Community-Based Distribution the Distributive Potential And

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Community-Based Distribution: The Distributive Potential and Economics of a SocialMarketing Approach to Family PlanningAuthor(s): T. R. L. BlackReviewed work(s):Source: Proceedings of the Royal Society of London. Series B, Biological Sciences, Vol. 195, No.1118, A Discussion on Contraceptives of the Future (Dec. 10, 1976), pp. 199-212Published by: The Royal SocietyStable URL: http://www.jstor.org/stable/77170 .

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Proc. R. Soc. Lond. B. 195, 199-212 (1976)Printed in Great Britain

Community-baseddistribution:the distributivepotentialandeconomics of a social marketing approachto family planning

BY T. R. L. BLACKPopulation Services International, London

Because of the shortage of medical manpower in the developing worldfuture family planning programmes will increasingly be supplementedby the use of non-clinical resources through what is known as community-based distribution (c.b.d.) programmes. Currently the c.b.d. resourcesbeing mobilized range from church groups to the commercial marketingindustry. The use of marketing techniques in this way to distribute con-traceptives at subsidized prices is an example of social marketing. Thisapproach has the advantage of being able to use the world's ubiquitousshop system and of being highly cost-effective. Fragmentary data suggeststhat in most countries there is one store for every 25 to 120 fertile couples.Evidence on the number and distribution of stores in various countries isdiscussed. Cost-effectiveness figures for the Preethi and Nirodh condomc.b.d. programmes are presented. These show that in 1973 the Nirodhprogramme was providing a couple-year of protection for $1.78. Com-parable evidence on cost performance figures for clinic programmessuggests that c.b.d. marketing programmes are substantially more cost-effective in purely quantitative terms. Finally, the most importantfuture development in this field is the recognition that an appropriatemanagerial environment for c.b.d. programmes would have a greaterdemographic impact than any foreseeable development in contraceptivetechnology.

INTRODUCTIONWhatever the nature of future contraceptives they will have to be distributed tothe fertile. Traditionally this has meant the use of doctors and clinics. But world-wide, according to W.H.O. statistics, there are no more than 2.5 million doctors(Doan 1974). Of these less than 500000 come from the developing areas of LatinAmerica, Africa and Asia. And probably not more than 50-60 000 work as primaryhealth physicians in the rural areas of these continents. Because of this acuteshortage future family planning programmes will continue the present trend andevolve along three lines. Activities requiring physician skills will be channelledthrough services which naturally bring the at-risk fertile patients in contact withdoctors such as in post-partum and maternal and child health clinics. Secondly,a widening range of family planning functions will be delegated to paramedical andauxilliary personnel. While clinical activities will increasingly be supplemented bythe use of non-medical resources to promote and deliver contraceptives, a processwhich has been given the generic term community-based distribution (c.b.d.).

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T. R. L. Black (Discussion Meeting)At the present time there are c.b.d. programmes or pilot projects of one kind oranother under way in 34 countries (People 1975; Huber et al. I975). The catalogueof resources being mobilized range through religious institutions such as with theChurch of Christ programme in the Philippines, women's organizations as in Nepal,teachers in Thailand, the postal services in Sri Lanka and Kenya, and as in the

pioneering Nirodh condom programme in India, the commercial marketingindustry. Some of these programmes are relying principally on volunteers todistribute contraceptives free, such as with the Benfam programme in northernBrazil. Others sell contraceptives at near commercial prices, as the JapaneseFamily Planning Association is doing with its door-to-door saleswomen, or athighly subsidized prices either through groups such as the welfare workers of HongKong or through the normal retailing system of shops as, for example, in India,Sri Lanka, Jamaica, Indonesia, Fiji, Kenya and Bangladesh.Critics of the use of volunteers argue that it is a retrograde step in the face of apopulation crisis; that it is not capable of massive expansion and that the highturnover of volunteers makes for inefficiencies and intermittency of supply whichnaturally is undesirable with contraceptives. Critics of the sale of contraceptivesmaintain that it is commercializing family planning and that however low theselling price this will effectively deny contraceptives to the extremely poor. Suchcriticisms are only partially valid. Apparently volunteers can be mobilized effec-tively in some political environments such as China (Chen 1975). The sale of contra-ceptives can be totally subsidized where necessary by the use of coupon systems,an approach which is currently being tried with some success in Costa Rica (IsaacsI975)-Advocates of community-based distribution maintain that the implications forfamily planning go beyond non-clinical distribution. They see it as an importantstep to involving the grass-roots community actually in the process of program-ming. In this way family planning can be promoted on a continuing basis fromwithin the society. This is in direct contrast to the prevailing situation in whichbirth control, a preventive community service, is being delivered from urbanbased clinic systems in the manner and style of curative medicine.

My experience over the last 5 years has been almost exclusively with c.b.d.programmes which use commercial resources. Therefore in this paper I propose tolook at the distributive potential and economics of a social marketing approach tofamily planning and speculate briefly on the future.

CONTRACEPTIVE SOCIAL MARKETINGThe commercially purchased contraceptives were available long before theadvent of family planning clinics (Peel I963; Levin 1968). In most countries more

people still buy their contraceptives from shops than obtain them from organizedfamily planning services (Sollins & Belsky 1970; A. D. Little 1972). It was thisobservation that led the Indian Institute of Management in 1963 to the concept

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Social marketingapproachtofamily planningof distributing contraceptives through commercial channels at subsidized prices(Indian Inst. Management I963). The result of this work was the launch of thepioneering Indian Nirodh condom programme in 1968 (for details see FrandaI972).The Nirodh programme is an example of what is now known as social marketing,or the use of marketing techniques and resources to further social as distinct fromcommercial objectives (Kotler & Zaltman I97I). This approach to social changeis being used not only in family planning but also in agriculture, nutrition (Wick-strom I974), health care (Zaltman & Vertinsky I97I) and education. For thoseunfamiliar with the social marketing model as applied to family planning it is aprogramme organized along the lines of a consumer sales organization (Roberto1972). This consists of a small management cadre which acts as a flexible, coord-inating nerve centre controlling programme activities through contracting, inter-acting and cooperating institutions usually from the private sector. In this waythe programming functions of research, promotion and distribution are undertakenby specialist agencies hired for the purpose, thus avoiding the necessity ofinstitution building.The key to successful social marketing of family planning is the use of consumerproduct distributors who can channel contraceptives nationally at very little costfrom urban wholesalers to village shops. Since a product increases in price by nomore than 50-60 % as it passes through this distributive pipeline it is possible byselling distributors contraceptives at subsidized prices to make them available onshop counters at nominal prices. For example, the Nirodh Programme which usesthe services of manufacturer distribution organizations such as Brooke Bond,India Tobacco, Lipton Tea Ltd, Hindustan Lever, is able to sell condoms in packsof 3 to the fertile for 3 U.S. cents or just over one penny. Similarly condoms arebeing sold 3 to a pack for 4 cents in Sri Lanka, 7 cents in Kenya and 10 cents inGhana, while in Bangladesh both condoms and pills are now on sale for 2.8 centsand 5 cents respectively.

Apart from mobilizing the technical and physical assets of the established anddemonstrably effective marketing industry for family planning purposes there aretwo advantages claimed for the social marketing of contraceptives. The distribu-tion of contraceptives through consumer goods channels can overcome the weakestaspect of current family planning programmes: the limited number of serviceoutlets. Secondly, the use of contracted services in this way is cost effective.

THE DISTRIBUTIVE POTENTIALEvery developing country has an extensive network of shops, through whichcondoms and pills can be distributed. The limited data available suggests that inmost countries there is probably one store of some kind for every 25 to 120 fertilecouples. In addition there are usually hawkers, fairs and a highly developed systemof daily and periodic markets, such as the Mammi markets of West Africa. Curi-

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202 T. R. L. Black (Discussion Meeting)ously enough, unlike the retail shop system, fairs and periodic markets have beenthe subject of exhaustive study world-wide, primarily by anthropologists andgeographers (for bibliography see Bromley I974). The extent of national retailingsystems is difficult to verify. Stores are usually unlicensed or only licensed locallyso that statistics are mostly unobtainable. But fragmentary data are available. An

TABLE 1. THE URBAN-RURALDISTRIBUTIONOF GENERALRETAILSHOPSIN KENYA 1972

area number people per shopNairobi 2131 235Mombasa 1231 203Nakuru 257 195Kisumu 201 164rest of Kenya 20165 529total 24585 508

Source: Min. Finance & Planning Nairobi 1973; Corcoran& Tyrrel 1974.TABLE 2. CENSUS OF RETAILOUTLETS N CEYLON 1972

(Courtesy the Sri Lanka Institute of Marketing.)number ofoutlets

government co-operative wholesalers 13government co-operative retail branches 89all-Ceylon Consumer Co-op Union (milk distribution) 1primary Co-op Societies (wholesalers) 370Co-op retail branches 5716marketing department shops 55restaurants, cafes, eating houses 12193general retailers, large 4725general retailers, small 37275general wholesalers 450semi-wholesalers 350chemists (pharmacies) 290drapers (textile shops) 2503bakeries 2020bars, cinemas, clubs 783hawkers, mobile vendors 8444

total 75277Egyptian study by Boyd et al. (196I) found that in 1960 there was a general storefor every 25 fertile couples. In Thailand a store census indicates that in 1966 therewas a sales outlet to every 46 fertile couples (Anderson 1970). Kenya, a countryin which stores are licensed annually, is the source of the data shown in table 1,illustrating the relative urban-rural distribution of shops (Corcoran & TyrrellI974). In Jamaica commercial brewers claim to sell to 15000 outlets, or one forevery 140 people (Westinghouse I973a). Shop census figures from Sri Lankaindicate one general store for every 348 people and provide a detailed picture of


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Social marketingapproachtofamily planning 203the typical spectrum of outlet in a developing country (see table 2). In practicalterms it is evident that unlike clinics the shop is the outlet of a system that clearlydoes have intimate contact with the fertile.

A retailer may be defined as someone selling to the general public from a shopestablished within a permanent structure. This excludes market stalls, panwallahs,kiosks and hawkers. Obviously with so many shops available the retailer plays amajor role in people's lives. A survey of 856 rural respondents in Kenya showedthat nearly three-quarters had visited a shop within the previous 48 h (P.S.I.I97zb).The developing country retailer is very different from your local storekeeper.He or she is usually semi-literate and keeps few records and carries a small amountof stock of surprisingly wide range. The typical East African 'duka', for example,stocks staple items such as maize, sugar, rice, spices, tea, salt and bread. It alsodeals in cigarettes, matches, kerosene, soap, baby food, cheap confectionery,cooking fat or oil, soft drinks, assorted cheap tinned foods and nowadays soappowders. A high proportion also sell patent medicines. A survey of 60 stores inrural Kenya showed that 72 % carried analgesics, 90 % anti-malarials, 42 % anti-worm preparations, 48 % laxatives, 70 % cough medicines and incidentally 68 %also sold sanitary napkins (P.S.I. 1972a). Personal observation reveals that inWest Africa and Asia many shops openly sell abortifacients and occasionally thepill. With this range of stock the addition of contraceptives to the store shelfshould present no problems.The sales turnover for developing country shops is very low. A survey by Harper(I972) of 130 rural shops in Kenya showed that 70 % had total sales of no morethan ?1000 per year, of which about ?120 was profit. In Thailand, according toAnderson (I97o), the average turnover of urban retailers in 1966 was only ?3700,while that for rural retailers was less than ?700. There are no reasons to suspectthat such figures are atypical. With such sales levels we cannot expect individualretailers to sell large numbers of contraceptives. The prospect is of a large numberof retailers each selling a small number of contraceptives.But to what extent are shopkeepers willing to participate in family planning?A survey by Westinghouse of a sample of retailers in eight developing countriessuggests shopkeepers are probably better informed about family planning, andpossibly more liberal than the general public as a whole, and that more would bewilling to stock contraceptives than not (Westinghouse 1973b). Surveys of retailersin Kenya and Sri Lanka support these findings (see table 3) (P.S.I. 1972a, I974).They also revealed that retailers willing to stock and display contraceptives do soprimarily for materialistic reasons.

In practice the recruiting of retailers as contraceptive salesmen has not provedto be a problem whether it be in rural Kenya, Sri Lanka, Bangladesh, India orJamaica. In the Kinga condom social marketing experiment in a large rural areaof Kenya just under 400 village retailers or one-third of all outlets in the districtwere stocking the product within two months of its launch (Black & Harvey 1976).


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204 T. R. L. Black (Discussion Meeting)The main deciding factors of whether to stock Kinga or not was the availabilityof cash when a salesman called (a major problem), and reassurance that the productwould be well promoted. Few shopkeepers refused to stock the product because itwas a contraceptive. In Sri Lanka within one month of the launch of the Preethinational condom programme the distributors, Reckitt & Colman Ltd, had thisproduct on the shelves of 3177 outlets (P.S.I. I974). Whatever family plannersmight like to think, most shopkeepers seem to regard contraceptives as just anotherproduct line and accordingly they ask the usual questions - how much do I make?,does it sell?, and will you advertise it? Their doubts appear to be predominantlycommercial rather than moral or religious.

TABLE 3. ATTITUDES OF A SAMPLE OF 30 PHARMACISTSAND 200 RETAILERS INSRI LANKA AND 60 RURAL RETAILERSIN KENYA TO FAMILY PLANNING IN 1972AND 1973 SriLanka 1973 ruralKenya...-. .. 1972pharmacist retailer retailer% % %awarenessof familyplanning 100 99 90awareof pills 95 69 63awareof condoms 97 61 67no. stockingcondoms 93 3 5willingto displaycondoms 77 57 93approveof condomadvertising 93 75 93

Source:P.S.I. preprogrammemarketresearchKenya and SriLanka.In our experience stockists are eager to learn about the contraceptives they sellso that they can advise their customers, just as they do very ably with, say, anti-malarials. But getting the shopkeeper to become a promoter of contraceptives ismore difficult. A survey of Nirodh stockists showed that only 21 % claimed to

actively sell the product (Mohammed I969). The principal reasons cited for notdoing so were shyness and fear of offending customers. In the Kenya experimentthe shopkeepers were entirely passive salesmen unless questioned by customers,but this is how they sell all products. Sales experience in Kenya and Sri Lankahas shown that if stockists are educated about contraceptives, the products areon display, and they are strongly supported by point-of-purchase promotionalmaterials, then customers are stimulated to ask questions as well as purchase.The other significant finding from the Kenyan project was confirmation thatthe pattern of contraceptive sales follows the general rule of thumb in marketingthat approximately one-third of outlets achieves two-thirds of all sales in a givenarea. These high sales shops tended to be bigger, better stocked and owned byyounger, more outgoing people. This suggests that programmes should adopt aselective distribution strategy, at least initially, an approach that was used togood effect by the Preethi programme in Sri Lanka.


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Social marketingapproachtofamily planningProvided commercial considerations are appreciated, experience indicates thatthere are no practical barriers to making condoms and pills readily available con-sumer goods through the ubiquitous shop system described, or to prevent therecruitment of shopkeepers as grass-roots advocates and educators for family

planning. Instead, the problems lie with the medical profession, family planningadministrators and the funding sources.THE ECONOMICS OF SOCIAL MARKETING

Performance budgeting studies in family planning are highly political, heavilyreliant on secondary data, and measure output on the basis of a variety of non-standard assumptions in terms of acceptors, couple-year of protection, or birthsaverted. Therefore, such studies are hardly routine. Yet with official funds world-wide for family planning, seemingly plateaued at about $500 million and no longerkeeping pace with the eroding effects of inflation and population growth, pro-gramme economics are more important than ever.

15.6% 20.4%

FIGURE 1. The allocation of funds from all sources for the Korean family planning programmefor the years 1964 to 1968. (Source: Penstate study I969.)Theoretically social marketing programmes should be highly cost effective. Theuse of contractors whose overheads are spread over a range of commercial activities

means that funds are spent primarily on contraceptives and promotion, rather thanon supporting an institutional establishment as is the case with clinic programmes.The resulting difference in the deployment of funds is well illustrated by twoprogramme budgets for which detailed data are available; the 1968 Korean clinicprogramme (figure 1), and the 1969 Nirodh social marketing programme (figure 2).

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T. R. L. Black (Discussion Meeting)On the other hand, social marketing programmes to date have been confined todistributing only a male related, not very effective or popular means of contra-ception, the condom (or in the case of Ghana, condom and foam), which hasnaturally meant high distribution and promotional costs for any given measureof outnut.

Advertisingand Promotion45%

Contraceptive Supplies 45% \

FIGURE 2. The allocation of the 1969 Nirodh programme budget. (Source: Government ofIndia Paper 1969.)One programme for which detailed cost and performance data is available is theSri Lanka Preethi (the brand name means 'happiness') condom social marketing

programme. This was funded by the International Planned Parenthood Federationand managed by Population Services International, a specialist non-profit familyplanning organization. Following a 6 months start-up period involving marketresearch and the creation of a promotional campaign, the programme was launchedin October 1973. Preethi was distributed nationally by Reckitt & Colman CeylonLtd and supported by a heavy advertising campaign created and managed by alocal agency. The lubricated condoms were sold in packets of three for 40 localcents or about 2 pence and promoted through a multi-media campaign involvingpress, cinema, radio and heavy point-of-sale promotion. In the first 9 months ofthe programme 2.9 million condoms were distributed, of which 96% were soldthrough shops, 2% sold by mail-order and 2% given away as samples. After a full18 months of marketing 5875000 condoms had been sold, and it is for this launchperiod that detailed budget figures are available.For the 2-year programme including the initial 6 months start-up the totalinput or local programming expenditure (excluding commodities) was $390500,of which approximately 19% can be attributed to start-up costs and 35% to

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Social marketingapproachtofamily planningPreethi promotion. During this period the income to the programme from Preethisales was $23 000 which means the net subsidy required was $367 500 for 2 years.Thus on sales of 5875000 items the subsidy required was 6.25 U.S. cents or justover 3.4 pence per condom sold. However, this excludes the actual cost of thecondom which was 2.2 cents or 1 penny an item, making a total cost of 8.45 centsof 4.2 pence per protected act of intercourse. Adopting the assumption used bythe one major cost-benefit study (Penstate 1969), that 100 condoms distributedis equivalent to one couple-year of protection (c.y.p.), suggests that 58750 c.y.p.were provided during the first 18 months of marketing, assuming only nominallevels of wastage. This means that the Preethi programme was delivering onec.y.p. for a subsidy cost of $8.45 or about ?4.20*, figures which are summarizedalong with the budget in table 4.TABLE 4. A SUMMARY OF THE COST AND PERFORMANCE OF THE PREETHI CONDOM

MARKETING PROGRAMME FOR THE PERIOD MARCH 1972 TO MARCH 1974sales subsidy per subsidyOct. 1973 to condom perlocal budget March 1975 U.S. cents c.y.p.

start-up costs $75000promotion $138000 5875000 2.35 $2.35other $177500$390500sales income $23 000net cost $367500 5875000 6.25 $6.25cost of condoms $129500total cost $497000 5875000 8.46 $8.46

Source: P.S.I.In interpreting these input-output figures it must be remembered that thePreethi programme was new. It was a major innovation for family planning in SriLanka. In other words these are the costs of launching a new programme which

are naturally higher than those for an established one, since with time costs wouldfall substantially as more new customers are recruited and old ones repurchase.In addition, the initial start-up costs would normally be written off over a 5-yearperiod. Furthermore, it was planned to launch an oral contraceptive in 1976 withthe brand name Mithuri (which means 'friend'). The introduction of a pill com-ponent to such a programme would substantially increase the number of couple-years of protection (13 cycles = 1 c.y.p.), without significant increases in non-product related costs.Some indication of the impact of pill sales on cost-effectiveness can be deduced.Mithuri was successfully test marketed in the spring of 1975 (Davies & Louis I975).On the basis of this test, 1976 sales projections were conservatively forecast at350000 cycles. Anticipated condom sales were pessimistically projected at4250000 or 0.3 per capita (0.27 in 1974). Assuming the programme was to achieve* $2.015 = ?1.

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T. R. L. Black (Discussion Meeting)these sales targets then it would be providing 26 900 pill and 42 500 condom couple-years of protection, or a total of 69400 c.y.p. in all. The budget required for the1976 programme was $305000 inclusive of contraceptive supplies. Thus if theprogramme were to achieve the sales forecast it would be providing a c.y.p. for$4.39 or ?2.18. On the other hand the anticipated cost for a c.y.p. for a condom-only programme at this level of condom sales and a budget of $227000 wouldbe $5.34 or ?2.65.The Indian Nirodh programme provides a second example of contraceptivesocial marketing economics. In 1969, the second year of the programme, 29.51million Nirodh condoms were sold (or 0.03 per capita) at a cost of $950000, ofwhich 45 % was for commodities and 45 % promotion (but excluding start-upcosts). This means that in its second year the programme was providing a c.y.p.for $3.23 or ?1.60. In 1973 the programme sold 116 million condoms (or 0.21 percapita) for a total cost of $2070000, of which 84 % was for the condoms sold.Therefore, in 1973 the Nirodh programme was providing a c.y.p. for $1.78 or?0.88, a reduction of 45 % in costs within 5 years. Some of the differences betweenthe costs of the Nirodh and Preethi programmes can be attributed to the effectsof a larger market, the forces of inflation, a lower level of promotional expenditure,and cheaper condoms. For example, the 1969-70 Nirodh promotional budget was0.07 U.S. cents per capita as compared to the 1974 Preethi promotion expenditureof about 1 cent. The unlubricated Nirodh condom cost 1.5 cents each as comparedto 2.2 cents for the lubricated Preethi product.

Attempts to compare these cost performance figures with those of clinic pro-grammes are fraught with difficulty. Obviously it is simpler to measure the inputsand outputs of a social marketing programme than it is for a clinical one. Thebudget is well defined and output is measured in terms of the sale of only one ortwo products, whereas clinic programmes have a multitude of hidden inputs suchas the uncosted use of buildings, supporting administrative services and capitalinvestment which spill over from health budgets. There is also the 'joint-cost'problem such as when health nurses provide family planning services. These andother difficulties associated with performance budgeting studies of clinic familyplanning programmes have been thoroughly reviewed elsewhere (Economic Com-mission I969). Cost comparisons are further complicated by the fact that the mostcommonly used measure of output in clinic cost-benefit studies has been acceptors- a rather ill defined and unreliable measure generated from service statisticswhich cannot be satisfactorily derived from contraceptive sales figures. Suchstudies have reported clinic programme costs ranging from $3.61 to $39 peracceptor (Lapham & Mauldin I972; Slavin & Bilsbarrow I974).

One major study, however, has measured clinic programme output in terms ofcouple-years of protection. In 1969 Pennsylvania State University compared thecost inputs including foreign aid of six national programmes and measured outputin terms of couple-years of protection on the basis of contraceptives distributed orsterilizations performed, using assumptions such as 100 condoms or 13 pill cycles

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Social marketingapproachtofamily planningdistributed equals one c.y.p. On this basis the cost of a couple-year of protectionin the countries studied ranged from $2.21 to $20 (Penstate 1969). By applyingthe same assumptions to three of the countries studied for which recent budget,contraceptive distribution and sterilization figures are available (Watson &Lapham1974; Nortman 1975), we can derive some indication of present costs of providinga c.y.p. through clinic services. The result of this exercise is shown in table 5,which is based on a constant 1968 rate of exchange for local currency budgets.TABLE 5. THE COST OF PROVIDING A COUPLE-YEAR OF PROTECTION FOR THREENATIONALCLINICPROGRAMMESN 1968 AND 1974 AT A CONSTANT 1968 RATE OFEXCHANGE country 1968 1974

India $3.10 $9.45Korea $2.48 $8.06Taiwan $2.21 $2.80Source: derived from Penstate (I969), Watson & Lapham (I974), Nortman (1975).100 condom or 13 pill cycles = 1 c.y.p. I i.u.d. = 2.5 c.y.p. Sterilization = 7.5 c.y.p.

On the basis of these figures, the apparent cost is between $8.00 to $9.45 to providea c.y.p. through the Korean and Indian clinic programmes in 1974. Obviouslythese figures, which unlike the earlier Penstate study are based solely on localgovernment statistics, must be interpreted with caution. But they do suggest thatinitially social marketing programmes may be no more cost-effective than theclinic programmes they are designed to supplement. However, as markets developand other contraceptives are introduced it would seem that this type of programmewill be substantially more cost-effective, at least in purely quantitative terms. Ifnothing else such comparison indicates an urgent need for an entirely independentlook at this whole cost-effectiveness question, preferably by an international firmof auditors.

FtUTURE DEVELOPMENTSThe future of contraceptive social marketing will depend entirely on the extentof high level appreciation of the concepts involved and commitment to thisapproach. Fostering supportive attitudes alone will be a major public relationstask. And it will have to be appreciated that the very language, style and tempoof marketing must be adjusted to cater for the biases of politicians and adminis-trators who currently perceive family planning in clinical terms. But there are twokey developments which would have a major impact on cost and demographiceffectiveness of these programmes.The first is the advent of a physician-free post facto or hindsight contraceptivesuch as the 'week-after' pill. Any product which can put the clock back andcorrect a mistake will be an instant success.The second fundamental development is the question of appropriate manage-ment. Of all family planning variables the one which has been virtually ignored

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210 T. R. L. Black (Discussion Meeting)by researchers is the issue of management and performance. Yet management is aparameter which is adjustable and which must have enormous influence on pro-gramme output. Since no controlled studies exist the extent of this influence indemographic terms remains unknown. However, on the basis of informed judge-ment we can speculate.

Marketing is still an art, not a science. Empirical evidence tells us that successfulsales operations require a particular set of talents which operate best in a flexible,dynamic, consumer orientated environment attuned to taking reasonable risks, asetting not usually associated with family planning, which is, of course, subject toprofessional, political, religious, cultural and social contraints. But the questionremains to what extent would the provision of such an environment for programmemanagers influence sales performance. Some years ago Ford Foundation expertsexamined the implications of changing the managerial setting for the Nirodhprogramme (Ford Foundation I969). They maintained that the optimal settingfor the Nirodh managers would be a specially created independent corporation.

-2with proposed effort

600-

00 decision1" to change 5rangeofexectations

x 068-69 69-70 70-71 71-72 72-73 73-74 74-75

eeardFIGURE. Nih mketingme: sales experience and projecs.co 200- [ ' ......xMinistryocorporat eetting would thpresead t efforto

68-69 69-70 70-71 71-72 72-73 73-74 74-75yearFIGURE. Nirodhmarketingprogramme: alesexperienceandprojections.

In their considered opinion the effect of relocating the management from a HealthMinistry to a corporate setting would have had the effect on sales shown in figure3: that is an increase in sales over the ensuing 5 years of between 300 and 600 %.In other words, changing the managerial environment to one conducive to free-range decision making would have had a far greater impact than any other likelydevelopments.This observation on the role of a non-bureaucratic managerial environment is


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Social marketingapproachtofamily planning 211not to be construed as an anti-government statement. It is merely a comment onsomething that we in family planning are choosing to ignore. This, I submit, isthat over the next decade the greatest gains in birth control are likely to resultnot from developments in contraceptive technology but the adoption of appro-priate and liberated management for community-based distribution programmes.

REFERENCES (Black)Anderson, D. A. I970 Marketing and development,theThai experience,pp. 158-159. MichiganState University.Boyd, H. W. et al. I961 Channels of distribution for consumer goods in Egypt. J. Marketing25, 26-33.Black, T. & Harvey, P. 1976 A report on a rural contraceptive social marketing experiment

in Kenya. Studies in Family Planning 7, no. 3.Bromley, R. J. I974 Periodic Markets, Daily Markets and Fairs: a Bibliography, Monashpublications in Geography, no. 6, Melbourne, Australia.Chen Pi-Chao 1975 Lessons from the Chinese experience: China's planned parenthoodprogram and its transferability. Studies in Family Planning 6, no. 10.Corcoran & Tyrrell I974 A marketing man's guide to Kenya, p. 41. Nairobi, Kenya.Doan, B. D. H. 1974 World trends in medical manpower. World Health Statistical Report27, no. 2. Geneva: W.H.O.Davies, J. & Louis, T. D. J. 1975 Doctors and community based pill promotion in Sri Lanka.I.P.P.F. Med. Bull. 9, 1-3.Economic Commission for Far East and Asia 1969 Reportof theexpertgroup meeting on socio-economic returns of family planning programmes. Asian Population Studies Series, no.12, Bangkok.Franda, M. F. I972 Marketing condoms in India: the Nirodh Programme. American Univer-sity Field Staff Reports 16, no. 8.Ford Foundation I969 The Nirodh Marketing Programme: the case for a new organizationalbase, New Delhi.Harper, M. I972 The discoveryand satisfaction of theperceivedand actual needs of rural shop-keepers in Kenya. Institute of Development Studies, Working Paper no. 16, Nairobi,Kenya.Huber, S. C. et al. 1975 Contraceptive distribution taking supplies to villages and households.Population Reports,Series 3, no. 5.Institute of Marketing 1972 Census of retail outlets in Ceylon. Colombo, Sri Lanka.Indian Institute of Management I965 A proposal for family planning promotion: a marketingplan. Studies in Family Planning 6, 7-12.Isaacs, S. 1975 Non-physican distribution of contraceptives in Latin America and theCaribbean. Family Planning Perspectives 7, no. 4.Kotler, P. & Zaltman, G. I971 Social marketing: an approach to planned social change.J. Marketing 34, 3-72.Lapham, R. & Maudlin, P. W. 1972 National family planning programmes: review andevaluation. Studies in Family Planning 3, 29-52.Levin, H. I968 Commercial distribution of contraceptives in developing countries, past,present and future. Demography 5, 941-946.Mohammed, P. S. 1969 The Nirodh Marketing Programme - a post-launch retailer survey.Report, the Ford Foundation, New Delhi.Nortman, D. 1975 Population and family planning programmes: a factbook. Reports onpopulation/Family Planning 2, 7.Peel, J. 1963 The manufacture and retailing of contraceptives in England. Population Studies18, 113-125.Pennsylvania State University 1969 Cost-benefitand cost effectiveness evaluation of familyplanning programs. Dept. Economics, Phase II Report, University Park, Pennsylvania.


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212 T. R. L. Black (Discussion Meeting)People 1975 Distributing contraceptives. People 2, no. 4.P.S.I., Population Services International 1972a A survey into the attitudes of Duka ownersin the Meru district to family planning and the marketing of condoms. Report, Nairobi,

Kenya.Population Services International I972b A pre-programmeknowledge, attitude and practicesurvey of 506 respondentsin the Meru and 350 in the Kirinyaga Districts, vol. 1. ResearchBureau Ltd, Nairobi, Kenya.Population Services International 1974 Preethi, a social marketing programme or theadvance-ment of family planning. A report, Colombo, Sri Lanka.Roberto, E. L. 1972 Social marketing strategies for diffusing the adoption of family planning.Social Sci. Quarterly53, 33-51.Slavin, S. L. & Bilsbarrow, R. E. 1974 The Barbados Family Planning Association andfertility decline in Barbados. Studies in Family Planning 5, no. 10.U.N.F.P.A. 1974 Theroleof international assistance in thepopulation fields. Report, New York.Watson, W. B. & Lapham, R. J. (eds) 1974 Family planning programmes, world review1974. Studies in Family Planning, 6, 205-324.Westinghouse Population Centre 1973 Distribution of contraceptives n the commercialsector,see reports on Jamaica, Iran, Panama, Thailand, Korea, Venezuela and Turkey.Columbia, Maryland.Wickstrom, B. 1974 Thefunction of promotion in social marketing. Paper presented F.A.O./S.I.D.A. Regional Workshop on Food Promotion, Nairobi, East Africa, 22-27 April.Zaltman, G. &Vertinsky, I. 1971 Health Services Marketing: a suggested model. J. Marketing35, 19-27.

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Community-Based Distribution the Distributive Potential And