LESOTHO (2009): MAP STUDY EVALUATING CONDOM COVERAGE, QUALITY OF COVERAGE, AND MARKET PENETRATION

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1 TRAC SUMMARY REPORT PSI DASHBOARD LESOTHO (2009): MAP STUDY EVALUATING CONDOM COVERAGE, QUALITY OF COVERAGE, AND MARKET PENETRATION Sponsored by: PSI s Core Values Bottom Line Health Impact * Private Sector Speed and Efficiency * Decentralization, Innovation, and Entrepreneurship * Long-term Commitment to the People We Serve

2 Research & Metrics Population Services International 1120 Nineteenth Street NW, Suite 600 Washington, D.C LESOTHO (2009): MAP STUDY EVALUATING CONDOM COVERAGE, QUALITY OF COVERAGE, AND MARKET PENETRATION Contacts: Mosele Machitje Research Department PSI/Lesotho 138 Moshoeshoe Road Industrial Area Maseru, Lesotho Suggested citation of this work: PSI Research & Metrics, Lesotho (2009): MAP study evaluating condom coverage, quality of coverage, and market penetration. PSI Social Marketing Research Series, (2009) < 2

3 ACKNOWLEDGEMENTS PSI/Lesotho would like to extend their gratitude to people and the organizations that have been instrumental in making this study a success. First, the Royal Dutch Embassy for the funding, Bram Piot and Navendu Shekhar for their guidance and assistance; the Lesotho Bureau of Statistics for providing valuable Lesotho geographic data and the sampling frame, the fieldworkers for their time and dedication in collecting the data, sometimes in not so favourable conditions. This will be incomplete without extending our appreciation to the outlets owners who were cooperate enough to allows us audit their outlets. EXECUTIVE SUMMARY The third round of MAP study was undertaken in May June 2009 following the two rounds of studies carried out in 2006 and The aim of the third round of MAP was to evaluate the strategies that were put in place in the previous year following the results and recommendations of MAP round two. As with the previous studies, the study continued to measure geographical coverage and quality of coverage of Trust Regular, Trust studded, Lovers plus and Lovers Plus Coloured and Flavoured. The study covered all the 10 districts of Lesotho and two selected urban high- risk areas (Maputsoe and Maseru). Although the main objective of the study was to assess the above mentioned indicators, other indicators such as penetration measures will be reported. The main findings on coverage show that, for all the indicators measured, there is a fair improvement from the first results. The national condom coverage has increased from 55% in 2007 to 69% in PSI condom coverage has increased from 47% to 53% for the same period. Disaggregating PSI condom coverage into rural urban depicts that rural coverage decline from 39% to 33% while the urban coverage has increased from 68% to 72% although it is still low compared to 2006 coverage with 95%. The high-risk areas have shown a decrease from 90% to 80% even though it is higher than the 2006 figure of 70%. Despite the constant rural coverage and fluctuations in urban coverage, urban coverage remains fairly higher than rural coverage. The three standards used to measure quality of coverage have shown some fluctuations. Visibility of products has declined by 8 percentage points from 52% to 44%, presence of promotional material declined by 1 percentage point from 45% to 44%, while adherence to recommended price has increased from 25% to 55%. This major achievement was as a result of price adherence education given to outlet owners every time they were restocking the condoms. The difference in PSI condom penetration between the two rounds is really minimal. This implies that no valid conclusion could be drawn from penetration results. It is important that condom distributors include product visibility education while doing price adherence education every time they visit the outlets. The Distributors should also make sure that the promotional materials are available and visible every time they restock the outlets. 3

4 BACKGROUND AND OBJECTIVES MAP is a PSI methodology that allows programmers to make an assessment of product availability and accessibility. The study aims to produce opportunity based performance measures such as coverage, quality of coverage, access and equity of access of socially marketed products. age is defined as the proportion of Enumeration Areas where there is at least one outlet that sells condoms. The benchmark set for this study was to increase the percentage of outlets that sell/distribute condoms to 80% in high risk areas, 70% in urban area and 60% in rural areas. Quality of coverage is the proportion of Enumeration Areas in which at least one outlet sells condoms and the outlet adheres to recommended price, there are promotional materials and also the condoms are visibly displayed. The benchmark for price adherence was 40% of all the outlets selling at the recommended price, for promotional materials was 55% of all the outlets having promotional materials and for condom visibility was 60%. Access is defined as the proportion of people in high risk areas who are within 500 metres of a condom outlet. The main objective of the MAP survey was to assess the geographical coverage and quality of coverage of Lovers Plus, Lovers Plus Coloured and Flovoured, Trust Studded and Trust condoms in Lesotho. Other expected additional outputs were measures of penetration, price levels of PSI condoms, stock outs and other sales and distribution indicators. DESCRIPTION OF INTERVENTION PSI/Lesotho is engaged in strategic set of interventions that fill the emerging gap of the on-going battle against HIV/AIDS in Lesotho. These interventions target both the general population and key high-risk groups in order to positively influence the underlying barriers to increased condom use and ensure that condoms are widely available to protect against HIV/AIDS, other sexually transmitted infections and unintended pregnancies. The socially marketed condoms include Trust Regular, Trust Studded Lovers Plus Coloured and Flovoured and Lovers Plus. The condoms are distributed via a range of traditional and non- traditional outlets, which are stocked primarily by PSI Sales Representatives and Sales Agents. 4

5 METHODOLOGY The project MAP employs the Lot Quality Assurance Sampling (LQAS) technique to draw a random sample of 19 urban and 19 rural enumeration areas (EAs) from each of the 10 districts in Lesotho. A sample of 19 provides an acceptable level of error for making management decisions. At least 92% of the time, it identifies whether a coverage benchmark has been reached or whether a product/ service area is below the average coverage of a program area. In addition to 38 EAs randomly selected in non-high risk areas of each district of the country, an additional 19 EAs were programmatically selected in high transmission areas of Maseru and Leribe districts respectively. Mobile populations (factory workers and mineworkers) predominantly occupy both these areas. They are also categorized as border gates that open 24 hours. Besides providing a basic measure of product coverage the LQAS assessment also determines quality of coverage, which is the proportion of EAs where products are available and conform to additional standards. Quality of coverage was measured using the following indicators: (1) presence of promotional items (2) visibility of condoms in outlets and (3) adherence to the recommended price. Minimum Standards age - at least one outlet selling one of the PSI condom brand per Enumeration Area. Quality of coverage - presence of promotional material, adherence to the recommended price and visibility of products. Benchmarks age Percentage of outlets selling/distributing condoms in high risk areas to be 80%, urban areas to be 70% and rural areas to be 60%. Quality of coverage presence of promotional materials in 55% of the outlets, adherence to recommended price to 40% and visibility of the product to be 60%. 5

6 DATA COLLECTION The data collection activities started on the 6 th of May and lasted until the 10 th of June The data collection team consisted of 15 members (2-PSI researchers, 11 external data collectors and 2 drivers). The sub teams were three and each team had five members. Due to the terrain of the country, the 4X4 vehicles were used to reach the sampled areas. In all the accessible sampled enumeration areas, all potential condom outlets were audited, including the recording of the coordinates for mapping purposes. Retail Audit All outlets in all the selected enumeration areas were audited using the electronic questionnaire incorporated in the Personal Digital Assistance (PDA). The audit sheet mainly contained questions related to coverage, quality of coverage such as price, stock out of PSI condoms, presence of promotional material, visibility of products, presence of competing product brands and their prices. During the audit process, all outlets were geo- referenced with GPS units so that data could be displayed and analysed in a geographical information system maps. Data analysis Once data was stored on the PDAs during data collection, it was then uploaded on the laptop for backup and analysis purposes using Statistical Package for Social Scientists (SPSS). Analysis was done using both SPSS and Microsoft ACCESS (for editing purpose). 6

7 MAIN RESULTS General results Out of 822 outlets audited, 360 (44%) were found to have condoms; 294 (40%) in nonhigh risk areas, and 66 (74%) in high-risk areas. age The benchmark for coverage was 80% for high risk areas, 70% for urban areas and 60% for rural areas. The main findings on coverage show that condom coverage in two high risk areas is just on 80% benchmark for all condoms although it is below the benchmark in Leribe (75%). Urban coverage appears to be above the 70% benchmark in lowland districts and below 70% in mountainous districts (Quthing, Qacha s Nek, Mokhotlong and Thaba Tseka). Rural coverage is below the stipulated benchmark of 60% in all districts except in Butha Buthe with 60%. Despite the constant rural coverage and fluctuations in urban coverage, urban coverage remains fairly higher than rural coverage. The results also show that PSI condom coverage is improving when compared with the previous MAP results although there is a need to improve rural coverage. Table 1 INDICATOR: age YEAR National age 55% 55% 69% PSI age 39% 47% 53% Rural age 11% 39% 33% Urban age 95% 68% 72% High Risk age 70% 90% 80% In terms of district performances, there are still differences across districts (Table 2). For rural coverage, the highest are Butha Buthe and Mafeteng districts with 50%, Berea, Mokhotlong and Quthing with 40%. The lowest coverage in the rural areas is evident in the district of Maseru with 30% and the rest of the districts have 35% coverage. The mountainous districts have low coverage than the lowlands. This implies that there is a need for developing new strategies that might help in distributing the condoms to those areas. 7

8 District Table 2 Population age All Rural age Urban age High Risk PSI age Population age All PSI age age All age PSI Butha % 50% % 70% Buthe Leribe % 35% % 75% 95% 75% Berea % 40% % 90% Maseru % 30% % 95% 85% 85% Mafeteng % 50% % 80% Mohale's % 35% % 70% Hoek Quthing % 40% % 60% Qacha's % 35% % 55% Nek Mokhotlong % 40% % 55% Thaba Tseka % 35% % 50% Total % 33% % 72% 90% 80% Quality of age Butha Buthe and Mafeteng are the only rural areas that are above the benchmark of 40% for adherence to recommended price. The urban outlets are above the benchmark except Mokhotlong with 35%. Presence of promotional material is below the benchmark in outlets in rural areas and higher in urban areas which are in the lowlands and lower in mountainous areas including Leribe. Visibility of condoms is very low in rural areas although it is above the benchmark in Leribe, Mafeteng, Butha Buthe and Berea. The condom social marketing program should consider revising the strategies to increase the coverage in rural areas. There is also some problems with quality of coverage implying that there is need to do education in adherence to recommended price and displaying of the condom. The increase in coverage can be attributed to the fact that the new strategy for employing sales agents has worked for PSI, although the concentration is mainly on urban and high risk areas not the rural areas. The other factor might be the fact that sales team is not fully aware of the rural urban demarcations that are adopted using the census data and mapping of EAs. 8

9 Figure 1: Number of outlets covered by MAP III The above figure shows that there are many outlets in Lesotho. This is presented on the above figure by all the circles. The green circle depicts the outlets with PSI condom and where condoms are distributed by PSI employees. The red shows the number of outlets stocking PSI condom from other sources such as wholesalers and big retailers. Trust and LP Condom age During the 2007 study, three brands of PSI condoms were audited. Those are Trust regular, Trust Studded, and Lovers Plus. The 2009 MAP audit introduced Lovers Plus Coloured and Flavoured. During the past study, LP C & F was not yet distributed. The results depict that Trust Regular coverage has decreased by 4% point from 45% to 41%, Lovers Plus coverage has declined by 16% from 31% to 15% and Trust Studded has increased by 13% point from 41% to 54%. The decline in coverage of Lovers Plus and Trust regular can be attributed to change of focus in distributing these products. Lovers Plus is now only distributed to exclusive retailers and Trust regular is no longer advertised. Increased Trust Studded coverage can be attributed tothe fact that it was fairly advertised. These results are illustrated in Table 3 below. 9

10 Table 3 INDICATOR: age YEAR Trust Regular 39% 45% 44% Trust Studded 41% 54% Lovers Plus 32% 31% 15% Lovers Plus C & F 11% Table 4 below displays brand coverage in each district and by rural - urban. Urban area shows the highest coverage in all brands with Trust studded being the highest. Butha Buthe rural has the highest coverage of Trust Regular while Leribe and Berea urban have the highest coverage of Trust Regular.. The Lover Plus brands could not be compared across the districts since they are sold to exclusive outlets at the selected districts. Table 4 Rural age Urban age District Populatio n age TR age TS age LP age LP C & F Populat ion age TR age TS age LP age LP C & F Butha Buthe % 30% % 55% 20% Leribe % 30% 35% % 70% 30% Berea % 30% % 75% 35% 20% Maseru % 30% 20% 30% % 95% 30% Mafeteng % 45% % 75% 25% Mohale's Hoek % 25% 20% % 60% 30% Quthing % 40% 20% % 55% 20% 30% Qacha's % 20% % 40% Nek Mokhotlong % 25% % 50% 30% 20% Thaba Tseka % 35% % 35% 25% 25% Total 1,448,716 30% 28% 5% 12% % 79% 25% 9% 10

11 Quality of age Table 5 below shows the quality of coverage indicators. Presence of promotional material has decreased by 1% point from 45% in 2007 to 44% in Visibility of products in outlets has declined by 8% points from 52% to 44%. Adherence to recommended price improved significantly 24% to 55%. The conclusion that could be derived from quality of coverage indicators is the PSI staff should make sure that they provide the retailers with promotional materials and also educate the retailers about the importance of the visibility of the condoms in their outlets. Table 5 INDICATOR: Quality of age YEAR Recommended Price 20% 24% 55% Presence of Promotional Material 20% 45% 44% Visibility of the product 27% 52% 44% Table 6 Rural age Urban age District Population Price Promo Material Visibility of Product Population Price Promo Material Visibility of Product Butha Buthe 96,052 45% 35% 45% 14,268 50% 60% 65% Leribe 237,063 30% 35% 35% 56,306 60% 50% 70% Berea 188,531 35% 25% 25% 61,475 75% 65% 85% Maseru 234,091 30% 25% 25% 197,907 85% 70% 55% Mafeteng 160,473 45% 30% 35% 32,148 85% 70% 60% Mohale's 148,618 30% 25% 30% 28,310 70% 70% 45% Hoek Quthing 110,272 30% 30% 25% 13,776 60% 55% 40% Qacha's Nek 61,582 35% 35% 35% 8,167 50% 45% 40% Mokhotlong 88,905 25% 25% 8,808 25% 50% 45% Thaba Tseka 123,129 35% 30% 40% 6,752 45% 35% 45% Total 1,448,716 34% 24% 28% 427,917 75% 64% 60% Table 6 presents the district urban and rural spit for all three indicators of quality of coverage. Presence of promotional materials benchmark was set to be 55%. Presence of promotional material in the rural areas was below the benchmark for all districts.in all the outlets that were audited in Mokhotlong, there were no promotional materials. On the other hand, for urban areas, presence of promotional materials was below the benchmark in Thaba Tseka, Mokhotlong and Qacha s nek. 11

12 The benchmark for adherence to recommended price was set at 40%. It was only in Mafeteng and Butha Buthe rural where the benchmark was reached. The rest of the districts were below the benchmark. Only Mokhotlong urban was below the 40% benchmark. The last indicator of quality of coverage is visibility of products in outlets. It was set at 60%. All rural districts were below the benchmark and the urban areas were differing with the most lowlands district reaching the benchmark and the mountainous falling below the benchmark. Penetration Penetration of PSI condoms has shown a decrease at national level, although there is an increase at the high risk areas (Table 7). In 2007, at national level, penetration of the market was 47% and in 2009, it decreased to 44%. In non- high-risk areas it has decreased by 4% point from 44% to 40 %.while it has increased by 2% points from 72% to 74% in high- risk areas. District comparison shows that Mohale s Hoek and Mokhotlong have the highest penetration of 47% each followed by Maseru with 46%. Butha Buthe has the lowest penetration of 30%. Table 7 INDICATOR: Penetration YEAR National 38% 47% 44% Non High Risk 27% 44% 40% High Risk 33% 72% 74% 12

13 Table 8 Districts Number of outlets Total with condoms Percentage Butha buthe % Leribe % Berea % Maseru % Mafeteng % Mohale's Hoek % Quthing % Qacha's nek % Mokhotlong % Thaba tseka % Total Non High Risk % Leribe % Maseru % Total High Risk % Total Non High Risk % Total High Risk % National % 13

14 Figure 1: Outlets receiving condoms through PSI sales agents and representatives The above map shows number of outlets where PSI condoms are found and supplied by PSI employees. LIMITATIONS Compared to the first and the second rounds, there were not as many challenges in this round. However, the main challenge remained inaccessibility of sampled areas due to lack of roads or bad conditions of existing rodas. PROGRAMMATIC RECOMMENDATIONS 14

15 age: Special attention and more appropriate strategies should be implemented towards improving national coverage particularly in districts that still display low geographical coverage. This will include districts such as Maseru rural, Thaba- Tseka, Qacha s Nek and Leribe rural. Though the overall rural coverage has increased substantially, more efforts will still be taken to increase it further focusing more in areas without established outlets. The idea is to explore innovative sales strategies that will increase coverage such as establishing new distribution channels at community level through local chiefs, community based organizations and other local authorities. Regarding urban coverage that has slightly increased compared to the previous year, the strategy will be to work towards either maintaining the scores. Quality of coverage: The focus of quality of coverage will be on visibility of product and presence of promotional materials, especially presence of promotional material since it s mainly provided by PSI staff. Retailers will be educated on the importance of displaying the product so that they will be visible to the end user. For other standards of quality of coverage like adherence, there was a substantial improvement and the same strategies should be used continuously. Market Penetration; the market penetration will be given attention particularly in nonhigh-risk areas, by identifying new outlets and negotiating them into selling PSI condoms. In high-risk areas, new outlets will still be given special prices. Both these strategies are hoped to increase the national market penetration. CONCLUSION The overall results of MAP Round III indicate that most of the sales strategies used increased or maintained the benchmarks. There is a need for increased emphasis in rural coverage and on condom display. 15