Petty Corruption In Public Health Care Towards Comprehensive Condom Programming Petty Corruption In Public Health Care Background Condom Programming Current situation Health Impact Market Distribution Barriers to condom use Strategic Objective Challenges Way Forward Prepared by:MOHSW-RCH NACP TACAIDS PSI

Background The Government of Tanzania, under the Ministry of Health and Social Welfare (MOHSW), provides large quantities of free‐issue condoms, which are distributed through public health facilities and other public outlets.  

Cont… Findings from THMIS 2012 and other related surveys indicated that condom use is going down, Access and availability of Public sector condom remains low, Reasons indicated include; perceptions of poor quality and psychological barriers associated with the ways of getting the condoms.

Cont… Thus, more efforts are required to enhance condom promotion, accessibility, availability and distribution to the public to ensure increased consistent and correct condom use.   There is a need to reverse the trend if the country is to achieve 3 zeroes

Condom Programming The Government is working with PSI-TZ through the MOHSW and key stakeholders to develop a marketing strategy for the Public condoms which is not branded, Consultative multi-step process is on going. The strategy will seek to address the challenges and barriers faced in the uptake and use of the public sector condoms.

Situation on the ground Consultative process between the Government and PSI is on going to increase condoms use: Conduct and disseminate research to determine total market To raise the Sale of over 103,592,283 condoms annually through social marketing of PSI and partner organization condom brands

Cont.… Support and develop a National condom Brands Support to the public sector to develop a National Condom Strategy

Health of the Total Market Health Impact: Reduced HIV and reduced unwanted pregnancy Increased Use of Condoms 250 million condoms needed annually Health of the Total Market Equity Sustainability Availability Size Health of the Public Sector Will present a framework for looking at the total market moving forward and present new data and research that is new in this quarter in terms of what we have been working on regarding these four pillars xxxYes Public Sector Deltaxxx Operational autonomy, customer competition, price influence (administred/ market), entry barriers, sbusidy coverage) Health of the Social Marketing Sector Health of Commercial Sector

Condom Use at Last Sex as reported by men and women xxxMarc Comment. Perhaps also plot on here: Omnibus and Needscope xxxPriscaxxx

Demand= Use: 23.6% last risky sex, 70mil Demand is simply not high enough- use is too low and we need to change the distribution into use… but to look further you need to see the sources of distribution and the use patterns by sector…. xxxyesxxx Supply: 41%, 111 mil Supply has been around 40% of Need since 2010

Total Condom Market Distribution Trends 2013 39.9 million public sector condoms xxxyesxxx

Equity Among men who had 2+ partners in the past 12 months, percent who used a condom at last sex. Men who had 2+ partners in the past 12 months HIV prevalence Q5 3.7% 2.6% 1% 0.8 % 15.8% 18.6% 24% 25% 23% 24.8% 12% 17% 26% 40% Q1 Q2 Q3 Prev from THMIS 2012; all other data from DSH2010 0.8% 1.0% 2.6% 3.7% 3.5% Q4 3.5% Men in wealthier Qs have higher prevalence More men in lower Qs are having risky sex Men in wealthier Qs are using condoms more

Consumer Price 1000 2000 3000 1 2 3 4 5 Public Salama, Dume 343 – 415 Lifestyle, Erotica, Bareback 3000-3800 Public Salama, Dume 343 – 415 Trust, Prudence, Protector, Lifeguard Rough Rider 1500-2000 Consumer Price 1000 2000 3000 1 2 3 4 5 Source: Price survey, TMARC June 2013

BRAND USE vs. Preference Trends (Current Users men aged 18 -40yrs) xxxPriscaxxx xxxMarc Comment. What is the take home message here? When Salama brand is ungrouped Dume if the most used and prefered male condom product. Of interest to note is that 3.5% of men that preferred Dume did not use Dume during their last sexual encounter. This is contrary for Salama Halisi, in that 5.8% of men used the product yet it was not their preferred choice/condom brand. xxxyesxxx Source; NeedScope Survey 2014

Barriers to condom use behaviour (Dume & Salama target audiences) YR 2014 xxxMarc Comment. I would put the most important barriers either at the left hand side of the graph or the right hand side of the graph rather than having them randomly scattered across the x axis. It makes it clear which are the key barriers visually in a easy fashion for the audience xxxYes Public Sector Deltaxxx xxxPriscaxxx Source: NeedScope Survey 2014

Branding of Public sector Condoms to increase condom use : Conduct and disseminate research to determine health of the total market Sale of over 103,592,283 condoms annually through social marketing of PSI and partner organization condom brands Support to develop a National condom Brand

Strong existing public sector Entry of DKT Branding of Public sector condom Price increase for Dume and Salama Introduction of Dume Line extensions Refresh of Salama targeting Youth All in the name of and on behalf of the mOH

Conducted 4 Day Marketing workshop BRAND. Lives forever in the hearts of the target audience. Can have many products. Marketing Strategy. A 1-3 year cycle for a particular product. Constantly reanalyzed and refreshed.

Audience Profile Why Kazimoto? With limited resources, we need to be sure our investment is targeted so that we can measure success. In Tanzania, 98% of the time, Kazimoto will acquire and bring the condom for sex. His partner , even FSWs, are less likely to bring the condom. Our public sector strategy works with SM strategies to segment the market. As such, the public sector condom will focus on lower SES men and high prevelance regions . Salama will focus on first and second quintile youth . Dume will also focus on quintiles 3-5, older men. Kazimoto is a married man, 37 years old, living in Kakonko, Tabora.. He is married with four children. He is a teacher with a monthly income of 210,000 Tsh. He takes care of his family, and sends two of his children to school. His wife owns a small shop/kiosk which he supports with additional capital. He drinks with friends and has two mistresses. He occasionally travels for workshops and meetings, or to get is salary in town. Where he also has casual sex with FSWs. He keeps these relationships hidden from his wife and friends. He owns a mobile phone and a motorcycle. He likes watching football in the bar with male friends where he listens to for advice. He likes politics. His hero is He is a church leader and listens to gospel music at home. He hopes to be a ward councilor one day or the head teacher. He’s conservative with strong social cultural beliefs and gender blind. He doesn’t use condoms with his wife as they trust each other. He only uses condoms when he meets his girlfriend, not consistently with no brand preference. He gets his condoms from the nearby shop or kiosk. For Kazimoto, GOT is the pleasurable condom that lets him enjoy an energetic and carefree social life

OBJECTIVES: Where are we going? Size Health of the Total Market STRATEGIC OBJECTIVES: Where are we going? In recent years, the health context and economy in Tanzania have been evolving quickly. While national health priorities remain the same, there is need to ensure proper targeting of limited donor and GOT resources to reach the poor and vulnerable groups with sustainable approaches. To keep pace with these changes and to ensure a healthy market that meets public health needs in the most cost-effective, efficient and sustainable manner, a strategic vision of the total market is required. Size Univ. of Need Goal: Health Impact Grow the supply and demand to meet the Universe of need. Reduce unwanted pregnancy Reduce transmission of HIV/ AIDS and other STDs Behavioral objective: Increase condom use Address demand side and supply side barriers to condom use Demand Purpose: Behavior change Strategic Objectives Supply Develop a National Condom Strategy Equity SUPPLY 2 Ensure consistent budget to fill 20% of the condom market need with public sector condoms 3 Ensure that condoms are earmarked for KPs groups, vulnerable youth. Ensure distribution thru targeted services to them. 4. Improve the consumer experience at health facilities 5. Pilot innovative new distribution strategies in specific regions targeting Q1-2 men Sustain 20% of the condom market to ensure access to lowest quintile and most vulnerable. Availability Increase availability of the public sector condom by expanding distribution channels and opportunities to access DEMAND 6 Brand and launch a public sector condom 7 Branded demand creation campaign targeting youth and (lowest SES) men with behavioral barriers of “trust’ and ‘time of use’ Sustainability Support and compliment social marketing and commercial sectors by continued targeting to the poor and vulnerable

Challenges Lack of Multiple sector working committees on condom issues (e.g. in the health sector – RCHS & NACP) Myths in condom use Inadequate availability of condoms in rural and sub urban centres Limited access of condoms beyond health sector Limited availability during the night beyond 10pm Dependence on donors to budget and supply condoms ( Public).

Way Forward Agree on Strategic Objectives and ensure ownership of each objective Designing and Focus grouping condom foil design To identify condom brands to be used to the public sector.

Where are we? TOR completed, shared and process for identifying a consultant is underway Marketing plan will be part of the strategy, but not the full strategy With funding from GF and USAID, consultative process will be followed in developing the condom Branding

Thank you. Asante. Identify and develop a valuable package of products and services to grow franchisee business’– many ideas here, but need to develop them- integrated Electronic Medical Records system that will allow providers to file claims and give visibility into their profitability, on the job business training, credit, demand creation including improving and standardizing the franchising experience, continuing education e-learning and health area trainings, incentive programs, networking opportunities with other private providers, Safecare like clinic audits, telemedicines, etc. Create linkages with sources of health financing to advance UHC agenda, increase volumes for providers and reduce OOP expenses for Sarah. This could be new social protection program in TZ, NHIF new initiative to target the poor, CBHIs, health wallets, etc. ** what we are doing: potential SIFPO funding to do a health financing assessment/ mapping in TZ. Better understand our providers and who would benefit from SF 2.0– we are conducting a provider survey, but need to work on a more extensive provider database with more information about our providers. Must decide what level of provider to invest in for best health impact. Create a full format franchise (rather than fractional) that meets Sarah’s needs – integrating new health areas into the franchised services ** all of these things take significant investment and support frm PSI globally as we develop global goods for franchising. This is a new global agenda for franchising- not just for TZ. A challenge of the global franchising community, and PSI TZ is no different, is how to ensure a sustainable franchising approach, where we as a sustainable ‘brokering role’ In PSI TZ, we willl need to consider who is willing to pay for franchising services and what services they are willing to pay for? Give some examples.