1. THE MARKET FOR
FAMILY PLANNING IN
NEPAL
Adrian Blair
Harvard Business School Social Enterprise
Summer Fellow
July 2003
Page 1 of 111

2. Table of Contents
Abbreviations 3
Acknowledgements 5
Introduction 6
Part One – Customers 9
Part Two – Other Brands 36
Part Three – Social Marketing Programme Potential 91
Part Four – Context 95
Part Five – Conclusion and Recommendations 101
Sources 108
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3. Abbreviations
ADB Asian Development Bank
ADRA Adventist Development and Relief Agency
AIDS Acquired Immune Deficiency Syndrome
BCC Behaviour Change Communication
CBS Central Bureau of Statistics
CEDA Centre for Economic Development and Administration
CHP Community Health Promoter (employed by MSI)
CHV Community Health Volunteer
CRS Contraceptive Retail Sales Company
DHS Department of Health Services
DFID Department For International Development
EU European Union
FCHV Female Community Health Volunteer
FHD Family Health Division
FHI Family Health International
FMCG Fast Moving Consumer Goods (eg. chocolate bars)
FP Family Planning
FPAN Family Planning Association of Nepal
HIV Human Immuno-deficiency Virus
HMG His Majesty’s Government
IPED Institute for Population, Environment and Development
IPPF International Planned Parenthood Federation
IEC Information, Education and Communication
INGO International Non-Governmental Organisation
IUD Intra Uterine Device
JHPIEGO John Hopkins Programme for International Education in
Reproductive Health
JHU John Hopkins University
JSI John Snow International
KfW Kreditanstalt fur Wiederaufbau (the German Development Bank)
LDC Less Developed Country
LMD Logistics Management Division
MCH Maternal and Child Health
MOH Ministry of Health
MOPE Ministry of Population and the Environment
MSI Marie Stopes International
MWRA Married Women of Reproductive Age
NAYA Nepal Adolescents and Young Adults
NDHS Nepal Demographic and Health Survey
NFCC Nepal Fertility Care Centre
NGO Non-Governmental Organisation
NSV No Scalpel Vasectomy
OC Oral Contraceptive
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4. PHCC Primary Health Care Centre
PSI Population Services International
RH Reproductive Health
RHFV Reproductive Health Female Volunteer (FPAN’s equivalent of
FCHV’s)
SMD Social Marketing and Distribution
SPN Sunaulo Parivar Nepal (the Nepal branch of MSI)
SRH Sexual and Reproductive Health
TFR Total Fertility Rate
UN United Nations
UNFPA United Nations Population Fund
UNICEF United Nations Childrens Fund
VSC Voluntary Surgical Contraception
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5. Acknowledgements
Everyone at PSI – an endless source of knowledge,
support, and fun.
The Team - Shruti, Binisha, Prasanna,
and Santosh.
Dr. Bidhan Acharya and his team for some
difficult work delivered in a very short time.
The many others who generously gave
their time and information, asking for nothing in return.
Aurore – distant, never forgotten.
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6. Introduction
At its current growth rate of 2.25%, Nepal’s population will double by 2030.1 The
consequences for an already crowded country of population approaching 50m are barely
conceivable. Yet nobody wants this to happen - least of all ordinary Nepalis, whose ideal
family size of 2.5 is barely above replacement level. 2 Hence the urgent need to narrow
the gap between this ideal and the current TFR of 4.1. 3
This study aims to help social marketers address the problem through more effective
marketing of family planning (FP).
To do this, it will identify the major groups of people with an “unmet need” for FP, and
attempt to deepen our understanding of their requirements and decision-making
processes. It will go on to examine what options are currently available to them, the
capabilities of social marketing programmes, and the prevailing socio-economic context
within Nepal.
In the light of this analysis, a target market will be recommended for new social
marketing FP products.
The way different parts of this structure fit together is illustrated below:
Logical framework for target market recommendation
1
CBS (2002)
2
NDHS (2001)
3
The actual TFR may be even higher. Retherford (2002), using the same raw data but a different
calculation method to the NDHS, put it at 4.7.
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7. Social marketing
Customers Existing brands Context
programme potential
Who are they, where are they, and Are others already Are social marketing What favourable
what do they want? giving it to them? organisations in or unfavourable
Nepal capable of political, social
• Who are the biggest If so, with what satisfying them ? and economic
groups with unmet FP need? degree of success? factors exist?
• What don’t we know
about them? Which of these
• Fill knowledge gaps are likely to
through primary and change?
academic research
Target market
selection
Positioning
Follow-on work
The 4 Ps
after this study
Action and
evaluation
Comparison with other LDCs
Contraceptive use in Nepal has come a long way over the last seven years. Chart 1.2
shows the clear correlation in LDCs between the wanted fertility rate and the proportion
of women using a modern method.
Nepal in 1996 was lagging well behind the level one would expect given wanted fertility
of 2.9. By 2001, although this had decreased by just 7% to 2.7, the CPR had increased
by 36% (though Nepal still lagged slightly behind the trend level).
Correlation between number of children wanted and contraceptive use in 50 LDCs4
4
Alan Guttmacher Institute; NDHS (2001)
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8. 80
Brazil
70
Dominican
Republic
60
% Women using a modern method
Egypt
50 Zimbabwe
India
40
Nepal
2001
30
1996 Malawi
20 Haiti
10
Niger
0
0 1 2 3 4 5 6 7 8
Wanted fertility rate
Despite this steep increase in the CPR, “unmet need” for contraception in Nepal over the
same time period decreased only slightly, from 31% of married women in 1996 to 28% in
2001 (having increased between 1991 and 1996). The next section attempts to
understand this 28% in more depth.
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9. Part One - Customers
This section will:
1) Profile the most attractive segments of potential target customers for new FP
products
2) Provide a qualitative overview using PSI’s BCC framework of reasons why
people in these groups are not yet using FP
3) Rank some of the key influencing factors on these groups in order of importance
1) Target customer segments for new FP products
This section runs through seven important variables by which the market for FP products
in Nepal can be segmented. These variables are:
• Marital status;
• Desire for more children;
• Current use of contraception;
• Age;
• Residence;
• Level of education;
• Parity.
For each variable, a recommendation will be given for new FP products.
Three criteria are used to make this selection:
- Acuteness of need for FP
- Size of potential market for FP products
- Consistency with the aims of social marketing.
Variable 1: Marital status (married / unmarried)
Few Nepalis give birth outside the context of marriage. But this does not mean extra-
marital pregnancy is not a problem.
A 2001 study of 1,400 unmarried 12-18 year-olds found that 9% of girls admitted to
having had sex. Of these, 26% said they had not used a condom, and 14% (ie. 1.3% of
the total sample) had got pregnant.5
5
UNICEF (2001)
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10. To avoid the stigma of extra-marital birth, a woman in this situation generally opts for
one of two unpalatable choices: abortion, or a speedy marriage. From the limited data
available, most women appear to opt for the latter. In a 1994 community-based study, of
the 1.7% of pregnant women who terminated their pregnancy, less than 1 in 10 were
unmarried or divorced.6
The clear implication is that (although most studies of unmet need to date have focused
on married people) young unmarried “spacers” (people who wish to delay their next
birth) as well as their married counterparts have an “unmet need” for temporary methods
(ie. they wish to delay their next birth but are not currently using contraception). This is
particularly important in the Terai, currently the only area of Nepal experiencing a
significant decline in nuptiality amongst young people (see “Context” section). Reducing
teenage pregnancy may also have the knock-on effect of reducing the number of early
marriages, hence reducing teenage fertility overall.
Further evidence for the attractiveness of spacing to young unmarried people was
provided by a 1999 study of 808 unmarried 12-19 year olds in Kapilvastu and Baitadi
districts (western terai and far-western hill respectively). The ideal age for a woman’s
first birth, the adolescents said, was 21 years (on average); and the mean ideal spacing
interval between births was 3.7 years.7 In other words, the current situation where over
1/3 of married women give birth in their late teens, and 31% in this age group have an
interval of just 7-17 months before their second birth, is not at all satisfactory for today’s
teenagers.8
Demand for “limiting” (having no more children) at this age, however, is almost non-
existent. It therefore makes sense that FP products should be targeted at married people
wanting no more children, and both married and unmarried people who wish to delay
their next birth.
Recommendation 1: Married and unmarried (spacers); Married only (limiters)
Variable 2: Desire for children (spacer / limiter / wants children soon)
Women wishing to delay the next birth beyond two years are known as “spacers”, and
those with no desire for more children as “limiters”. This does not in itself indicate
anything about method choice. A limiter, for example, may be using a temporary
method, or indeed no method at all.9
6
S. Thapa, P.J. Thapa and N. Shrestha (1994) - Abortion in Nepal: Emerging Insights, Journal of Nepal
Medical Association 1994, Vol. 32, p. 175-190, quoted in Gautam (1999)
7
Karki (1999)
8
NDHS (2001) p.61-62
9
The commonly used terms “spacing method” and “limiting method” often add to this confusion.
“Temporary method” and “permanent method” are clearer.
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11. People wanting children soon have little use for FP, and so are not an attractive target
market. By contrast, FP can help spacers and limiters achieve their objectives.
Moreover, there are a large number of women in both groups: 0.7m MWRA are spacers,
and 2.3m are limiters.10
Recommendation 2: Spacers and Limiters
Variable 3: Current use of contraception (met need / unmet need / no need)
Because social marketing aims to expand overall use of FP rather than gain share from
existing providers, new products should be targeted at people who are not currently
using. Therefore they should not be targeted at people with a “met need”.
People in the “no need” category may want more children soon (see above), be in-fecund,
menopausal, or not sexually active. Either way, they are clearly not an attractive target
market.
Non-users of contraception wishing to space or limit are said to have an “unmet need” for
FP. Targeting new products at them does not entail taking share from any existing
providers. They want the benefits of FP, and are a large group (28% of MWRA11).
Hence they are the most attractive target market.
But this does not mean the job of converting unmet need to use is an easy one. It is
important to bear in mind that “unmet need” does not equate to “unmet demand”
(although no distinction is drawn in any of the studies to date in Nepal, and the terms are
used synonymously).12 Somebody with unmet need is the result of a demographer’s
equation subtracting one group (FP users) from another (spacers and limiters). They have
not necessarily expressed “demand” for FP. Desire for one of the benefits of something
does not automatically entail demand for the product itself. Wanting in principle to travel
to Pokhara does not imply demand for a plane ticket if you are ill, elderly, scared of
flying, and work full time in Kathmandu.
Because this distinction is not drawn, the tone in the literature on unmet need is often one
of mild bafflement at the irrational behaviour of people who “demand” something but do
not use it. The question “why on earth don’t they use this thing they demand, even when
it’s free? (or, with VSC, even when they are paid!)” seems to lurk at the back of the
author’s mind.
In fact the subjects being studied have not always expressed “demand”, and as we shall
see generally have perfectly rational reasons for their non-use.
Discontinuation rates
10
CBS (2002); NDHS (2001)
11
NDHS (2001)
12
For example: Aryal (1997) p.91; Shrestha (1991) p.29; NDHS (2001) p.120
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12. It is worth noting here that a significant minority in the unmet need category are previous
users who have discontinued. A recent study found the following one-year
discontinuation rates for each method:
Table 1.1 - One-year discontinuation rates for temporary methods13
Method One-year discontinuation rate
Pill 38%
Depo 30%
IUCD 13%
Norplant 3%
Overall, around 1/3 of pill and Depo users discontinue each year.
The picture is extremely mixed, however, at a district level. In some districts, according
to the government’s Annual Report, discontinuation exceeds 100%. In others it is
apparently negative.14 However, the government’s data on this varies so wildly by
district and method type that it is difficult to draw any firm conclusions, other than about
the quality of the data itself.
Recommendation 3: Unmet need
Variable 4: Age &
Variable 5: Residence (urban / rural)
These two variables are most revealing when analysed together. Chart 1.1 shows the
largest urban and rural groups by proportion of married women with an unmet need for
either spacing or limiting.
Chart 1.1 - % of married women with unmet need15
13
Pradhan et al (2003
14
DHS (2003). Eg. Pill dropouts as a % of current users in Dolpa district are 507%. Depo dropouts in
Morang as a % of current users are -8%. This was calculated by assuming Dropouts in 2001-02 = Current
users in Jul 01 + New Acceptors during 01-02 - Current users in Jul 02.
15
NDHS (2001)
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13. 35
30
25
% with unmet
20
need
15
10
5
0
15-19 20-24 25-29 30-34 35-39
Age
Urban spacers Rural spacers Urban limiters Rural limiters
Clearly young spacers in both urban and rural areas, and rural limiters aged 25-39, are the
groups whose needs are currently most underserved. However, the actual number of
individuals in these groups is very different.
Chart 1.2 illustrates the largest groups by absolute number. The two outstanding groups,
numbering 0.29m and 0.43m respectively, are rural women aged 15-24 with an unmet
need for spacing, and rural women aged 25-39 with an unmet need for limiting.
Chart 1.2 - Largest categories of married women with unmet need16
16
CBS (2002); NDHS (2001). This analysis assumes that the proportion of women in these categories
living in urban areas is the same as that of the population as a whole (14.2%).
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14. 180
160
140
120
unmet need ('000)
Number with
100
80
60
40
20
15-19 20-24 25-29 30-34 35-39
Age
Urban spacers Rural spacers Urban limiters Rural limiters
Chart 1.3 makes the point even more starkly, showing how over 90% of married women
aged 15-39 with unmet need live in rural areas.
Chart 1.3 - Married women aged 15-39 with an unmet need for contraception17
Total number = 987,917
17
NDHS (2001); CBS (2002)
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15. Urban Spacing
5%
Urban Limiting
4%
Rural Limiting
51%
Rural Spacing
40%
This is also reflected in fertility and contraceptive usage rates for rural and urban areas.
As table 1.2 shows, the urban fertility rate has now reached replacement level, whilst
contraceptive use is considerably higher than in rural areas.
Table 1.2 - Fertility and contraceptive usage18
Urban Rural
Births per woman 2.1 4.4
MWRA using a modern
method 56% 33%
In some urban areas the disparity is even higher than this suggests. In Kathmandu and
Bhaktapur for example, the CPR is over 75%. In neighbouring Lalitpur it is 69%.19
The clear implication is that population growth in urban areas is not caused by high urban
fertility. It results primarily from rural-to-urban migration. And one of the prime causes
of this (though there are many other causes of a trend that is to some extent inevitable as
Nepal’s economy develops) is overpopulation of rural areas caused by high rural fertility.
Paradoxically, therefore, measures limiting rural fertility may yield a greater reduction in
urban overcrowding than those targeted at urban residents.
In summary, rural couples have an urgent need for limiting methods to help them achieve
their desired family size. Urban couples are now much closer to achieving this objective.
18
NDHS (2001)
19
DHS (2003) p. 64
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16. However, a large proportion of urban youth - as Chart 1.1 showed - are failing almost to
the same degree as their rural counterparts to achieve the interval between births that they
want. And the younger the mother, the more acute the problem - 31% of births to
women aged 15-19 take place within 7-17 months of the preceding birth. This is three
times higher than the equivalent figure for any other age group.20
And this matters not just for the convenience of the mother. Infant mortality where the
mother is under the age of 20 is 108 per 1,000 live births - 60% higher than that of the
20-29 age-group.21 There is no doubt that helping young mothers to space their births
will save lives.
Therefore young spacers in both urban and rural locations are an attractive target market;
older limiters in rural areas are another.
Recommendation 4: Age 15-24 (spacers); Age 25-39 (limiters)
Recommendation 5: Rural and urban (spacers); Rural only (limiters)
Variable 6: Level of education (none; primary; some secondary; SLC or above)
Most women in Nepal receive little or no education. Despite huge improvement since the
early 1980s, the majority (57.5%) are still illiterate.22
Table 1.3 shows (as demographic transition theory predicts) that the fertility rate declines
steeply as the level of a woman’s education increases. Although women with secondary
education or above still have an unmet need for spacing, their fertility rates are very close
to replacement level.
Table 1.3 - MWRA by education level23
Unmet need for Unmet need No. of MWRA with
Level of education % of MWRA Fertility rate spacing for limiting unmet need
None 72% 4.8 10% 19% 908,702
Primary 15% 3.2 16% 13% 193,832
Some secondary 10% 2.3 17% 8% 104,923
SLC or above 4% 2.1 13% 7% 36,606
Women with primary level education have the highest level of unmet need of all, at 29%.
In contrast to women with no education, their unmet need is biased in favour of spacing
rather than limiting. Just 2% of women with no education use contraception to space.24
20
NDHS (2001) p. 62
21
NDHS (2001)
22
CBS (2002)
23
CBS (2002); NDHS (2001)
24
NDHS (2001)
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17. Women with an unmet need and primary education or no education are also the largest
groups in absolute terms, numbering 0.2m and 0.9m respectively. Putting all of these
factors together, they appear to be the most attractive target markets.
Recommendation 6: Primary education or no education
Variable 7: Parity
Number of living children is a vital determinant of need for FP products. Unmet need for
spacing predominates at parities of 2 of below; limiting becomes much more important
at parities of 2 and above.
Table 1.4 - Unmet need by parity25
Number of living Unmet need Unmet need for No. of MWRA with
children for spacing limiting unmet need
0 23% 1% 126,627
1 28% 3% 217,718
2 13% 16% 264,579
3 5% 19% 205,669
4 3% 22% 172,270
5 1% 31% 258,142
The absolute number of MWRA with unmet need at each parity is relatively even,
although because as we have seen spacers and limiters overlap at parity 2, this is where
the biggest number with unmet need are to be found (0.3m).
Recommendation 7: 2 children or fewer (spacers); 2 children or more (limiters)
Summary: Profile of target customers
Putting each of the 7 recommendations above together yields two distinct potential target
groups:
Table 1.5 - Profile of target customer groups
25
Pant (1997), revised 2003 to incorporate NDHS (2001) data; CBS (2002)
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18. Variable Target Group 1 Target Group 2
Marital status Married and unmarried Married
Desire for more children Spacer Limiter
Current use of contraception Unmet need Unmet need
Age 15-24 25-39
Residence Urban and rural Rural only
Education level Primary or none Primary or none
Parity 2 or below 2 or above
2) Reasons for non-use of FP among target segments
This section aims to deepen our understanding of the decision making process of women
in the target segments above. We will do this by examining qualitative reasons for
current non-use of FP among the target groups, based around PSI’s BCC framework.
Primary research
To complement existing academic literature, PSI commissioned two brief studies of
unmet need in Nepal. Because, as we saw in Chart 1.3, over 90% of people with unmet
need are from rural areas, both studies focused on these communities. One involved
focus groups with potential FP customers, the other interviews with providers.
The methods used by both studies are described below.
Primary research methodology - customer focus groups
The study of customers (from here on referred to as IPED 2003) was carried out by at
team from the Institute for Population, Environment and Development (IPED),
coordinated by Mr. Bidhan Acharya, an academic at Tribhuvan University.
Focus group discussions were conducted in four VDCs in different parts of Nepal:
• Dandabazaar VDC of Dhankuta district (eastern hill), a rural settlement of
some 621 households of hill ethnic orign, around 90 minutes drive from
Bhedetar on the Dharan-Dhankuta highway.
• Aurabani VDC of Sunsari district (eastern terai), a poor rural area of 1,445
households.
• Bharatpokhari VDC of Kaski district (western hill), a semi-urban area 13
Kms. south-east of Pokhara. 2,172 non-migrant mid-hill origin households.
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19. • Jutpani VDC of Chitwan district (central terai), a rural area in the north of the
district 10 kms. from Ratnanagar. A majority of the population are migrants
of hill origin. 2,557 households.26
We decided to include men as well as women (although they are generally not included
in studies of unmet need), given the extent of their influence over FP decisions in Nepal.
The aim in each VDC was to select two group of males and two of females, each group
approximately matching the profile one of the target groups in Table 1.5 above. This
was done by asking six questions:
Table 1.6 - Questions to select participants for focus group discussions
Question Possible answers Status Group
How old are you? a. 15-24 Selected Not decided yet
b. 25-39 Selected Not decided yet
c. Others Discarded -
Are you currently married? a. Yes Selected Not decided yet
b. No Discarded -
Are you (or Is your wife) pregnant? a. No Selected Not decided yet
b. Yes Discarded -
c. Don’t know Discarded -
Are you using any kind of a. No Selected Not decided yet
contraceptive? b. Yes Discarded -
c. Don’t know Discarded -
(15-24) Do you want to delay your a. Yes Selected Selected for Group 1
next birth? b. No Discarded -
(Limiters are discarded)
(25-39) Do you want to have no a. Yes Selected Selected for Group 2
more children? b. No Discarded -
(Spacers are discarded)
On average 9 people took part in each focus group. There were a total of 142 participants
in 16 discussions across the four districts (79 females and 63 males).
Primary research methodology - providers
Research among providers was carried out by four MBA students from Kathmandu
University (from here on referred to as PSI 2003a).
The aim was indirectly to get an insight into the decision making processes of a large
number of customers (in a shorter period of time than it would take to approach them
individually), by talking to people who may have interacted with several hundred over
the course of their careers.
26
All household numbers from CBS (2002)
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20. The research covered five districts, selected to provide some overlap with those of the
consumer researchers. These were: Baglung (western hill), Chitwan (central terai),
Dhankuta (eastern hill), Kaski (western hill), and Parbat (western hill). Pairs of students
spent one week in each area.
Interviews were primarily with nurses, doctors, FCHVs, other health workers, and people
providing FP counseling services. The organisations they represented included HMG,
NGOs such as FPAN and Aama Milan Kendra, and regular pharmacists. A total of 80
provider interviews were carried out.
PSI’s BCC Framework
The rest of this section integrates qualitative findings from both of the above studies with
academic research on unmet need in Nepal, and presents findings around PSI’s “bubbles”
framework for BCC (illustrated below). All of the behaviour influences are dealt with
here except for “brand appeal”, which is covered in the next section (“Other Brands”).
Chart 1.4 - PSI Behaviour Change Framework27
GOAL HEALTH STATUS QUALITY OF LIFE
PURPOSE USE RISK-REDUCING BEHAVIOR
NEED
OUTPUTS OPPORTUNITY ABILITY MOTIVATION
POPULATION CHARACTERISTICS
ACTIVITIES PRODUCT PRICE PLACE PROMOTION
Opportunity Ability Motivation
Social Norms
Affordability Awareness of
and Support
Severity
Availability Behavior Personal Risk Awareness of
Assessment Causes
Outcome Awareness of
Brand Appeal Self-Efficacy
Expectations Health Problem
27
PSI (2003)b
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21. Particular “bubbles” above take on a special importance in the Nepali context. As we
shall see, perhaps the three most important in this market are “outcome expectations”
(also known as “Solution Efficacy”), “social norms and support”, and “availability”.
1. Opportunity
a) Availability
Transportation
The most popular FP methods have to be delivered at a health facility. This creates a
serious problem of transportation for most Nepalis.
NDHS data reveals that the median time users of temporary methods spent travelling to
obtain their method was 30 minutes.28 Even in remote areas it did not exceed 1 hour.
However a revealing contrast arises between this and the data in Chart 1.5 showing the
time all women in Nepal (users and non-users) take to travel to a health facility.
Chart 1.5 - Time taken by women to reach a health facility29
> 1 day
18% < 1 hour
25%
3-4 hours
32%
1-2 hours
25%
28
NDHS (2001) p. 87. Surprisingly, this was 30 minutes both for users of condoms (available in retail
outlets and from FCHVs) as it was for injectables (only obtainable from health posts) - though just 20
minutes for pills, presumably because of the large number distributed by FCHVs.
29
S. Thapa and K.R. Pandey (1994) - Family Planning in Nepal: An update; Journal of Nepal Medical
Association 32: 131-143, quoted in Shakya (1999)
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22. If this study is to be believed, the median time to travel to a health facility is over 2 hours.
For nearly 1/5 of women it takes over a day. So the average FP user can get to a health
facility in half the time it takes the average woman. This implies that distance to a health
post may be a significant barrier to use.
This finding was supported by our primary research. “Availability” was much more
commonly cited as an important factor in FP decision-making by people living in remote
areas. People we surveyed in Pokhara, by contrast, rarely mentioned it, seeming to take
availability of products for granted.
Opening hours
To compound the problem, many government health facilities have inconvenient opening
hours. In Chitwan, we found the National Park Area had a single health post, where a
health worker attends to patients daily from 10am to 2 pm. This made it difficult for
people walking from far away to reach the health post before it closed.
We also heard reports of government sub-health posts being found closed (sometimes for
days at a time) at times when they were theoretically open, because staff had got bored
and gone to take a break in an urban area. It is difficult to tell how widespread this
problem is however.
Even if the health-post is open at the correct time, users in remote areas find it difficult to
find out exactly what the opening hours are supposed to be. They may end up walking
for several hours, only to find that the weekly clinic does not open that day.
FCHVs
In theory, FCHVs are a far more accessible channel, as they operate at a local level. This
often works well, though we found several people who viewed them with mistrust, and
others with outright derision. One FCHV in Parbat said some people feel FCHVs are just
giving out product because they have to fulfil their quota for the month.
Mrs. Radha Poudel, Nursing Supervisor at the Western Regional Hospital in Pokhara,
said that the work done by FCHVs is not properly assessed. Reports they file are
apparently taken at face value, making it difficult to gauge their effectiveness. People
planners assume to be using contraceptives may not actually be getting them.
So, to summarise, availability is a major factor for some people, and a complete non-
issue for others. This depends on where they live, the opening hours of the local health
facility, how much time they have to spare, the effectiveness of their local FCHV, and
other contextual factors such as the vagaries of the local bus timetable.
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23. 2. Ability
a) Affordability
Our consumer focus groups found that price was one of the least important considerations
in making contraceptive choices. This may of course be because 80% of contraceptive
supply is still free distribution via government channels, so is not habitually factored into
the decision making process.
The following sums up the priorities of most focus group participants:
“If methods are found with no side effects we will use them whatever
the price. It's a matter of personal health and the next generation.”
[Numerous participants in all areas.]
Limiters and people from urban areas in particular appear willing to pay for their
contraceptive needs. Many better-off people are unwilling to be seen waiting in line in
government hospitals for free products.
Many health workers, FCHVs and district hospital employees believed people would be
willing to pay for VSCs. The Chitwan District Hospital even charges a minimum fee for
VSC and claim no significant decrease in the number of patients due to charging. The
destination of the money still officially paid to all VSC participants was not explained.
A meeting with 27 FCHVs in Dhankuta revealed much more concern about issues such
as expired pills and inadequate hospital equipment. Price, they said, was of far lesser
importance if quality was maintained.
The next section (“Other Brands”) discusses pricing for each separate product in more
detail.
b) Self efficacy
Embarrassment
Many providers in our survey commented on the embarrassment people feel in
approaching them for contraceptives.
“In my experience of 7 years in this field, only one female has come to
buy contraceptives. Usually men come to buy for their wives as well.”
[Mr. Arjun Kumar Shrestha, Kusma, Parbat]
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24. Mr. Arjun’s experience is revealing; many Nepalis are extremely reluctant to approach a
member of the opposite sex about contraception. A surprising number of men in our
consumer survey expressed a strong demand for Male CHVs for precisely this reason.
A particular type of embarrassment was also mentioned by several consumers in relation
to FCHVs.
“The FCHV in my village is my aunt. I know the methods are available
from her. I also need them. However, I can't talk about sex and those
devices with her. I asked my wife to go to her, but she also does not like
to ask for such devices from her. Once I had to ask my wife to ask one
of her friends to consult the FCHV. These indirect ways are not always
convenient.”
[A Brahman man, Dhankuta]
“My sister-in-law is an FCHV. I know she distributes condoms, but
neither I, nor my wife can ask her for condoms. I have take them from
outside.”
[A Tamang man, Chitwan]
c) Social norms and support
Spousal communication and approval
Studies throughout the world consistently reveal women’s perception of their husband’s
attitude to FP to be one of the key predictors of use. Spousal communication is closely
link to this, as women who do not talk to their spouse often assume that he is opposed. A
John Hopkins University study of IEC strategies to boost FP usage in Nepal found that
spousal communication and approval was the single most important predictor variable.30
Amongst limiters, both of our surveys found spousal communication almost universal, as
the decision to stop having children is perceived as a momentous one.
Amongst spacers, however, it appears to be less common. A recent survey of married
urban youth found that 35% of men and 29% of women had never discussed
contraception with their spouse.31 The most commonly cited reason (given by 58% of
men and women) was simply embarrassment. Spousal communication in this survey was
strongly correlated with living standards and education levels (the level was much higher
in Kathmandu than in other urban locales). This implies that there is likely to be even
less spousal communication amongst rural spacers.
30
Storey (2000)
31
Aryal (2002)
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25. This lack of communication is particularly disappointing given the widespread approval
by Nepali men of FP. In fact, in 87% of cases where a woman surveyed by the NDHS
believed her husband was opposed to FP, he was actually in favour.32
Where the husband disapproves of FP, or spousal communication has not taken place at
all, secrecy is vital if a woman is to use FP. Many women find injectables, and (to a
lesser extent) pills useful for this purpose. But secrecy is not always possible.
“My husband did not want me to use contraceptives nor did he use. He
was so aggressive and completely against contraception. I did not want
to have dispute in the family. I did not tell him, and used Sangini
[injectible], but my deteriorating health revealed the use of method, for
which my husband was furious with me. Out of six, two children died.”
[A Magar woman, Kaski]
Other relatives
Although the husband-wife partnership is undoubtedly the most important influence on
FP decisions, our two surveys revealed considerable anecdotal evidence about the part
played by other relatives.
“I did want to adopt a permanent surgical method to avert births when I
had two daughters. My father ran after me to hit. He wanted to have at
least one grand-son. My wife gave birth to one daughter more and
finally to a son recently. Now I am prepared to adopt the permanent
method.”
[A Tamana man, Chitwan]
Several young women in our focus groups had been influenced to have more children by
their mothers and mother-in-laws.
“My mother insisted me to have at least a child immediately after
marriage. Therefore, I did not even think of using any method for
spacing before the first child. She had advised me that a child makes my
position strong and permanent in my family.”
[A Dalit woman, Dhankuta]
In many cases, however, FP is still considered an inappropriate topic of conversation for
young people to have with their parents (in urban as well as rural areas).
Women also commonly discuss FP with their sisters and sister-in-laws.
Peer groups
32
NDHS (2001) p.100
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26. A surprising finding from our customer focus groups was the apparently minimal
influencing role of peer groups. People did not openly acknowledge, or even to be
consciously aware of, influence from this source.
The main influence of peer groups in fact appears to be a negative one. People do not
generally mention their peers in the context of questions like “who influences your
decisions regarding FP?”, but it is rare to find someone who cannot recall hearing about
somebody in their locality with a dreadful experience of side effects (see below).
The pervasive influence of such stories shows the power peer groups could have if used
positively. Many focus group participants commented after an hour or two of discussing
FP with their village peers that they were now more likely to begin using. This is not
something which government health personnel currently promote, and discussion groups
may be a productive way to encourage use at a grassroots level.
Health workers
Our researchers in rural areas found health workers to be important FP influencers.
FCHVs travel around their assigned areas (3 VDCs each), counseling women on the
advantages of family planning. Being local, FCHVs are generally trusted by the people
they meet.
MCH workers also occasionally offer FP counseling to women coming for neo or post-
natal care.
Son preference
Our researchers spoke to a Mrs. Chandrakala Rai, a senior FCHV in the region of
Pakhribas. She told the story of a woman who had been abused by her husband ever
since marriage. Desperate for a son, she so far had 3 daughters. After each birth, her
husband would throw her out of the house. On her eventual return, the man would
proceed to get her pregnant again, in the hope of producing a son. Each time she bore
another girl, the cycle repeated itself. She is currently pregnant with her fourth child.
Son preference arises for a multitude of reasons deeply embedded in Nepal’s culture.
One of the most powerful relating to contraceptive use is a woman’s own self-interest.
Her status within the household will be boosted by the birth of sons.
Male son preference is often motivated by concern for their family’s wellbeing as well as
more symbolic reasons like continuation of the family name. In the words of one
polygamous rural man in Chitwan:
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27. “My [youngest] wife should not suffer because of my financial problems
now, or because of my wishes. If I prevented her from having sons
because of my current financial difficulties, then I would leave her with
no recourse later, and with no means of support. This is traditional
practice here. It came down from the time of our ancestors. If I did not
allow at least one son to be born to each woman, I am certain to bathe in
hell.”33
Table 1.7 shows in detail the effect of son preference on contraceptive use. The data is
based on the principle of deriving a hypothetical level of contraceptive use in the absence
of any son preference. This hypothetical level is found by looking at the rate of
contraceptive use of women with 1 boy at parity 1, 2 boys at parities 2 and 3, and 3 boys
at parity 4. The final column states the net effect of son preference - ie. the % difference
between actual use at a particular parity and expected use in the absence of son
preference.
Table 1.7 - Impact of son preference on contraceptive use34
Parity and no. of Contraceptive use without Actual contraceptive Effect of son
sons son preference (%) use (%) preference
All 33 25 -24%
Parity 0 3 3 0%
Parity 1
0 14 11 -22%
1 14 14 0%
Parity 2
0 44 17 -62%
1 44 27 -39%
2 44 44 0%
Parity 3
0 49 6 -88%
1 49 29 -42%
2 49 49 0%
3 49 44 -11%
Parity 4
0 46 14 -69%
1 46 22 -52%
2 46 43 -7%
3 46 46 0%
4 46 43 -8%
33
Quoted in Stash (1999)
34
Leone et al (2003). The study was based on data from the 1996 NDHS.
Page 27 of 111

28. For example, a woman at parity three with two sons and one daughter is assumed not to
exhibit son preference. Usage of contraception amongst this group is 49%. So, in the
absence of son preference, we would expect 49% of women at parity 3 to be using. In
fact, of women at parity 3 with no sons, contraceptive usage is just 6%. In other words,
contraceptive use declines by 88% for these people as a result of son preference.
The overall effect of son preference is that contraceptive prevalence in Nepal is some
24% lower than it otherwise would be. The effect is particularly acute for couples at
parities 2 and above with one son or no sons.
A qualitative study of 98 couples with unmet need in Chitwan found that women were
particularly susceptible to the influence of their husbands on this issue. Even women
with a clear desire to bear no more children tended to give in to their husbands when
having more sons was at stake.35 The study included the following exchange between a
newly married woman and her childless sister-in-law:
Bride: People around here, in this village, if you don’t have babies, they
say, “Get rid of her! She won’t have children!”
Sister-in-law (laughing): Oh, that’s what they say!
Bride: [They say,] “He’ll bring another wife. He’ll bring her to the
house, and you two wives will fight.” That’s why women try to have
their babies fast. Do you understand?”
Sister-in-law: This one will have a son soon; really, she will.
Bride: If I say I will have a baby 2 or 3 years from now, they’ll say,
“Bring another wife! This one is no good! She is spoiled! She won’t
have any sons! Send her running!” That is what they’ll say.
Religion
Our research overall found that religion is no longer a major barrier to the spread of FP in
Nepal. However, certain traditional beliefs were still encountered.
Some Brahmins, for example, apparently believe that VSC prevents a person from
reaching heaven. In Dhankuta, our researchers learned about a tribe of Rais who
maintain traditional beliefs forbidding any form of FP. Despite this, some of their
women apparently sneak into district hospitals to get their injectibles every three months.
3. Motivation
35
Stash (1999)
Page 28 of 111

29. a) Awareness of problem, causes and severity
Nepalis appreciate in abstract the difficulties associated with having a large family. They
obviously realise too the mechanism by which a large family comes to exist. But they
often do not regard the problem as being acute enough to tackle now, today.
In particular, there is reluctance to experience economic loss today for the sake of some
abstract, long-term benefit. This economic loss is not confined to the charges (if any) for
FP products. More significant is the opportunity cost - what people think they will have
to forego in order to adopt FP.
Many people in rural areas need to undertake long hours of strenuous manual work each
day in order to survive. This makes the side effects of contraception far more costly than
just physical unpleasantness. If there is a risk of missing a day in the field then the
potential cost of FP use is extremely high. And there is little confidence in the
willingness of government providers to take care of women should such problems arise.
This is appears to be supported by other research into unmet need.36
b) Personal risk assessment
The most common reason for low personal risk assessment is that the woman’s husband
is an absent migrant worker. This is becoming increasingly common in Nepal, as more
men travel to India and the Middle East to earn a living.
This results in a serious dilemma for many women. Because of their low personal risk
assessment, they see little point in the hassle and side effects of chemical methods. Our
researchers also found that their husbands generally oppose use during their absence,
fearing this may incite their wife to promiscuity (apparently not an entirely baseless fear -
our team heard several stories of pregnancies during a husband’s absence).
But if the woman chooses for these reasons not to use, then she risks pregnancy on her
husband’s return (assuming, as is likely, they do not condoms).
Most women in this position appear to opt for non-use. Temporary methods are either
too much hassle (pills), or protect them (and hence expose them to side effects) for an
unnecessarily long period (3-month injectable, IUD, Norplant).
c) Solution efficacy
36
eg. Stash (1999) - “The perceived potential for sizeable indirect costs associated with illness and loss of
work served as major explanations for unmet need.”
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30. Side effects
Side effects were the overwhelming reason for non-use amongst our consumer focus
group participants. Even young never-users had generally already heard about the bad
experiences of their older peers.
It is important we do not dismiss stories about side effects as groundless rumour for
social marketers to dispel heroically. Many of the most pervasive are well grounded in
medical reality.
“I had used Sangini (the injectible) for four years. I had not menstruated
during the period of use. I discontinued using this method some six
months ago. I am not even menstruating yet.
This is not just my story. There are a number of sisters facing this
problem in my village.”
[A Tharu woman, Sunsari]
“My friend had used injectible for spacing just after the marriage, but
she did not conceive even after she discontinued the method. We don’t
know the reason in details, but we fear that using injectibles and oral
pills might result in sterility among women. Therefore, many women in
my village do not approve such methods.”
[A Magar woman, Chitwan. Echoed by several other participants.]
Both stories show the potentially devastating effects not of injectable contraceptives, but
of inadequate counselling.
The first woman should have been warned in advance about the potential consequences
of Sangini for her menstrual cycle, and offered an alternative method when the problems
failed to stabilise after the first few weeks. She should never have had to continue
suffering for four years, before giving up completely.
The second story again shows the distress caused by lack of information about a perfectly
normal consequence of injectable use (a period of infertility up to 9 months after the last
injection is expected, and women have a right to know this in advance). Had the woman
been told about this, she would presumably either have opted for another method, or not
been distressed when the problem arose. Instead, the idea that Sangini causes infertility
spread throughout her community. The fear then naturally began to extend to other
chemical methods.
This is the mechanism by which side effects have come to be the biggest single reason for
unmet need. Inadequate screening and counselling leads to side effects that are more
severe, or more prolonged, or less expected or understood than they need to be. And
women working with friends in the fields of Nepal do not suffer in silence. The story
spreads, and contraception rapidly becomes something to be feared.
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31. This is what leads to the widespread phenomenon of clustering of particular methods in
small geographical areas. Sharon Stash (1999) mapped contraceptive use in 3 village
sites, and found distinct clusters of households where sterilisation, injectables, or
complete non-use was the order of the day. As we shall see in the “Other Brands”
section, similar patterns occur at a macro level, different districts opting for a surprisingly
diverse mixture of methods.
Of course, not all stories of side effects are grounded in reality. A popular (and, for men,
convenient) misconception in Nepal is that vasectomies cause several days of weakness.
The “No Scalpel Vasectomy” (NSV) method now used in Nepal very rarely has this
effect, yet still this is the most commonly cited reason for non-use.
“I had severe side effects from pills and injectibles. My husband is a
wage labourer and I did not want him to go for a vasectomy because of a
fear that he might be weak after the operation. Therefore, I wanted to
shift to permanent method myself; but my husband suspected that if I
have that method adopted I might sleep with others in the village and he
refused. I don’t know what to do. Is there any method that makes my
life easier?”
[A Tamang woman, Chitwan]37
Such beliefs cause understandable frustration to providers. In Dhankuta, Ms.Bal Kumari
Tamang of the district hospital complained that some women blame all their medical
problems on contraceptives. She apparently finds it difficult to convince women that
their ailments are caused by anything other than contraceptives.38
Nonetheless, no IEC campaign should attempt to tackle the effects (fear of side effects)
without addressing the cause (inadequate counselling). To do so would be to risk a
catastrophic loss of credibility. Supply-side improvements are the most important single
step that can be taken towards removing side effects as a barrier to take-up and continued
use of contraception in Nepal.
Range of products available
Predictably enough, women in our focus groups complained that in addition to all their
other burdens they were also expected to assume responsibility for contraception. The
surprising finding was the number of men (in separate focus groups) who agreed, and
complained that there were not more male methods.
“My wife is suffering from side effects of injectibles. I have only one
child and wanted a vasectomy, but my wife wants to have at least one
more. Using a condom is clumsy. Once a chicken found it and played in
37
IPED (2003)
38
PSI (2003)a
Page 31 of 111

32. the yard in front of parents and others. Storage and disposal of condoms
is also problematic. My wife's body is not ready for further use of pills
and injectibles. Instead, I am ready to use if male oral pills are available
in the market.”
[A Brahman man in Kaski]39
C. Ranking of key influencing factors
It may be interesting to learn about the extraordinary diversity of factors influencing
decisions of people with unmet need, but it can also be confusing. Marketers need not
only to understand the full range of influences on customers, but also how different
factors directly related to marketing mix decisions stack up in order of importance.
So in addition to qualitative focus group discussions and individual interviews, our
researchers introduced a quantitative element. Customers and providers were given five
separate sets of playing cards. Each set contained cards relating to one of five categories
of interest to social marketers (reasons for non-use, influencers, marketing mix, product
attributes, and place). Each individual card was labelled with one factor relating to a
particular category. Subjects were then asked to rank the cards in order of preference,
omitting any they did not feel were relevant.
Table 1.8 summarises all of the findings from this exercise. It lists factors in order of
importance, judged by their aggregate score. This was calculated by assigning 1 point to
a first preference, ½ a point to a 2nd preference, 1/3 of a point to a 3rd preference, etc., and
adding the points to derive a single composite figure reflecting both the number of times
a particular factor was mentioned and the rank it was assigned.
Alongside the aggregate score from consumer focus groups, the table also gives the
provider score (provider opinions of consumer preferences, not providers’ personal
opinions), and a breakdown of the aggregate consumer score into male and female
spacers and limiters. To make the results clearer, and because of the small sample size,
only the top 3 preferences of each such subgroup have been given. To give an idea of the
relative importance of the top 3 preferences, the actual score for each subgroup is given,
rather than a simple 1-3 ranking.
Table 1.8 - Summary of customer preference ranking40
39
IPED (2003)
40
IPED (2003); PSI (2003)a
Page 32 of 111

33. All Female Male Female
Category Factor All consumers Male spacers
providers spacers limiters limiters
Fear of side effects 66 51 7 21 15 24
Spouse disapproves 24 41 9
Low risk of pregnancy 24 15 9 6
No suitable product 23 21 10
Want more children 22 12 7 7
Reasons for
Lack of knowledge 18 55 8
non-use
Risk of losing child 11 19 6
Unaware of true cost 6 20
Embarrassment 5 33
Religious prohibition 4 17
No friends use 2 21
Husband or wife 90 91 15 21 25 30
Self 42 - 13 14 9 6
Mother-in-law 13 25 6 5
Influencers
Other relatives 9 22 2
Health workers 9 55
Friends / peers 6 55 4
Product is effective 101 77 19 28 25 29
Marketing Trusted source 62 48 15 17 15 15
mix Easily accessible 51 70 9 19 10 13
Reasonably priced 28 37
Few side effects 90 52 12 33 18 27
Easy to use 82 79 19 24 20
Product
Reliability / quality 68 53 19 19 20
attributes
Prevents disease 67 39 24 24
Attractive image 12 24
FCHVs 98 55 14 33 23 29
Gvt. health post 82 85 18 21 19 24
Place
Pharmacy 45 54 10 13 10 13
General store 29 20
Reasons for non-use
As expected, fear of side effects tops the ranking by some distance. But some revealing
differences emerge between the various sub-groups.
Providers are acutely aware of consumer ignorance, and rank lack of knowledge as being
the most important reason for non-use. Male spacers, however, were the only consumer
group to include this in their top 3.
Side effects are important to all 4 consumer sub-groups, but their relative importance is
far greater for women than for men - presumably because they tend to be the ones who
actually endure the side effects. Male spacers, for whom condoms are the only option,
were the only sub-group not to rank side effects as their top reason for non-use.
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34. Surprisingly, the only sub-group to give a top-3 ranking to spousal disapproval was male
limiters. These turned out to be men who wanted their wives to have minilap operations,
but whose wives were not keen on the idea.
Both spacer groups included “want more children” in their top 3. In the light of previous
studies, this result was to be expected. One such study found that 47% of women with an
unmet need for spacing gave desire for more children as their primary reason for non-use
(the same study found fear of side effects to be the overwhelming reason for unmet need
for limiting).41
This may be linked to the history of FP in Nepal. Even as recently as 1996, 80% of FP
users had been sterilised. Many people still appear to equate “contraception” with
“sterilisation”. Even among people using temporary methods, the vast majority are using
to limit rather than to space (88% of Norplant and IUD users, 74% of Depo users, and
77% of OC users are using to limit, according to a recent survey42). The standard pattern
of contraceptive use is still to begin only when desired parity has been reached.
Influencers
The spouse emerged as by far the most important influencer on FP decisions overall. The
only other relative playing a significant role was the mother-in-law, though their
influence appears to extend only to women.
Providers considered themselves and peer groups to be important influencers, though few
customers mentioned these.
Marketing mix
A fairly clear picture emerged across customer groups on the most important elements of
the marketing mix. Top by some distance was an effective product, followed by a trusted
source. Price for all groups was considered the least important factor.
The only divergence was that female spacers appeared relatively more concerned about
accessibility than the 3 other groups. This may be because many in this age range (15-
24) are nursing young children, and so find it hard to travel long distances.
Product attributes
Clear differences emerged here between the sexes.
41
Aryal (1997)
42
Pradhan et al (2003)
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35. Men, perhaps aware of difficulties with the only temporary method available to them
(condoms) cited ease of use as the most important attribute, followed closely by
reliability.
By contrast, women were most concerned that a product carried few side effects. A
surprisingly high proportion of female spacers and limiters also ranked prevention of
disease as a key attribute.
Place
FCHVs and government health posts were the most popular choices of contraceptive
source, though the enthusiasm of males, and in particular young males, for FCHVs was
more limited, perhaps because of the embarrassment factor we encountered in our focus
groups.
A stark contrast emerges between this data on where non-users would like to get their
contraception, and where people who do use actually obtain supplies. FCHVs in practice
account for just 1.7% of all contraceptive supply.43 This suggests that if FCHV
distribution were to be scaled up, non-users may start to use, as a source more to their
liking became available.
43
NDHS (2001)
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36. Part Two - Other Brands
The aim of this section is to identify areas in which the largest groups of people with an
unmet need for FP identified in Part One - 15-24 year old spacers and 25-39 year old
rural limiters - are currently being inadequately provided for.
It is possible, for example, that products currently available in the market do not have the
blend of attributes target customers require, or are not available in certain areas or
distribution outlets, or priced unrealistically. Equally, it is important to identify areas
where provision is already more than adequate.
The section has three main parts:
1. Trend in use of different product categories
2. Geographical “Gaps” in the market
3. Detailed information on each product type, including:
1. Strengths and weaknesses
2. Sales levels and market share for each major brand
3. The price charged by each major brand
4. Key distribution channels used by each brand
5. The current positioning strategy of each brand
The product categories covered are:
• VSC
• 3-Month Injectables
• Pills
• Condoms
• IUD
• Norplant
• Pregnancy test kits.
In the light of this information, any current or emerging “gaps” in the market - areas
where the needs of the major target segments are not being adequately met - should
become clear.
1. Trend in use of different product categories
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37. This section aims to give a high-level account of the relative popularity of different
method types available in Nepal, and recent trends in their usage rates.
60% of all modern method users in Nepal are people who have been sterilised. The
historic domination of FP by permanent methods (in part because of money paid by the
government to clients and providers - see below) has over time led to the relative neglect
of people who want to space: ¾ of their overall need is unmet, whilst the equivalent
figure for limiters is less than 1/3. 44
Chart 2.1 shows the current split between all modern method users.
Chart 2.1 - Breakdown of FP users by method45
IUD, 1%
Norplant, 2%
Condom, 8%
Female VSC,
Injectables, 24% 42%
Pill, 5%
Male VSC, 18%
But the dominance of sterilisation is rapidly being eroded - a trend that has accelerated
markedly over the last decade. In 1991, over 80% of all modern method users had been
sterilised; now, as we have seen, the proportion is much smaller.
Chart 2.2 shows the changing method mix since the 1976 Nepal Fertility Survey.
44
Pant (1997), updated with figures from NDHS (2001)
45
NDHS (2001)
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38. Chart 2.2 - method mix in Nepal, 1976-2001 46 Method mix
18
Female
16 VSC
14
% non-pregnant MWRA
12
Injectables
10
8 Male
VSC
6
4 Condom
Pill
2
Norplant
IUD
0
1976 1981 1986 1991 1996 2001
Future intentions
The 2001 NDHS asked married women non-users to specify which method, if any, they
intended to take up in future. Table 2.1 shows the answers to this question given by the
two target age groups highlighted in Part One, split out by ecological zone.
Table 2.1 - % of non-using MWRA intending to use47
Mountain Hill Terai
15-24 25-49 Total 15-24 25-49 Total 15-24 25-49 Total
Female Sterilization 15 9 12 19 19 19 50 43 47
Male Sterilization 12 7 9 14 14 14 3 4 3
Injections 37 48 43 26 30 28 24 27 25
Pill 12 12 12 8 10 9 6 9 7
Condom 1 1 1 2 2 2 1 2 1
Norplant 5 4 5 4 3 4 2 4 3
IUD 1 1 1 2 1 1 1 1 1
Other / don't know 18 19 18 26 21 23 13 11 12
Total 100 100 100 100 100 100 100 100 100
46
1976 Nepal Fertility Survey; 1981 Nepal Contraceptive Prevalence Survey; 1986 & 1991 Nepal Fertility
and Family Planning Survey; 1996 Nepal Family Health Survey; 2001 NDHS; all quoted in MOPE (2002)
47
NDHS (2001). Note that these figures understate the likely future popularity of condoms, as the sampled
respondents were women only.
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39. This shows that the trend towards injectables is likely to continue - they are a more
popular method for future use than even female sterilisation in hill and, particularly,
mountain regions. Mountain regions also look set to overturn their traditional preference
for male over female sterilisation.
The aversion to vasectomies in the terai looks set to continue, with female sterilisation a
more popular method for future use than any other, though injectables are not far behind.
This shows considerable growth potential for injectables in the terai, where currently less
than 9% of MWRA use depo.
Conclusions
Clearly the main reason for the erosion of share of VSC has been the rapid rise since the
late 1980s of the 3-month injectable. None of the other 4 temporary methods available in
Nepal have shown anything like the same surge in popularity - around 1998, injectables
overtook male VSC as Nepal’s second most popular method.
At the same time, whilst vasectomies have stagnated since the late 1980s, there has been
a consistent increase in the proportion of MWRA relying on the most popular method of
all, female VSC.
Non-users’ intended methods for future use suggest the dominance of female sterilisation
and depo are set to continue.
2. Geographical gaps in the market
This section identifies districts offering the greatest untapped opportunity for new FP
products. To do this, we will take three factors into account:
• Proportion of MWRA currently using a modern temporary method
• Proportion of MWRA belonging to a couple practising VSC (male or female)
• Addressable market size.
Why are these factors important?
The proportion of MWRA currently using contraception indicates the size and
effectiveness of ongoing FP programmes in each district48. By separating temporary and
permanent methods we also see the method type that has so far been focused on by these
programmes.
48
It is not the whole story however. A district (such as Kathmandu) containing an exceptionally large
proportion of people with a demographic profile lending itself to high FP use will have a higher proportion
of users. This means the district must have a large FP programme, but does not necessarily give an
indication of its effectiveness.
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40. A high proportion of MWRA currently using suggests that customers most amenable to
FP are already being provided for. This is likely to make winning new users more
challenging than in a district where the proportion of current users is low. So, other
things being equal, it is better to target a programme at a district with a lower proportion
of current users, even if the number of non-users is the same in both districts.
For a social marketing organisation aiming to grow the user base than win share from
existing providers, the addressable market for FP in a given district comprises all MWRA
who are not currently using a modern method. Economies of scale make this an
important variable for potential providers. Given the costs involved in setting up a new
programme in a particular district, as many potential clients as possible should lie within
easy reach. A district may have a tiny proportion of current users, but if only 1,000
people live there it is difficult to justify the cost involved in setting up a programme.
Chart 2.3 illustrates these three factors for each of Nepal’s 75 districts:
Chart 2.3 - Underserved districts in Nepal, July 200249
(area of each bubble is proportional to addressable market size)
50% Kathmandu
Dhankuta
40% Kapilvastu
% MWRA using temporary
Baglung
30%
Kaski Chitawan
20%
10%
0%
0% 5% 10% 15% 20% 25% 30% 35% 40%
% MWRA using VSC
Terai Hill Mountain
The most attractive districts on the chart are represented by large bubbles in the bottom
left-hand corner50 - in other words, big addressable markets with currently very small FP
49
DHS (2003): CBS (2002)
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41. programmes. Table 2.1 lists the 16 districts in the bottom left-hand corner in order of
bubble size (ie. number of non-using MWRA).
Table 2.2: Nepal’s most attractive districts for FP?
Temporary / MWRA using no
District Region Ecological Zone VSC / MWRA
MWRA method
Kapilvastu Western Terai 10% 9% 77,857
Gulmi Western Hill 14% 8% 46,635
Achham Far-Western Hill 5% 7% 41,406
Baitadi Far-Western Hill 7% 7% 39,715
Arghakhanchi Western Hill 13% 7% 34,046
Rolpa Mid-Western Hill 7% 11% 34,016
Doti Far-Western Hill 9% 13% 33,279
Khotang Eastern Hill 6% 11% 32,811
Bajhang Far-Western Mountain 8% 5% 30,823
Jajarkot Mid-Western Hill 9% 8% 22,874
Darchula Far-Western Mountain 8% 4% 22,354
Dadeldhura Far-Western Hill 12% 12% 18,946
Bajura Far-Western Mountain 9% 7% 16,793
Humla Mid-Western Mountain 10% 9% 6,004
Mugu Mid-Western Mountain 11% 7% 4,945
Dolpa Mid-Western Mountain 9% 8% 3,393
Total 465,897
But there are several problems with this list. Most are mid and far-western hill and
mountain districts, which may pose problems with distribution due to harsh terrain or
Maoists. More serious still is the fact that their addressable markets are relatively small
(an average of 29,000 MWRA non-users per district).
A better approach is to focus on districts with a high population of non-using MWRA and
an exceptionally low proportion of either temporary or VSC users - in other words
districts lying below the horizontal line in Chart 2.1, or to the left of the vertical line.
Table 2.2 lists the top ten of 37 districts in the former category (below the horizontal line
in Chart 2.1), and Table 2.3 lists districts to the left of the vertical line - ie. districts with
an exceptionally low proportion of VSC users.
Table 2.3 - districts with an exceptionally low proportion of temporary users
50
The definition of “bottom left-hand corner” used here is to the left of the vertical line and below the
horizontal line - ie. less than 15% of MWRA use VSC and less than 15% use temporary methods. The
exact position of the two lines is arbitrary.
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42. Temporary / MWRA using no
District Region Ecological Zone VSC / MWRA
MWRA method
Bara Central Terai 22% 4% 84,476
Sarlahi Central Terai 29% 6% 84,387
Rautahat Central Terai 22% 4% 83,055
Mahottari Central Terai 28% 2% 79,924
Siraha Eastern Terai 26% 9% 78,368
Dhanusha Central Terai 36% 6% 78,206
Kapilvastu Western Terai 10% 9% 77,857
Nawalparasi Western Terai 28% 10% 73,774
Saptari Eastern Terai 29% 10% 72,015
Parsa Central Terai 32% 7% 62,814
Total top 10 774,876
Total other (27 districts) 954,352
Overall total 1,729,228
Table 2.4 - districts with an exceptionally low proportion of permanent users
Temporary / MWRA using no
District Region Ecological Zone VSC / MWRA
MWRA method
Kapilvastu Western Terai 10.0% 9.1% 77,857
Gulmi Western Hill 14.4% 7.6% 46,635
Dhading Central Hill 11.9% 16.5% 46,234
Achham Far-Western Hill 5.2% 7.2% 41,406
Baitadi Far-Western Hill 7.4% 7.4% 39,715
Udayapur Eastern Hill 14.6% 16.0% 36,833
Arghakhanchi Western Hill 12.7% 6.8% 34,046
Rolpa Mid-Western Hill 7.3% 11.2% 34,016
Doti Far-Western Hill 8.6% 13.0% 33,279
Khotang Eastern Hill 6.4% 11.2% 32,811
Total top 10 422,832
Total other (21 districts) 384,012
Overall total 806,844
A similar approach can be used for each individual method. In Salyan district, for
example, 34% of MWRA use Depo, so any new introduction of a 3-month injectable
there would probably steal share from existing providers. It makes more sense to target
districts where an exceptionally low proportion currently use a particular method, but
where there is also a large absolute number of MWRA non-users.
So Table 2.5 runs through each temporary method, and for each identifies the ten districts
in Nepal where the lowest proportion of MWRA are using that particular method.
Districts are again listed in descending order of MWRA non-users.
Table 2.5 - Districts for with the lowest proportion of MWRA using each temporary method51
51
DHS (2003); CBS (2002)
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43. Users of each Number of MWRA
Rank District Region Ecological Zone
method using no method
Condoms Condom users / MWRA
1 Bara Central Terai 1.2% 84,476
2 Rautahat Central Terai 1.0% 83,055
3 Mahottari Central Terai 0.4% 79,924
4 Kathmandu Central Hill 1.0% 78,178
5 Gorkha Western Hill 1.1% 39,425
6 Sindhuli Central Hill 0.7% 36,668
7 Sindhupalchok Central Mountain 1.2% 34,143
8 Lalitpur Central Hill 1.0% 23,523
9 Jajarkot Mid-Western Hill 1.0% 22,874
10 Bhaktapur Central Hill 0.8% 12,940
Depo Depo users / MWRA
1 Bara Central Terai 2.5% 84,476
2 Sarlahi Central Terai 3.0% 84,387
3 Rautahat Central Terai 2.2% 83,055
4 Mahottari Central Terai 1.6% 79,924
5 Syangja Western Hill 2.9% 45,791
6 Arghakhanchi Western Hill 3.2% 34,046
7 Bajhang Far-Western Mountain 2.8% 30,823
8 Darchula Far-Western Mountain 1.1% 22,354
9 Jumla Mid-Western Mountain 3.7% 10,603
10 Dolpa Mid-Western Mountain 3.5% 3,393
Pill Pill users / MWRA
1 Bara Central Terai 0.5% 84,476
2 Mahottari Central Terai 0.3% 79,924
3 Siraha Eastern Terai 0.6% 78,368
4 Dhanusha Central Terai 0.4% 78,206
5 Nawalparasi Western Terai 0.7% 73,774
6 Parsa Central Terai 0.3% 62,814
7 Tanahun Western Hill 0.1% 47,705
8 Ramechhap Central Hill 0.8% 27,826
9 Jumla Mid-Western Mountain 0.5% 10,603
10 Mugu Mid-Western Mountain 0.6% 4,945
IUD + Norplant IUD + Norplant users / MWRA
1 Bara Central Terai 0.0% 84,476
2 Bajhang Far-Western Mountain 0.0% 30,823
3 Parbat Western Hill 0.0% 24,121
4 Jajarkot Mid-Western Hill 0.0% 22,874
5 Darchula Far-Western Mountain 0.0% 22,354
6 Bajura Far-Western Mountain 0.0% 16,793
7 Jumla Mid-Western Mountain 0.0% 10,603
8 Humla Mid-Western Mountain 0.0% 6,004
9 Mugu Mid-Western Mountain 0.0% 4,945
10 Dolpa Mid-Western Mountain 0.0% 3,393
Table 2.6 gives more analysis of which specific districts are the most attractive for each
product. It shows the number of districts in which the proportion of MWRA using each
method falls within a particular range, and the absolute number of MWRA non-users
living in all of these districts. For female VSC, for example, although there are 20
districts where over 15% of MWRA are current users, there are another 21 where less
than 1% of MWRA use. This information should help in selecting specific districts for
specific programmes promoting specific methods.
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44. Table 2.6 - Distribution of districts by % MWRA using each method52
% MWRA using each
Condom Depo Pill IUD+Norplant Male VSC Female VSC
method
Number of districts
<1% 5 0 17 51 4 21
1% - 2% 33 2 24 15 4 5
2% - 5% 29 22 24 6 10 7
5% - 10% 7 18 8 2 32 14
10% - 15% 1 16 2 1 18 8
> 15% 0 17 0 0 7 20
How many MWRA currently using no method live in the above districts?
<1% 290,765 0 846,794 1,830,505 312,851 421,581
1% - 2% 1,378,202 102,278 904,109 552,346 329,160 109,051
2% - 5% 932,496 945,180 751,323 231,698 545,464 182,949
5% - 10% 132,777 658,478 189,721 55,310 992,703 464,230
10% - 15% 13,797 626,429 56,090 78,178 446,565 326,741
> 15% 0 415,672 0 0 121,294 1,243,485
Conclusions
This presents two stark alternative geographical target markets.
The most distinctive feature of the tables is that all of the 10 biggest53 districts with an
exceptionally low proportion of temporary method users are in the Terai, and all but one
of those with an exceptionally low proportion of permanent users are in Hill areas.
When we drill down into each individual temporary method, three district names seem to
crop up again and again: Bara, Rautahat, Mahottari. These and other large terai districts
are potentially a very attractive market for temporary methods, targeted primarily at
women with an unmet need for limiting, as an alternative to sterilisation.
Likewise, large hill districts where access to VSC has so far been limited are an attractive
target market for minilap and NSV services.
3. Detailed information on each product type
52
DHS (2003); CBS (2002)
53
“Biggest” here meaning “having the highest number of MWRA non-users of any method”
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45. 3.1 Voluntary Surgical Contraception (VSC)
a) Strengths and weaknesses
In the Nepali context, VSC has several important strengths. For the consumer it requires
- unlike temporary methods - only a few days of inconvenience in return for a lifetime of
coverage. For providers, it requires seeing each individual only once, and has none of the
supply problems associated with moving physical product across Nepal’s unreliable road
network.
However, male VSC can be an unreliable method, particularly if clients are not told about
the need to use condoms for several weeks after the operation, during which there is still
a significant risk of pregnancy. Female VSC (now almost always “minilap” in Nepal, the
more expensive “laposcropy” method having been phased out by the government) is
almost 100% reliable, but side effects are more common.
As we saw in Part One, misconceptions about side effects are also very common. The
popular belief that NSV (the main male method used in Nepal) leads to several days of
weakness means provision of VSC in Nepal is highly seasonal. Very few people get the
operation done in the busy summer months where the agricultural workload is heavy.
There are also concerns about the risk of infection in hot weather. The vast majority wait
until winter for their operation.
b) Sales levels and market share
For each product type we will contrast two alternative forms of measurement: The “top-
down” approach of the NDHS, derived from surveying consumers, and the “bottom-up”
approach of adding up distribution figures claimed or forecasted by the various providers.
“Top-down”
Despite the boom in the NGO sector since the early 1990s, HMG is still responsible for
around 80% of VSC provision for both sexes. Chart 3.1 shows the split by channel and
provider.
Chart 2.4 - Market share of providers of VSC54
Female Male
54
NDHS 2001
Page 45 of 111