that ACMS will resolve these programmatic issues with the NACC and find a way to utilize large-scale free condom sampling that benefits the social marketing network. The last, but definitely not least focus for impact assessment concerns whether ACMS has been able to contribute to poverty reduction and thereby to the achievement of the MDG and the pursuit of the broader country poverty reduction strategy (PSRC). ACMS's impact on poverty reduction has to be determined on the basis of evidence relating to behavioral change, with regard to condom use, but also with reference to the delayed onset of sexual activity amongst youth and the reduction in the number of sexual partners, and the subsequent reduced rate of HIV infection. A quantitative analysis of the number of HIV infections prevented, i.e. estimation of the reduction in negative consequences of sexual intercourse and the rate of HIV prevention due to correct condom use (cost-utility analysis), is difficult to carry out and would necessitate a number of complex assumptions. Increasing condom sales figures in combination with preliminary research results concerning behavioral change, however, provide convincing evidence that the program definitely contributes to poverty reduction in terms of opportunity, empowerment and risk reduction. Driving Factors Commitment and Political Economy for Change The political, economic, social and epidemiological context (health context) has drastically changed since the program's inception in 1989. Whilst, at the beginning, it was very difficult for the program to gain acceptance or even be taken seriously in its attempts to address the issue of HIV, it is now a key partner of the Cameroonian government when it comes to the execution of HIV/AIDS control activities. It is acknowledged by the international community and its messages and products are accepted by a large majority of the population. 9 CASE STUDIES IN SCALING UP POVERTY REDUCTION Institutional Innovation PMSC's most significant institutional innovation concerns the creation of a Cameroonian NGO, the `Association Camerounaise pour le Marketing Social' (ACMS). Creation of the local institution was supported by an international NGO, Population Services International (PSI) and the ACMS is a member of its international social marketing network. PSI provides for financial oversight, training, quality control and international exchange of best practices through formal representation on the ACMS board. This is complemented with representation by local independent board members who have no direct commercial interest in program activities. There are now five Cameroonian board members who act as antennae in the larger community and have helped the ACMS avert problems and take advantage of opportunities. The fact that the ACMS is a true local institution increases opportunities and eligibility for donor funding. Institutional innovation is also evident in the design of ACMS's distribution system. Severely constrained by funding levels from the outset, the program had to be creative in identifying ways of using the commercial distribution system. Problems with a local packaging, warehousing and distribution enterprise at the start of the program had made it clear that using one exclusive national for-profit partner was in conflict with the NGO emphasis on maximizing health impact and would create problems at different levels, monopoly pricing being one of them. In addition, as warehouse and for-profit distributor alike, effective flow of product to regional distributors depended on the willingness of the partner to serve these clients, rather than on the efforts of the program to develop its distribution network. Therefore, the program chose to bring packaging and warehousing in house and to use a network of independent sales managers working individually within their own territories and remunerated on a commission basis (8%). ACMS's third institutional innovation lays in the widening of its scope. The introduction of new products oriented to the broader concept of family health - as opposed to condoms only ­ has supported the program's credibility and thus broadened acceptance of its mission and messages. In terms of institutional development, the range of goods ACMS handles today has helped to fine-tune distribution strategies and streamline distribution processes. The ACMS furthermore broadened from a product- to a service-delivery orientation. This has implications for in-house training and management and it has benefited greatly from lessons learned by other members of the PSI network. The ACMS is only beginning to implement this innovation in its organization, which will certainly have a positive impact on public perception of the program and the development of health care policy governing the private sector. Learning and Experimentation One of the major strengths of ACMS is its awareness of the particular needs of highly vulnerable groups, such as commercial sex workers, truck drivers and young people. With limited funding for its regular operations (promotion and distribution of condoms to the general population), the program was creative in mobilizing additional resources in order to launch targeted initiatives. ACMS benefited also from regionally available expertise and materials and used them, with minor adaptations, for highly vulnerable groups like truck drivers. ACMS showed a lot of creative energy which it used for experimentation and to try out new ­ sometimes time-limited - 10 ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON approaches. The best practical experience was the launch of the project '100% Jeune' funded by the Gates Foundation. The project's concept, implementation and evaluation are all state-of-the- art approaches to youth work. The ACMS is constantly adapting, not only to lessons learned locally but also to those learned through its affiliation with the PSI network. Learning has evolved around the following issues: · PMSC needed to develop a strong and positive relationship with the MoH in order to be accepted as a health impact NGO and not as a profit making marketing enterprise pretending to pursue social goals. The move of the main office from the commercial capital, Douala to the administrative capital, Yaounde, after four years of activity confirmed the advantages of being more closely positioned to government. · Research results on barriers to condom use provided evidence to the MoH that a sustainable increase in condom use does not depend on reducing the current price. Instead, this depends on other factors and variables such as perception of quality, perception of pleasure, or reducing incorrect use leading to breakage. Positioning PRUDENCE PLUS as a high quality affordable condom for modern people through appropriate advertising which addresses identified condom use barriers, along with the introduction of PRUDENCE PLUS in pharmacies, has helped to increase the demand for condoms. · PMSC was faced with the challenge of developing information and sensitization campaigns in a country characterized by multi-ethnicity, religious pluralism and remarkable socio- economic disparities in the various regions. Differences in acceptance of condom use are clearly shown by the provincial breakdown of per-capita condom consumption, which ranges from 3.4 condoms in more urbanized predominantly Christian areas to 0.3 condoms in northern regions with a lower socio-economic standing and Muslim population groups. The project is creative in meeting the challenge by giving special attention (e.g. radio broadcastings for youth) to areas with a low rate of acceptance. · At the onset of the program, condoms were essentially only available in pharmacies and were primarily purchased for family planning purposes. Even now, when compared with traditional methods, women prefer the condom which they perceive as a modern contraceptive method. In the beginning, the pharmaceutical sector was hostile to the sale of condoms outside the pharmaceutical sector and pharmacies refused to carry PRUDENCE. In order to win their cooperation, PMSC developed a second brand, PROMESSE, to be sold exclusively though pharmacies. Pharmaceutical sector cooperation was essential, since the PMSC had planned to launch an oral contraceptive and an oral rehydration salt. As time went on, pharmacies' opposition to generalized condom sales began to wane, enabling PMSC to discontinue the second brand. · ACMS arguments to convince wholesalers to sell condoms have evolved with time. Wholesalers needed first to be convinced that it was legal to sell condoms in retail outlets (boutiques etc.) since they feared harassment by the forces of law and order. They thought condoms could only be sold in pharmacies and were skeptical as to whether consumers would 11 CASE STUDIES IN SCALING UP POVERTY REDUCTION buy from them. Once these concerns were addressed, ACMS utilized commercial arguments, helping wholesalers understand that by selling condoms they would earn the same profit margin as for any other consumer product they carry. ACMS assured them that promotion would stimulate demand for the product, and advised them how to merchandise condoms and assist condom clients. Presently, the message is conveyed that while earning a fair profit margin for a well-promoted product, wholesalers are helping Cameroonians to fight HIV/AIDS. This social aspect has proved highly motivating. · To remain in touch with field realities, the ACMS director visits and consults with wholesalers and retailers as part of the process of strategic decision-making. These same visits serve to remind the ACMS staff of the importance of the sales network and to renew wholesaler commitment to help in the fight against HIV/AIDS. · The program learned that it had to limit the number of wholesalers included in the program, so that the incentive for each single wholesaler would still be large enough to motivate continued work on the program's behalf. The actual number is thus one or two per province - the resulting coverage 'gaps' were filled with semi-wholesalers. With only one or two per province, the wholesalers still had enough semi-wholesalers (and retailers) as customers to earn a decent income from condom sales and could thus be motivated to offer the product. · When German DC funding became available in 2001, the number of sales people in the field increased from 3 to 11 and promotion measures were intensified. Sales managers focused on cultivating their wholesalers; tending to 'sell through' to the existing network. In other words; they provided a delivery service to existing retailers. With parallel promotion and sensitization activities, 'selling through' led to an increase in sales and sufficient coverage in urban areas - however, accessibility in rural areas still remains inadequate, because the network is not dense enough to enable 'selling through' to work. Indeed, the results of a major distribution study showed that the ACMS reached only an estimated 60% of the potential sales points. Consequently, the ACMS reoriented its distribution strategies. Sales managers are now asked to focus on establishing new points of sale and tying them back into the distribution system. At the same time, management is sensitizing its wholesalers to the advantage of increasing the number of retail outlets. Complementarity of approaches in German Developmental Cooperation The approach of ACMS - marketing condoms in conjunction with promotion and sensitization campaigns - is complemented by the `Youth and Adolescent Reproductive Health Project'. This project also aims to prevent HIV transmission but focuses on social transformation and mobilization of vulnerable groups as well as model development for improved self perception, social roles and responsible behavior. To ensure that strategies reflect the realities of the epidemic as experienced by PLWHA, the project supports their organizational network in order to address the prevailing stigma and denial surrounding the HIV/AIDS epidemic - a major obstacle for effective prevention. The relationship between poverty, gender and vulnerability to HIV/AIDS is addressed by a component supporting teenage mothers (Tantines - aunties) who take on an advisory role for youth. Their advice is legitimized by their own life experience. Together, these 12 ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON German DC approaches encompass the spectrum of preventive measures: Financial, geographic, socio-cultural and cognitive access to condoms are preconditions for prevention, while promotion of civil spirit, courage, the ability to communicate and community development help to overcome taboos and stigmatization still connected with sexuality and HIV/AIDS, making condom use more sustainable. Without both approaches the HIV/AIDS epidemic cannot be overcome. External Catalysts Poverty-reduction strategies are becoming the main development-planning instrument, shaping national priorities and domestic as well as external resource allocation. In the case of Highly Indebted Poor Countries (HIPC) countries like Cameroon, poverty-reduction strategies determine the speed of debt relief and the allocation of debt-relief savings. Integrating HIV/AIDS control into poverty-reduction strategies therefore helps to create the policy and planning environment needed for a comprehensive multi-sectoral and adequately funded response to the epidemic. The ongoing observation of the Cameroonian process by donors from the debt-relief process acts as an external catalyst for the support of HIV/AIDS prevention and thus for the program. Lessons Learned ACMS experience suggests that - at the bottom line - consumers and the private sector are willing to invest in their own health as well as in public health objectives if given the opportunity and offered affordable and high-quality alternatives. Further lessons learned from this example of NGO involvement in the broad range of poverty reduction activities include: · Think "public health" and "private sector" at the same time; · Remain focused on measurable health impact; · Stay in touch with customers/stakeholders and keep asking questions (via KAP research, focus group research, visiting wholesalers, service providers, pharmacies, etc); · Develop a strong partnership with the Ministry of Health but maintain autonomy and support views with facts; · Build a strong partnership with other stakeholders, share your experiences and promote complementarity in action among them; · Remain open to learn from others both in country as well as internationally. 13 CASE STUDIES IN SCALING UP POVERTY REDUCTION References Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung (BMZ): Armutsbekämpfung ­ eine globale Aufgabe. Aktionsprogramm 2015. Der Beitrag der Bundesregierung zur weltweiten Halbierung extremer Armut. Institut de Recherche et des Etudes de Comportements (IRESCO) : Etude Quantitative de Base du Projet de Santé de Reproduction des Adolescents (« 100% Jeunes »), Janvier 2001 Millennium Development Goals (M.D.G.): Second Progress Report on Cameroon, December 2002 Ministère de la Santé Publique: Stratégie Sectorielle de Santé, Cameroun, 2001 Ministère de la Santé Publique: Programme National de Lutte contre le SIDA (Groupe Technique Central): Plan Stratégique de Lutte contre le SIDA au Cameroun, 2000 ­2005, Yaoundé 2000 OECD: Sustainable Development Strategies: What are they and how can Development Cooperation Agencies Support them?, Paris 2001 OECD: The DAC Guidelines on Poverty Reduction, Paris 2001 OECD/WHO: Poverty and Health. DAC Guidelines and Reference Series. Paris-Geneva, 2003 Programme de Marketing Sociale au Cameroun(PMSC) / Institut de Recherche et des Etudes de Comportements (IRESCO) : Etude sur les Barrières à l'Utilisation des Condoms en Zones Rurales au Cameroun, Septembre 2003 Programme de Marketing Sociale au Cameroun(PMSC) / Institut de Recherche et des Etudes de Comportements (IRESCO) : Etude Qualitative sur les Barrières à l'Utilisation des Condoms en Zones Rurales au Cameroun, Juillet 2003 Republic of Cameroon: Poverty Reduction Strategy Paper, April 2003 Sachs, Jeffrey et al: Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health. Geneva (WHO), 2001 UNAIDS: Condom Social Marketing. UNAIDS Best Practice Collection. Genf, November 2001 UNDP Policy Note: HIV/AIDS and Poverty Reduction Strategies. August 2002 World Bank: World Development Report 2000/201. Attacking Poverty. Washington, Oxford University Press, 2001 Report of the UN Secretary General: Road Map towards the implementation of the UN Millennium Declaration. UN General Assembly 56th session, Doc. 01-52607 (E) 130901 14 ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON Annex 1 Detailed description of selected aspects of PMSC 1. Variety of products The first product, "PRUDENCE" condoms was launched in 1989. A second, more expensive condom brand "PROMESSE", was developed in co-operation with MoH and WHO, launched in 1993, and sold exclusively in pharmacies. An oral contraceptive "NOVELLE DUO", and an oral rehydration salt, "ORASEL", were launched in 1994 (originally under different names). socially marketed version of Depo ProveraTM, an injectable contraceptive, was put on the market in 2000, followed by a female condom "Protective" in 2002. Impregnated mosquito nets branded "SUPERMOUSTIQUAIRE" and a home retreatment kit, "BLOC" are scheduled for launch in March 2004. The demand for emergency contraception using donated NorlevoTM will be evaluated in 2004 and a `safe water system' for home treatment of drinking water is currently under development. 2. Changes within the organization of PMSC The program started with one office in Douala and an exclusive contract with a firm offering packaging, warehousing and distribution services. The main office and warehouse are now in the capital Yaounde. Douala remains a regional office as does and one in the north (Garoua). There are also two suboffices to support 100% Jeune activities including a radio team in the extreme north (Maroua) and an English-language journal editorial team in a key Anglophone province (Bamenda). 15 CASE STUDIES IN SCALING UP POVERTY REDUCTION Annex 2 Condom Sales 25 000 000 SALES ET SAMPLEAUTRES SALES MOH 20 000 000 SAMPLE 15 000 000 PPLUS SALES PPLUS 10 000 000 5 000 000 0 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 Sales Sample Sales and All pplus pplus Sales MOH samples, others condoms 1989 725 888 0 0 0 725 888 1990 1 967 712 0 0 0 1 967 712 1991 2 976 000 0 0 201 600 3 177 600 1992 4 884 480 227 520 0 481 200 5 593 200 1993 5 088 960 215 171 0 390 918 5 695 049 1994 6 701 760 334 190 0 175 920 7 211 870 1995 6 789 120 291 081 0 452 850 7 533 051 1996 8 385 776 245 275 0 549 636 9 180 687 1997 11 296 436 133 749 0 474 960 11 905 145 1998 6 556 936 115 173 0 141 852 6 813 961 1999 11 360 640 199 634 0 326 400 11 886 674 2000 13 111 760 377 293 0 935 280 14 424 333 2001 14 449 920 584 733 0 0 15 034 653 2002 16 821 120 704 274 0 0 17 525 394 2003 18 916 320 381 961 4 155 840 0 23 454 121 TO DATE 130 032 828 3 810 054 4 155 840 4 130 616 142 129 338 16 ROLE OF SOCIAL MARKETING IN HIV/AIDS PREVENTION IN CAMEROON Annex 3 Details on condom market, offer and cost Increasing market share While the total number of condoms distributed in Cameroon in 2002 was estimated at 28.3 million, PMSC's market share came to 62% (17.5 million). The market share for the public sector was 33%, whilst other private distributors and other distributors of subsidized products such NGOs each had a share of 2.5%. Stimulation of the overall condom market The availability of PRUDENCE PLUS condoms in a high number of outlets and the parallel behavior change and brand promotion campaigns are believed to have also considerably increased the demand for other more expansive brands. Anecdotal evidence indicates that ACMS efforts have stimulated all condom sales. This `halo effect' has been observed in other social marketing programs, although little attempt has been made to systematically document and quantify it. Reduced cost for condom distribution/increased cost recovery According to international data, the gross cost of distributing 100 condoms in Cameroon is FCFA 5,850; in contrast, PMSC distribution costs amount to FCFA 3,645. This is lower than international estimates and is expected to fall even lower in the years ahead given the increase in sales figures for condoms. In turn, the sale of 100 condoms to wholesalers generates an income of FCFA 1,174 which means that the cost of distributing 100 condoms is still higher than the respective income from sales. However, efficiency is expected to improve here as well: while cost coverage at the start of the project was 11%, it had gone up to 18% by 2002 and is expected to rise to 23% by the end of the present funding period (06/2005). Offer of affordable high quality condoms The cost of one commercially branded condom ranges between FCFA 120 and 1,000. The selling price for PRUDENCE PLUS is FCFA 25 per condom, sold in a packet of four for FCFA 100. 93% of the ACMS sales points respect the selling price, however, some 2% are below and some 4% above the official price. Improved accessibility of condoms to the poor The ECAM II household survey (2001) estimates that 40.2% of the population (equivalent to 6.4 million people) is poor. While measuring the extent to which the poor have been reached by the program is a very difficult undertaking, partly due to statistical problems, it is assumed that the percentage share of condom sales to the poor (out of total sales in %) is about 90%. This is based on the assumption that non-poor people prefer the more expensive/prestige condoms which are now widely available in urban areas in Cameroon. 17 CASE STUDIES IN SCALING UP POVERTY REDUCTION Annex 4 Details on impact assessment on efficient use of resources in terms of distribution system PMSC's distribution model makes use of existing resources. A small group of what is now 27 Cameroonian wholesalers have been accredited to purchase PRUDENCE PLUS condoms in bulk and to resell the product to semi-wholesalers and retailers. The sales manager regularly monitors stock levels at the wholesale level and informs one of the regional offices when a sale is made. A locally contracted delivery service moves product from central to peripheral warehouses and local re-supply is managed by taxi or one of the few project vehicles. ACMS sales managers are independent and earn an 8% commission for the condoms they sell. They receive regular training supervisory support and are provided with a modest travel allowance. This is beneficial since people in the field are paid on an output basis, ensuring a high degree of motivation and overall business orientation. By using this approach, PMSC decreases fixed and operating costs remarkably. Second, by maintaining a lean and flexible operational structure, the program has adapted well to a financial base characterized by ad-hoc, short- and medium-term funding which may necessitate quite sudden changes in strategy and workforce. ACMS does not bind itself to a single research or communication/media agency, but rather invites tenders for each separate research or communication product, thereby ensuring good quality and transparent costs. ACMS's own presence in the field during research projects, along side the research agency, ensures each contractor develops and maintains a high standard of quality. More importantly, it facilitates an understanding of the multiple realities that exist among customers, keeping ACMS work 'at the grassroots level'. 18