1. The Business Case for Female Condoms
Published by Global Health Visions LLC.
Commissioned by Rutgers and Equilibres et Populations for UAFC
With financial support of the William and Flora Hewlett Foundation
May 2014

2. Aim of the Business Case
Convincing donors, governments and other implementing organizations that their argument of high cost of female condoms is no longer valid.
Economic analysis to show that investing in female condoms has a high Return of Investment.
Formulation of recommendations for sustainable, comprehensive female condom programming.
The argument of high cost of female condoms, which is often used by not to invest in this life-saving, women initiated, dual protection method, will no longer hold after taking note of the calculations and analysis in this Business Case for female condoms.
UAFC and Equilibres et Populations commissioned this study to Global Health Visions to analyse if and how investing in female condoms has a high Return of Investment.
The Business Case concludes with recommendations for sustainable, comprehensive female condom programming (comprehensive means all aspects of female condom programming, from procurement and supply chain management, advocacy, (media) communication, awareness raising, and distribution to the end-user).

3. Methods used Four countries 1 million female condoms
Analysis based on:
Cost-effectiveness models
Health impact modeling
Economic outcome estimations using open source models
Broader socio-economic impact analysis through desk research and key informant interviews.
Four countries with a current female condom programme were selected; Cameroon, Kenya, Nigeria and Myanmar.
The study looked at the expected effects of the distribution of units in each country.
Costs in the study are extrapolated from the actual costs incurred by programs currently running in the four countries.
Health impacts and the resulting economic outcomes are estimated, using open source models from PSI, MSI and the Futures Institute.
Desk research and interviews were completed to further document the impact of female condoms on a society’s prospects for economic growth and income equality (14 key informant interviews with practitioners, policymakers, and donors in the FP and HIV/AIDS arenas). These findings were analysed to draw out key social implications of greater female condom use, all of which have wide-reaching economic consequences.

4. Costs
Commodity costs (in USD) include procurement, shipping, wastage and loss due to improper use.
Note that commodity costs are not the key cost driver!
Programming costs include warehousing, transport, salaries, behavior change communication programmes, awareness campaigns.
When introducing female condoms, investment in marketing, user awareness, and community education is required, as is the case for all new products.
Note that such programming costs are expected to drop as the market matures, as per example from Zimbabwe.

5. Benefits
Benefits:
Health care systems see immediate AND long-term savings:
number of HIV infections averted
number of unintended pregnancies, maternal deaths, infant deaths and unsafe abortions averted.
The national economy:
- increase in worker productivity because of HIV infections averted and a decrease in maternal morbidity and mortality.

6. Return on Investment
Return on Investment is often used to guide decision-making on investment. This graph compared total investment (commodity + programming costs) with total estimated economic benefits of distributing female condoms, showing an excellent return on investment for female condoms in sub-Saharan Africa:
In Cameroon the investment of $1 offers $2.37 return on investment to the country’s economy;
In Kenya, the investment of $1 offers $1.94 return on investment to the country’s economy;
In Nigeria, the investment of $1 offers a $3.20 return on investment to the country’s economy.
In Myanmar, $1 offers $.61. This differs from the other three countries in several respects:
the female condom program there targets sex workers, and targeting can lead to higher programming costs;
the HIV prevalence is lower compared to sub-Saharan African countries, leading to fewer infections averted for the same level of condom use;
Myanmar’s economy is affected by international sanctions, which can raise the cost of routine activities.
Note: a negative ROI does not mean that an intervention is not cost-effective! The general lesson from Myanmar seems to be that broad programs that involve the general public and treat female condoms as a commodity are likely to yield a better Return on Investment than programs that treat female condoms as a specialty item targeted to specific target groups.

7. Health outcomes Cameroon Kenya Myanmar Nigeria
female condoms
Cameroon
Kenya
Myanmar
Nigeria
# DALYs averted
9.292
9.713
4.122
9.488
# unintended pregnancies averted
1.939
# HIV infections averted
108
125 62
100
# maternal deaths averted 8 4 2 7
# infant deaths averted 53 39 14 77
# unsafe abortions averted
243
265
521
213
Distributing female condoms through effective programming will deliver impressive health benefits in the four case study countries, which can be replicated in other countries. In Cameroon and Nigeria, these benefits are already underway, where UAFC supported the programming of female condoms which has surpassed units already.
DALY = Disability Adjusted Life Years.
The DALY combines years lived with a disability and years lost to early death. One DALY averted represents one year of healthy life.
Each of these numbers represents an individual whose life is better, and each case averted represent the chance for women and men to continue to contribute to their economy, to consume goods and services, and to reduce using the public health system for preventable diseases and conditions.

8. Cost effectiveness
Cost per DALY of programming 1,000,000 female condoms
Cost per DALY (USD)
WHO Threshold (USD)
Rating
Cameroon
235
1.151
Highly cost effective
Kenya
209
862
Myanmar
757
1.200
Nigeria
158
1.555
A key question for governments (and donors) is whether female condoms are a cost effective way to achieve these health outcomes. Could the same outcomes be more efficiently achieved through an alternative intervention? First a cost effectiveness analysis is needed.
WHO classifies a health intervention’s cost per DALY within three thresholds:
highly cost effective: less than the GDP per capita
cost effective: 1 to 3 times the GDP per capita
not cost effective: more than 3 times the GDP per capita
Framing cost effectiveness thresholds against country GDP per capita helps to contextualize what spending levels are possible and reasonable for the resources of a certain country. In the four case study countries, cost per DALY for female condoms is rated highly cost effective against WHO thresholds.

9. Cost per DALY averted
Then, comparative cost effectiveness analysis helps decision-makers to understand how a given intervention measures up against alternative uses of funds. Using average cost per DALY available in the literature for both prevention and treatment interventions in sub-Saharan Africa, this graph demonstrates that female condoms offer a competitive cost per DALY when compared with other methods. This means that, compared with alternative interventions, female condoms represent a competitive purchase price for one unit of health.

10. Economic implications
Improving choice and coverage
Supporting women’s empowerment
Increasing equity of health outcomes
 investment now saves health budgets and economy millions of dollars.
Economic implications of female condom programs are wider than the results of a single investment.
Broad macroeconomic benefits are associated with higher rates of protected sex acts, lower fertility, and reduced HIV prevalence, all achievable through greater access to a broad basket of contraceptive methods, including female condoms. The full economic impact of female condoms is complex; direct and indirect outcomes, over time, and across generations.
Female condoms  social benefits  improved individual wellbeing  contribution to economic growth.
Adding female condoms to the method mix improves method choice and coverage, resulting in fewer STI/HIV infections and fewer unintended pregnancies.
Consistent access to a product that allows women to initiate dual protection supports mutually reinforcing goals: women’s empowerment and better health outcomes.
Addressing the health needs of disadvantaged women and men reduces health disparities within a country, facilitating the income equality associated with better rates of economic growth.
Recommendation to your government: investing in female condoms now will save your government’s health budgets and the economy millions of dollars over the coming years.

11. Recommendations Investment in female condoms is strategic
Understand the gains made from female condom programming
Keep costs down by leveraging existing distribution channels
Develop and communicate key messages to each target group
Expand the female condom market
Investment in female condoms is strategic. Female condoms offer excellent value for money and bring unquantifiable benefits to users and their wider communities.
Understand the gains made from female condom programming. Experiences need to be documented and disseminated in order to replicate success in new contexts and bring pilot programs to scale.
Keep costs down by leveraging existing distribution channels that currently bring other health products to last-mile consumers. Add female condoms into this product mix to vastly increase access.
Develop and communicate key messages to each target group, covering broad STI/HIV prevention and family planning topics alongside the unique product attributes of female condoms.
Expand the female condom market through focus on product innovations and the registration and prequalification processes that are essential to bringing new products to market. A broader mix of female condom products increases consumer choice and competition in the marketplace.

12. Key message
Investing in female condoms is an efficient use of resources, and has economic and social advantages that create growth, income equality and economic development.
Consistent access to a product that allows women to initiate dual protection supports women’s empowerment. Women’s economic empowerment is linked with higher per capita incomes and better rates of economic growth.