Successful Elements of Family Planning
Interview with Claire Stokes, PSI
Conducted on March 4, 2008 by Rose Reis and Heather Sanders
Rose Reis: What does it mean to say that PSI has a private sector approach to addressing health problems, such as an unmet need for family planning?
Claire Stokes: Well if you're asking about the private sector approach at PSI, for us it's really using private sector techniques to develop and market services that respond to population needs, in particular in health issues. What does private service techniques refer to? For us, it's really a process of understanding consumer needs and then developing all the programmatic elements that will respond to these needs to serve an end result which is health impact. And in that case we would be addressing unmet need for family planning. The second aspect to PSI's approach is that we use and we give priority to private sector infrastructure when we are in a country because we think it's a very sustainable way of giving access to supplies for populations. So we work it out with private sector and this involves really two types of channels: the first is the outlets that will carry the product (the pharmacies and the drug stores), and the second one is the clinicians, so the providers who will be there to vehicle information to customers. I think the way we work is to be focused on the consumer and making sure we're looking at health impact and the end result of our action and I think that's what really drives our approach.
RR: How has your prior experience with the private sector influencing your work with PSI?
CS: That's an interesting question. My prior experience with the private sector was in marketing and sales and so everything I learned in marketing and sales about meeting consumer needs, understanding consumer behaviors and developing strategies to change that behaviors now apply to PSI. So it was a very easy transition for me. Except that in the past I was marketing toothpaste and oral care and shampoos (because I used to work with Unilever) and now I'm marketing both a behavior (the use of contraceptive) and the contraceptive products that go with this behavior. I would say that all my attention is again on the consumer (or on the potential consumer, the woman) and understanding her needs, her expectations, her fears, her concerns and then help develop these programmatic elements that will eliminate these fears and concern and help her adopt specific behavior. The other way I think my private sector experience influences my work is that I tend to consider that there is a not a "one size fits all" approach. You have many women with many different needs and at different stages of their lives. For me it's important that we understand that and we develop a variety of approaches and methods and services that will respond to these varieties of women's profiles.
RR: What kinds of communication and outreach does PSI use to promote family planning?
CS: In terms of the communication and outreach means that PSI uses to promote family planning, we usually use three channels of communication. The first one is the mass media which involves the TV, the radio with radio shows, the press sometimes with magazines and then billboards. The second level is the community-level media where we do a lot of drama groups, street theaters, we do mobile video units. We generate what we call neighborhood talks. So in Pakistan for instance, we have these Mohalla meetings, which are meetings convened with women from the community and then encourage women to talk about their issues with contraception. The last level is the individual-level which is really the brochures, the leaflets and every type of support that's provided also in one-on-one counseling sessions for women.
There is another way that we do communication and outreach, which is through providers. So we use providers almost as a channel because they are one of the important influencers of women's choices and they also have a very big role to play in terms of continuation of contraceptive use. So marketing to providers is done through our detailing team. Basically they're our sales team but they do more than just selling--the also train the staff that they sell to. So typically, pharmacists, drug store staff and clinicians are our main target and we work a lot with them to make sure they actually provide the right information to their clients and they consult their clients properly.
RR: How should family planning managers begin to develop a family planning outreach strategy?
CS: So how should family planning managers begin developing an outreach strategy? There are two things to a communication outreach strategy: the first thing is the messages and the second thing is the channels. You really need to start with the messages I think. You need to start by going to talk to people, to potential users, to women of reproductive age. And the objective is really to understand what we call the key determinants of behaviors. So what influences them? Is there any cultural pressure, is there any social pressure, social norms, is there any issues with their spouses, what are their fears, what are their beliefs? So we really explore all this in depth. And then from this we try to really identify the key communication that we need to set up to overcome these usage barriers.
The other audience that we work with are the providers and in a broader way all the influencers (people that will make an influence on the woman's decision) for instance it could be their husband. So we also need to work with these people and understand if their role in the woman's life is actually hindering or, on the contrary, helping her adopt the behavior that we want her to adopt. For me, this is really like the most important part of the work, understanding what messages need to be developed.
In terms of channels it really depends on your targets, it's very country-specific. We go back to the three channels that we discussed earlier: the mass-media, the community level and the individual level.
RR: How much should family planning program managers in resource-poor settings decide to invest in communication?
CS: To respond to your question about how much of their budget family planning managers should decide to invest in communication, I think we need to really look at the priorities that come up when you think about programmatic implementation. I think the huge priority is on the supply side, so even investing in communication for me, the main thing to ensure is that there is a product, it's packaged correctly and it's distributed in the outlets that are the most accessible to people. The second step in this process is to look at training people and providers who are going to be in touch with women--people who are going to influence women's choice. So my first investment would be communicating to these people, training them, making sure they console their clients correctly. And only then (if I have money left) I would start investing into broader mechanisms of communication. How much you spend on that depends on your priorities, your objectives and your target group. A lot of it is going to be influenced by your choice of channels. If you have a lot of mass media it's going to be more expensive. If you have a lot of IPC, it can also get very expensive on a per person basis. So I couldn't tell you exactly how much or per person, but I think it really depends on program objectives at the end of the day.
RR: Can you talk specifically about how one program you've worked on has decided where to allocate their resources in terms of the channels and the messages?
CS: There is a good example would be Zambia. In Zambia, they launched their product about 10 years ago, so it's been around awhile. They did a lot of mass media and TV ads to raise awareness about the product, raise awareness about the safety of the product and about the behavior of using the pill. As the product was more familiar and became more popular, they refocused their efforts on investing community level and individual level interventions. Through working with that (I was working with that for a number of years) to identify these channels and the messages that need to be vehicled by these specific channels. And to me it was obvious that they had to focus on side-effects, on misconceptions and rumors on the pill. To do that, the best way to do that, was through community-based interventions. So they decided to create this intervention called the Circle of Friends, which is a group of women that get together on a monthly basis. Each woman is expected to bring a new user with her every month and this new user would share her experience and they will all will work together on this. So that's where they're investing most of their money now because they are that stage where it's much more much efficient for continuation and they are feeling good about using.
RR: Why's that more effective than a mass media campaign?
CS: Specifically for side effects, misconceptions and rumors, the fact that you can share with other women about your own experience is much more convincing for a new user than something she heard on the radio or the TV. The radio or TV, you have to raise awareness and bring up questions or interest among the women, but then she feels much more convinced when it's her own friends and neighbors who share their experiences and say "I have been using this product for ten years and I feel perfectly fine and had no health issues." That works much better.
RR: How can managers mobilize local resources for family planning, I guess in terms of communication.
CS: I didn't quite understand what you meant by the question?
RR: How can you tap into local funding streams and existing channels in terms of partnering, like with local TV stations or local radio station? How could you mobilize? How could you partner with those people to get your message across?
CS: To answer your question about how managers can mobilize local resources for family planning, I would like to use a fairly recent example from Togo where we actually struck a deal with the local TV channel and asked them to air family planning ads for free. And the way we reached that agreement is that we had been investing in TV channel a lot for our other programs, including HIV/AIDS program, and we had this long time partnership with them. We found ourselves in a situation where we didn't have any funding for family planning. We just had product and our distribution networks but no funding for communication. And so we started to become creative and we went to see the TV channel and we asked if we could get some free air-time for our ads and they accepted to do that. Because this worked out fairly well, the local team in Togo started thinking creatively about how to mobilize other resources and so one way that we're doing that is that when we go to do an HIV/AIDS intervention, like a street performance, we always systematically integrated messages on family planning. And that's a way to leverage on an existing resource and communicate onto crucial elements of sexual and reproductive health.
RR: Well you just discussed one campaign that you liked, could you talk about some of your other favorite communication campaigns and what made them successful?
CS: To talk about my favorite campaigns and what made them successful, I'm going to have to look at my experience with PSI and really focus on more recent interventions. There are two campaigns which are among my favorites, and that's completely a personal view that I am sharing here. One campaign is a campaign that was launched in India a few years ago, specifically to promote Emergency Contraception. And it's specifically a spot where you have a couple, a man and a woman, and they have a little baby and they're about to take a train and they have all these people singing around them: "Three days only, three days only, three days only!" And so finally when they settle in the train they ask a question and the husband says "Three days to do what?" and the singer says, "If you get too close to your wife you have three days to take the emergency contraception and she won't get pregnant." And so it's a very simple message. It focuses on the time that you have to take EC before it's too late, the three days. And what I like about it is that being able to make a TV ad about the product that used to be so controversial is a huge success for PSI and for the family planning world in general. So it's really normalizing a product that when it was launched was so controversial. I like the fact that we went from the controversy to a main stream product through that ad in India. That's one example.
Another example is the Congo campaign; the DRC launched a new family planning program about 4 years ago. They developed this umbrella campaign using an umbrella brand call Confiance, which means confidence, and they have three TV ads, each of the focusing on a key determinant of behavior. So one TV ad is about side effects and it shows a young woman, active professional, and she talks about the safety and the very limited side effects of the pill. The next ad is on the economic well-being provided by family planning; it's more about family planning benefits. And it involves a couple. And then the third ad is targeted at men and it's really about mens' role in family planning, and helping their wives make the right decisions for their couple. It's really these 3 things decline and then they'll decline everywhere, they'll decline on the billboards, they're used in the brochures, the leaflets, and you can even find them at the point of sales and the clinic level. It's a thematic campaign with themes you can find everywhere, all the way from mass-media to individual-level and I think that's the best way to get health impact and behavior change and continuity in the messages. They are very clear, very straight-forward, so I like this because of that.
RR: When did PSI begin to integrating HIV and family planning services and why did PSI make this program change?
CS: I don't really like to talk about a change. For us it's more of an evolution rather than a change and it's a fairly natural evolution when you think about it. HIV and family planning are both in the area of sexual and reproductive health and there are needs that population has, whether you talk about men or women. Maybe needs for family planning with men are not obvious, but it's there. So it's something that we always doing, it was always part of our approach to talk about both. but we became more systematic about doing it about 3 or 4 years ago. And by systematic I mean we started to really look at our service networks. We have networks of volunteer counseling and testing for HIV/AIDS and we have networks for family planning service and we started to really think critically about this and design a systematic way of integrating services. So obviously these centers started to add FP counseling to their services for both HIV+ and HIV- people. And the FP services, for instance we have a network in Cambodia more focused on family planning, and they started to integrate and offer VCT services. So it's more systematic now I would say, but it was always part of our approach. The other example that comes to mind is the network in Madagascar, we have a network of clinics called Top Reseau, which is targeted at young people and has always targeted both issues because they are pretty much daily issues for young people. So very early on we had FP and STI services and then we started to incorporate VCT a couple of years ago. I think it's a very natural movement to make and I think it's probably important that we stop working in terms of thinking about these issues vertically because the consumers don't think about them vertically.
RR: So have you had success with those services?
CS: To integrate? It depends on how you define success. The services have been integrated. We've trained VCT counselors in FP and FP counselors in VCT. We are making sure that there is a referral system so that if someone goes through VCT and wants FP services that they can get the services and the products that they want. I think it's successful from that aspect. The integration has happened and it's functioning well. It's probably much more efficient because you're talking to a captured audience because once they're in front of you, you can really talk about various issues--HIV and family planning together. It's also been pretty successful for discordant couples. It's great to promote both consistent condom use but also the use of another contraceptive method, so I think it was pretty successful from that aspect.
RR: Is that a bigger issue recently?
CS: We're entering a territory that's less familiar to me because I don't really work on HIV/AIDS that much. It's an issue in many of the sub-Saharan countries where HIV prevalence is high and is transmitted through heterosexual contact. I've read recently and it's probably a very strong statement but, in some countries of sub-Saharan Africa getting married is one of the first risk factors of getting HIV and so obviously there is a huge work to with discordant couples, just married couples, to make sure that they don't transmit HIV to each other.
RR: Can you talk a little bit about PSI in general, how many countries you work in, how many people you reach, which countries are more focused on right now and when it started?
CS: To answer your question about where PSI is and what we do, PSI is present in 60 countries around the world--Latin America, Asia and Africa essentially. In the 60 countries, we have a variety of programs, we have a lot in HIV prevention, malaria prevention, safe water systems, ORS and for family planning specifically we have 25 countries with an active family planning program. Most of our programs are in Africa for family planning. We have 10-12 countries is West Africa, 8 countries in East Africa and a few in Asia and only one or two in Latin America. in terms of impact, we sold about 900 million condoms in 2007, so it's a very big reach for PSI. We're very strongly present. In some countries, our product accounts for 80-90% of the market. In family planning, we're talking about reaching 7 million couples with essentially oral contraceptives, injectables and more and more IUDs and implants. We also have activities more focused on services. We have 20-25 VCT networks now that provide volunteer counseling and testing and we have about 12 networks that focus more on family planning, in countries like Myanmar, India, Cambodia, Pakistan but also a few in Africa (Benin and Cameroon). I think that's about what I can say about the extent of our projects.
RR: Did you want to follow-up on anything we talked about? Why do programs need communication and outreach? Why can't they just offer contraception and services?
CS: The reason why programs need communication and outreach strategies is because you can't have the supply side without the demand side. Communication and outreach is demand and offering contraceptives and services is supply. And they need to be both together to create a market and to create consumers or users of specific products. i think something that's very important when we design a program is the "push", the supply, you know when we push the products down to consumers and giving them access and making sure the services they are receiving are good quality and consistent. And the reality is that there is still a lot of work to do about the benefits of family planning--communicating to women about the safety of contraception, making sure that the rumors and the misconceptions are dealt with because even though contraception has been around 30-40 years, in some of these countries you still have major rumors going around. I think one of the main objectives of the communication and outreach strategies is to work on that, informing the consumer, reassuring her and making sure she knows what she's doing and knows that it's good for her health.
The other aspect that I think it's really important in communication and outreach strategy is that it's an ongoing work. You always have new women, teenagers become women of reproductive age, and they need to be informed. So if you don't have the communication and the outreach to inform them, then they may end up at reproductive age without even knowing how to conceive a baby or prevent an unwanted pregnancy. It's a crucial part of the programmatic elements and it's been relatively neglected to some extent. I think in recent years we've focused a lot on the supply side and probably not enough on the demand side.
RR: So how does that work, you keep making campaigns or does the message get integrated in society?
CS: I think the message is not necessarily hard to develop. However what is hard is to make sure that you have enough exposure to these various media levels so at the end of the day you can make sure you have changed someone's behavior. And that I think is the challenge. It's not as much about the content, but it's about the repetition and the right amount of repetition for women to really understand and integrate the message.
