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Meeting the unmet need for family planning: why social marketing is not the answer

More than 200 million women and girls in developing countries who would like to avoid becoming pregnant are unable to access modern contraception methods. Urgent action is needed to address this huge unmet need. Next week the UK Government will host a high-level Summit to consider the options.  

The barriers which prevent women and girls from accessing sexual and reproductive health services are multiple and complex. Even when services are technically available, social barriers can mean that women and girls do not feel they can use them – whether its partners and husbands restricting women’s choice or negative attitudes of health workers that push women away. Women and girls may also be denied access to family planning because they are too poor to pay.

On 11 July the UK Department for International Development will be hosting the London Family Planning Summit: a high level meeting which aims to galvanise political commitment and generate the resources needed to scale up access to family planning. There is no doubt that a focus on sexual and reproductive health is long overdue, so the initiative is welcome. However, some of the approaches being considered appear not to be based on evidence of what works. It seems likely that there may be a strong emphasis on the role of the for-profit private sector in service delivery, including a focus on social marketing and social franchising. There is little evidence that these approaches are able to deliver results for poor women and girls.

Social marketing and franchising have been enthusiastically embraced by governments, donors and some NGOs to deliver health programmes, especially for contraceptives. Put simply, social marketing uses the basic principles of commercial marketing to “sell” behaviour change. Social marketing organisations promote goods and services that are considered to have a social value and in return they receive public subsidies to expand their enterprises. Social franchising involves a network of for-profit private providers contracted to provide services under a common brand. In both cases, consumers are required to pay for products.

In 2010 DFID commissioned a review of the evidence on private sector engagement in sexual and reproductive health. The review identified significant risks with the private sector including problems with accreditation and regulation, and found little evidence on the question of equity. With regards to social franchising, while there was an increased uptake of family planning services overall, there is only moderate evidence of increased uptake by the poor. Similarly, social marketing schemes may be effective at widening access, the review notes that, “obviously it does not reach the very poor who cannot afford to pay for the product or service”. The review did not compare the effectiveness of the private sector with that of the public sector.

A more recent 2011 study assessed the contribution of social franchises to universal access to reproductive health services in 27 countries in Africa, Asia and Latin America. Not only did the authors find that the franchises had not widened the range of reproductive health services available, “in almost two-thirds of the franchises the full cost of the services was paid out of pocket, which was largely unaffordable for low-income women”. In many cases prices crept up over time which effectively priced out the poor. They concluded that continued investment in social franchises in the provision of reproductive health services could not be justified unless further evidence is forthcoming.

The trend of increased investment in unproven and risky private sector solutions is concerning given the lack of robust and convincing evidence that these can improve equitable access and quality of care for women. These studies clearly show that more evidence is needed before governments and donors promote social marketing and social franchising as the ‘magic bullet’ that will meet the unmet need for family planning.

Instead, investment should be used to strengthen the country health systems that are best placed to deliver comprehensive sexual and reproductive health services. To have the greatest impact an integrated approach based on rights and choice should be promoted and the social and financial barriers to access must be addressed. In a report published last week, ActionAid stress the importance of ensuring women are fully informed about the options and a have a range of contraception methods to choose from.

The London Family Planning Summit promises change on an unprecedented scale. Business as usual is clearly not an option, but to achieve the vision of universal access to family planning, solutions must be based on evidence of what works.

Ceri Averill is a Health Policy Advisor at Oxfam-GB

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7 Responses to “Meeting the unmet need for family planning: why social marketing is not the answer”

  1. Karl Hofmann says:

    By suggesting that the trade-off is between social marketing, private sector solutions, and reinforcing the public sector, Ms. Averill misses the point that BOTH strategies are needed to meet the challenge before us. Of course, equity must be a key focus of any interventions to help meet unmet contraceptive need. But we must keep in mind that most of the world’s poor get their health care services from the private sector, not the public sector. Strategies that help to grow the overall market (i.e., meet more unmet need), reduce the need for subsidy (i.e., let the overburdened public sector concentrate on those who truly need free services or product), and protect equity — what we can call the “total market approach” — offer the best prospects for success. Relying ONLY on the public sector to meet unmet need in the developing world would be, in fact, just the trap Ms. Averill urges us to avoid: business as usual.

  2. Dominic Montagu says:

    The evidence from large surveys around the world shows that the private sector is the main source of family planning goods and services in most developing countries…. for people at ALL income levels. Pragmatic donors and governments, wanting the best for their people, will support both effective and equitable delivery of care through the channels – public and private – that serve those most in need. This multi-channel delivery model is the way the NHS assures access to care in the UK, and indeed the way most governments in Europe work. These lessons should be heeded.

    The evidence shows that government supply of family planning in most developing countries has done a poor job as meeting unmet need. Ms. Averill is wrong in her conclusion, but correct in stating that continuing business as usual would be a disservice to the poor, and a gross misstep for donors and governments.

  3. Ceri Averill says:

    Karl and Dominic, thank you very much for your comments on the article. I would like to respond to your point about the private sector being the majority provider in developing countries. While the private sector may play a significant role in some developing countries, having a high proportion of health care provided by the private sector does not mean that people’s right to health is being fulfilled. The case for expanding private provision should be made on its merits compared to the public sector and not simply on the grounds that it is currently a significant player. The point I was trying to make is that the status quo has failed to deliver and governments and donors must look at the evidence of what works. Research shows that while social marketing and social franchising can widen access to contraceptives overall, simply increasing the availability of contraceptives will not ensure that these products are available for women to use – financial barriers put products and services out of reach and social barriers may mean that even when services are technically available women and girls are not free to use them. For women to enjoy their right to sexual and reproductive health services they must be able to make multiple visits to good quality health services, have access to trained health workers, and the freedom to choose from a range of products and services. Any new investment in sexual and reproductive health should focus on the evidence of what works and support the country health systems that can best deliver comprehensive and integrated services.

  4. Grace Mbekem says:

    A lot has been done to meet the unmet need. Interventions should consider the geographical location and most affected target group. Traditional beliefs, perceptions of different methods and cultural differences (e.g gender and equity) need emphasis on correct information in the underserved age groups such as young women.The private sector is not widely accessible in developing countries. A focus on strenthening public sector systems may have impact.

  5. Mukul Taparia says:

    No single lop sided approach can work considering the diversities of economic situation that exists throughout the world. Generalizing that only public or private or combination will work for all economies may not be necessarily true. A very poor country in Africa may first need strengthening of public sector services which can serve not only the family planning needs but also address other health concerns at the same time. A private sector outfit may not have the resources or skill sets to provide all services under one roof.

    Alternatively a country in South East Asia may have a situation where the lady is specifically looking for family planning services and would prefer to use the private /social / franchisee clinic to get the services because of the better quality services.

    Having said this, the social sector should have a possibility of providing services at subsidized / free prices to deserving clients and charge others market rates for services. This is possible by having differently priced products / models thereby helping the clinic owner/ provider offer choice in the method of contraception itself.

    Also haven’t read any study which talks about women not using IUDs because of high cost of the product. Is it just out of general perception or is there some data to support it?

  6. In Bangladesh still more than 60% people go to private health providers for their first contact. So by excluding the private sector in contraceptive unmet need cannot be a solution and of course only social marketing approach also is not he answer. In our Country still about 50% of Contraceptive users are from Social marketing Company. Public health system strengthening is necessary including accessibility and availability of contraceptive as well as human resources are very much essential to address the unmet need. There are geographical barrier which also limit women to get contraceptive services.

    So we need all out efforts like Public sector, private sectors and NGOs to address the unmet need of Family Planning.

  7. Social marketing can be just a part of an overall campaign. Developing nations need more vigorous and inclusive channels to promote family planning.

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