How did this happen?
In 1997, with funding from USAID, PSI/Bénin developed a social marketing project in family planning designed to improve the reproductive health of the Beninise population. The initial situation analysis indicated a pattern common to many Sub-Saharan countries: high level of unmet needs for family planning, alarming medical indicators (such as high maternal and infant mortality), an annual population growth rate of almost 3% and a high incidence of abortions due to unwanted pregnancies.

The first Demographic and Health Survey in 1996 revealed an important gap between knowledge and practice: almost 60% of all women of reproductive age knew that modern family planning (FP) methods existed, but only 3% actually used them. In addition, the public sector had irregular and inadequate supplies of modern FP methods, overall quality of FP services offered by health care providers (HCPs) was poor and the many medical barriers and negative attitudes of HCPs limited access to modern methods.

In 1997, PSI/Bénin launched its family planning social marketing program with the goal of improving access and availability of affordable high quality hormonal contraceptives, increasing knowledge of modern FP methods amongst target groups, and improving the quality of FP services provided by medical and pharmaceutical staff.

At the request of the Ministry of Health, PSI/Bénin's social marketing project focused on the private sector thus complementing other activities undertaken with support of UNFPA in the public sector and by other NGOs.

In April 1998, an oral contraceptive "Harmonie®" and, two years later, a three-month injectable contraceptive "Equilibre®" were launched. Given governmental restrictions, both products could only be sold by PSI/Bénin to four private medical wholesalers who in turn distributed them to the 133 pharmacies and a certain number of rural so-called "depot pharmacies". (No direct sales were allowed to pharmacies, depot pharmacies, or to clinics.)

Based on lessons learned from PSI elsewhere it was critical to involve private sector pharmacists and pharmaceutical wholesalers successfully in this project (making them understand and support the social marketing concept and accepting less profit per unit sold than for commercial brands).

Strategies to get pharmacists on board
A two-tier approach was designed to get the support and buy-in from the pharmacists themselves and to reach and inform the counter agents who in most cases have the real face-to-face contact with consumers and guide most product selection. (Even though pills should only be sold under medical prescription, many clients buy them directly in pharmacies without prescription.)

Information days for pharmacists
A month after Harmonie® was launched, PSI/Bénin organized the first "National Pharmacy Information Day on Reproductive Health/Family Planning". The organizations involved in this event included MOH, the private sector Pharmacy Board, a national reproductive health research organization and the American NGO "INTRAH", whose special expertise is training of HCPs and innovative research related to health programs. INTRAH has provided the technical assistance for all aspects of the pharmacist training program with the funding of USAID.

The second "Pharmacy Information Day" in 2000 focused on the introduction of the injectable "Equilibre®", and in 2002 the scope was enlarged and the event was entitled "Information Day on Family Health" integrating all six PSI/Bénin products. The 2002 event was a major validation of the buy-in goal: pharmacists themselves were heavily involved in planning and execution and the turnout was massive.

Training sessions for counter agents
In order to improve product knowledge, counseling and sales skills of counter agents, PSI/Bénin collaborated with INTRAH to design a specific training module for contraceptive technology. The training concept was based on self-study of participants using a home study guide with short exercises before the training followed with two days in-class learning emphasizing the acquisition of skills and role-plays. This innovative concept was a good compromise to reduce absence of pharmacy staff from work and at the same time reduce overall training costs.

In 1998, 80 agents from 50 different pharmacies participated in the training. With nationwide extension of the project in 1999, 60 additional agents from 38 pharmacies were trained; in parallel the previously trained agents were invited to participate at a one-day refresher course, which has been regularly conducted annually since 1999 (and involved a total of 173 participants).

Evaluation and follow-up studies by INTRAH
Since the launching of the training project, three evaluations have been conducted in 1998, 1999 and 2001, with technical assistance from INTRAH in order to measure the impact of the training activities of pharmacy counter agents. These studies have used a combination of interviews with participants, the pre- and post-test of the initial training, mystery client survey as well as interviewing the pharmacists themselves on their perceptions of the training and its impact on performance of their staff.

These studies clearly showed that the trained agents were delivering a higher quality of family planning services than their counterparts in pharmacies that had not participated in the training. They demonstrated significantly better family planning competencies monitored by mystery clients, (see graph) and their knowledge level of family planning topics was much higher.

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Broad dissemination of evaluation results among pharmacists and discussion at the 3rd Pharmacy Information Day in 2002 motivated pharmacists to massively inscribe their counter agents for further training sessions. At the same time, the pharmacists expressed their desire to extend the scope of future trainings to integrate other public health aspects such as malaria prevention, diarrhea prevention and STI/HIV/AIDS prevention.

For the first time, the pharmacists contributed financially to the 2002 conducted training sessions and covered roughly 25% of the total costs. A total of 95 counter agents were trained in June and July 2002 in four sessions.

Counter agent's compliance with prescribed steps for effective counseling and sale of pills (mystery client survey)

What about sales and health impact?
Of course, no one would claim that the training activities of pharmacists and their agents alone are responsible for product sales and for creating health impact. Multiple project components (IEC, mass media generic spots, BCC interpersonal generic activities and intense medical detailing among HCPs) have all contributed to the success of the project. However, without the collaboration and support of the private pharmacists and their counter agents - the sole sales points in the country for Harmonie® - the project would not have achieved its overall results.

Harmonie® sales exceeded AIDSMark's initial sales goal of 140,000 cycles from February 1999 to September 2002 by far. The initial sales goals were increased by 71% to 240.000 cycles in November 2000. As of July 2002, sales have already surpassed even these revised targets.

PSI/Bénin's social marketing project contributed substantially to meet latent demand for pills (and to a minor extent for injectables) and successfully created new demand for modern family planning methods among target groups.

— Angelika Kobilke, Family Planning Manager/DED Technical Assistant, PSI/Benin