Social marketing has become a significant method of delivering needed health products to lower income people in developing countries.¹ Yet not all social marketing projects have satisfied donor or local ministry of health expectations regarding impact.

As a result, donors have asked PSI,² a nonprofit social marketing organization operating in more than 40 countries, to revitalize six existing projects—in Bolivia, Lesotho, Malawi, Nigeria, Rwanda and Tanzania.³ This profile describes those experiences in an effort to determine what lessons can be learned about how to make social marketing programs more successful.⁴ Although other products were involved, the analysis focuses on condom marketing.

In summary, all of the revitalized projects, after various changes were made, dramatically increased sales and impact. For example, sales in Malawi went from an average of 14,000 condom units per month in the original project to an average of more than 400,000 per month in the new PSI project within a year. Sales increased fivefold in Bolivia, even though the same price structure was maintained. Sales in Tanzania originally totaled 150,000 over 18 months; after a new launch with the same brand, PSI reached sales averaging a million units a month. And in Nigeria, couple years of protection (CYPs)⁵ from family planning products increased from 132,000 in the last year of the original project to more than 500,000 in the first year of the PSI project, with the same price structure.

Why this substantial change? The original projects often shared some characteristics that were thought to contribute to their limited performance.

First, supervision and management of significant issues were handled from a regional office, by telephone or brief trips by a supervisor; this remote control resulted in less effective management and slow decision making.

Second, promotion and other demand creation communications often were simply inadequate, uninventive and inappropriate to the local culture. In at least one case, packaging and promotional materials included pictures and dates not relevant to the target country. In another instance, the generic communications work was produced by an unrelated organization under a separate contract; the separation of supply and demand was said to hinder effectiveness.

Third, some of the original projects used their limited financial resources to dwell on the process of marketing, rather than the results. Extensive strategic planning and research seemed to be ends in themselves, rather than means to implement through the more practical functions of promoting and distributing. This resulted in delay and even output that was not used or relevant, and insufficient attention and funding for basic marketing needs.

Fourth, in some cases, the pricing structure of the first project was probably too high for lower income persons to be served and sales to have meaningful impact; however, in other instances, the follow-on project kept the original prices and was, nonetheless, able to increase sales.

Fifth, in both the original and the follow-on projects, commercial distributors were used for distribution functions; however, in the original projects, excessive reliance was placed on commercial distributors to promote and stimulate sales. In most cases, their interest waned when it became clear the product would not generate meaningful profits.

Finally, in the original projects distribution was often restricted to pharmacies and clinics, thus severely limiting availability and sales.

This sampling is too small to assume these factors will be relevant to all social marketing projects of all types of products in all countries. The countries involved had relatively low per capita gross domestic products; in wealthier countries other factors come into play and different approaches may be suitable. Further, the follow-on PSI projects no doubt benefited from the desensitizing and promotion of earlier efforts. And many of the problems in the original projects came not from the implementing organization but rather from questionable design features, not controlled either by the donor or the organization.

Nonetheless, where donors and host governments want meaningful impact in less wealthy countries, the type and location of management; quality, nature and reach of promotion; extent of distribution; motivation and commitment of the managing organization; and pricing strategy will be important factors in determining whether high impact goals of a project will be achieved.

MALAWI The Malawi social marketing project was originally funded in 1988. The donor's contractor subcontracted to a local subsidiary of an international manufacturer/distributor to market, distribute and promote a condom; but the activity generated low profits and was viewed as a low priority, charitable endeavor by the company. In the second year, a part-time local marketer was retained to oversee operations; he was unfamiliar with the modus operandi of the donor's prime contractor, and was the employee of, and beholden to, the commercial concern. Another part-time employee performed other functions. A second local firm was contracted to do research. All this was overseen by the prime contractor's regional office in a Francophone, West Africa country, in part through short-term trips.

A one-year delay in the product launch was caused by extensive brand name research, which was eventually disregarded in favor of a continent-wide brand name already in existence. The packaging graphic was not local and featured an identifiable Zimbabwean couple. A promotional calendar highlighted Zimbabwean, not Malawian, holidays. The project sold 421,326 units in two and one-half years of sales. The price was reduced twice since it was thought, on reflection, to be too high.

PSI was asked in April 1994 to revitalize the project. A PSI employee, who was held responsible for management and results, landed in Malawi in May. He used local researchers to design a new brand with an appealing, locally appropriate packaging; advertised using a variety of new media and messages; and increased distribution to non-traditional outlets. Sales are now averaging more than 500,000/month, or more than 30 times the original project.

NIGERIA
A multi-product, social marketing program was started in Nigeria in 1985 by an international nonprofit family planning organization with donor funding that resulted from a competitive bid. The organization contracted with a local pharmaceutical manufacturer and distributor for both marketing management and product distribution and sales. Sales of condoms and pills began within a year; foaming tablets were added in 1986 and IUDs in 1987. The products sold were not branded or over packaged (until late in the program when a branded condom was developed). Despite low consumer prices, the program satisfied neither consumer need nor donor expectations, and PSI was asked to take over in 1993. The results were dramatic; in the first year of operation, the PSI program more than tripled couple years of protection (CYPs) of its predecessor and did so without any change in prices. CYPs generated in the second year of operation again doubled the previous year's results. Today, the Nigeria program is the largest and probably the most cost effective (in terms of cost per unit sold) social marketing program in sub-Sahara Africa.

The crucial difference between the PSI program and the previous effort was that PSI's partner, a local NGO (the Society for Family Health), had only one mission-the successful management of the CSM program. In the previous program, the sale of contraceptives was an adjunct to existing marketing activities of a pharmaceutical manufacturer/distributor which simply lost interest in what was considered a time-consuming and unprofitable sideshow. The PSI project used a commercial distributor (thus taking advantage of the existing infrastructure) but did not rely on it for direction, impetus, promotional ideas, or sales motivation. Further, the original project essentially "dumped" most of the unbranded products without the real marketing effort a product usually needs.

RWANDA
Rwanda was first targeted for social marketing in the 1980s. The donor's prime contractor selected a local family planning NGO to be the implementing entity and provided technical assistance and supervision from an African regional office. A continent-wide brand was launched and reached sales of about 30-35,000 units per month by 1992/93.

Concern had been expressed about the original project's slow start; modest sales; distribution primarily through pharmacies (which most Rwandans did not regularly frequent); and aspects of local management.

It was suggested that PSI, rather then taking over that effort, start a new project with a different brand. It did so, but with less funding, since at that moment no governmental donor was willing to assist a second social marketing activity in Rwanda. PSI quickly launched an attractive brand used in other Francophone African countries; sold in more and nontraditional outlets; used attention-getting promotion; and priced the product lower. The result was sales averaging more than 100,000 units per month virtually from the start. (PSI was evacuated from Rwanda in mid-1994 due to the civil strife there. It restarted operations in 1995, is now partially donor-funded, and is selling well over 200,000 units per month.)

TANZANIA
Condom social marketing was initially part of a broad AIDS prevention program run by a donor's prime contractor when it was started in 1990 in Tanzania. Marketing and distribution were subcontracted to a local pharmaceutical company. The prime contractor's resident advisor had duties in several areas and could devote only part-time to social marketing. She felt she could exercise little control over the local pharmaceutical company because of time constraints and the terms of the contract with the local company which left her only supervising the contract, not the project. Indeed, to the extent the prime contractor made significant decisions, they apparently came from the home office in the United States. A substantial portion of the limited funding and a great deal of time and effort were spent surveying and cataloging possible outlets; however, the results were not applied (except as a printed model for potential use elsewhere); and the project sold mainly in pharmacies. The advertising was ordinary to Tanzania and a small percent of the cost of the overall budget. The project, to its credit, succeeded in getting the word "condom" mentioned on radio. Packaging was of rather poor quality (an economy measure said to be required by insufficient funding), and the dispenser design failed.

When PSI assumed responsibility for the social marketing project in 1993, it kept the same brand name, but sent a resident advisor who had run a PSI social marketing project elsewhere in Africa to oversee package-redesign, a re-launch, promotion and distribution. The exclusive commercial distributor was changed to several local, and competing, distributors, and the number and type of outlets were substantially increased. Varied kinds of modern advertising were incorporated.

Sales in the original project were said to be about 150,000 units in one and one-half years. The PSI project sold more than eleven million condoms in 1996 and is now averaging more than one million per month.

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In sum, all of the revitalized products had and have significantly higher sales than their predecessors. The causes of the increased impact were several—focus on quality promotion, extensive distribution, and sales motivation, rather than process and planning; management and control locally, rather than from a distance, and by an entity committed to the social objective; and, in some cases, a more realistic price structure (although the price was not changed in several cases). Some factors adversely affected both the first and second projects, like the Rwanda hostilities in 1994, and some favorably affected both, like a growing acceptance and demand for health products of this type.

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