Forming Partnerships to Influence Health Policy

Policy Advocacy: The Fifth ‘P’ of Health Marketing

August 13, 2009

Bryan Callahan, Ph.D.Social Marketing PracticeOgilvy Public Relations WorldwideWashington, DC

bryan.callahan@ogilvypr.com

Kimberly WhipkeySr. Associate, Advocacy and OutreachCenter for Health & Gender EquityWashington, DC

kwhipkey@genderhealth.org

Presenters

Bryan provided support for strategy development, branding, and materials development for the launch of Prevention Now! and continues to provide senior counsel to the campaign.

Kim manages the day-to-day operations of Prevention Now!, spearheading advocacy initiatives and providing technical assistance for Prevention Now! activities worldwide.

Policy Advocacy: The Fifth ‘P’

Traditionally Health Marketing Has Operatedwith “Four P’s”

Product The health commodity or health behavior that you are seeking to market to consumers

Price The real cost of the item, or the cost/benefit equation used to engage consumers

Place The physical placement of the item to raise visibility among consumers

Promotion The promotional tactics used to raise awareness, engagement, and behavior change

Increasingly, global health and development organizations – from the Bill & Melinda Gates Foundation, to the World Health Organization, to the World Bank – are recognizing the need for Policy Advocacy as an essential Fifth P for health marketing.

Policy Advocacy

To promote important changes in health behavior, advocates must engage key decision-makers with evidence that demonstrates the costs and benefits of specific health interventions. Policy advocacy is essential to secure the required funding, institutional support, and dedicated human resources to make health interventions accessible to those who need them.

Primary Audiences: Heads of state, members of Congress or Parliament, Ministers of Finance, Ministers of Health, Bilateral Aid Agencies

Secondary Audiences: Scientists, researchers, think tanks, foundations, other policy advocates, the media

What are the differences between policy advocacy and health marketing?

Health Marketing

Consumer oriented (often general population)

Promotes health behavior change at the personal, family & community levels

Delivers message with low-literacy materials Information designed to demonstrate personal benefit Information designed to be accessible to all audiences

Engages information gate-keepers and key influencers at the community level

NGOs support community-level programming focused on consumers

Policy Advocacy

Focused on key decision-makers and their key influencers

Promotes policy change at the national, state, municipal, and district levels

Delivers message with high-literacy materials Scientific evidence Evidence of need and demandCost-effectiveness evidenceDemonstration of civil society support

Engages key influencers and key decision-makers at the national, state, municipal and district levels

NGOs support advocacy by targeting key decision-makers with evidence of need and demand

What are the similarities between policy advocacy and health marketing?

Health Marketing

Simple messages

Based on credible evidence

Framed by a clear call to action

Delivered by trusted intermediaries

Key intermediaries are often grassroots NGOs

Policy Advocacy

Simple messages

Based on credible evidence

Framed by a clear call to action

Delivered by trusted intermediaries

Key intermediaries are often grassroots NGOs

“I don’t care what you tell me about the female condom.

I’ve heard that women don’t like it.

Until I hear different, don’t call me back.”

— Senior Health ReporterAssociated Press

October 2005

Policy Advocacy for the Female Condom:Changing the Conversation, 2005-2009

The Female Condom: From Concept to Reality®

1981

MMWR identifies AIDS in U.S. gay men

1988

● Heterosexual transmission seen as dominant vector in Africa● Women account for 5% of diagnosed AIDS cases in U.S.● Wisconsin Pharmacal announces development of Female Condom

1993

FDA approves FC1 by narrow 4-3 vote

1994 2001

● FC1 fails to take off in U.S. & Europe cost and product characteristics play role● First ARVs become widely available

● NSC declares AIDS global security threat● UN creates Global Fund● Bush Admin. Commits $15 billion to PEPFAR● UNFPA begins targeted FC1 distribution ● FHC commits to developing lower-cost FC

2005

● FHC introduces FC2 (2005)● WHO includes FC2 in EPL (2006)● IAC “Time to Deliver” (2006)● Women ~50% of PLWHA (2006)● Prevention Now! launched (2006)● FDA approves FC2 by 14-0 vote (2008)

2009

In 2008, 33 million people worldwide were living with HIV or AIDS. The global pandemic is centered in southern Africa. In other regions of the world, HIV and AIDS disproportionately impact MSM, CSW, IDU, and women. In many regions of the world, marriage is the #1 HIV risk factor for women and young girls.

Source: UNAIDS, 2008

A Growing Global HIV Pandemic

Women and HIV/AIDS: A Growing Pandemic

By 2006, ~50% of all PLWHA worldwide were women. By 2006, nearly 60% of PLWHA in sub-Saharan Africa were women. Women and girls between the ages of 15-24 accounted for 76% of all new infections.

Source: UNAIDS, 2008

An epidemic at home among Black & Latina women

Transmission Route Male Female Total

Male/Male Sexual Contact 22,472 - 22,472

Injection Drug Use 3,133 1,806 4,939

Male/Male Sexual Contact & Injection Drug Use

1,260 - 1,260

High-Risk Heterosexual Contact 4,551 9,076 13,267

Other/Risk Not Identified 102 96 198

TOTAL 31,518 10,977 42,415

In 2007, females accounted for 26% of U.S. HIV diagnoses in 34 states where surveillance was conducted.

In 2007, high-risk heterosexual contact accounted for 83% of HIV diagnoses in U.S. females.

Black women account for the largest share of new HIV infections among women – 61%

Black females account for 69% of new AIDS cases among young women.

The AIDS case rate among Latina women is 5 times higher than among White women (suggesting late diagnosis).

Source: CDC data.

High-Risk Heterosexual Contact = 83%

IDU = 15%

HIV Transmission among U.S. Women - 2007

But little movement to equip women with the only woman-initiated HIV prevention method available

Despite strong clinical evidence that the female condom had high rates of acceptability as a prevention method, only 12 million units were sold and distributed to prevention programs worldwide in 2005.

Global distribution of male condom vs. female condom in 2005 was 6-9 billion vs. 12 million Just 1 FC available for every 100 women of reproductive age

The high cost of the female condom – which was up to 20 times more expensive per unit than the male condom – made the method inaccessible to many prevention programs in the developing world.

When FC was available, it was only programmed to specific high-risk populations (e.g., commercial sex workers).

Many reproductive health advocates saw the development of a safe and effective microbicide as possible by 2011, and their commentary suggested that the FC was strictly a second-tier alternative as a woman-initiated method.

Many influencers in global health stressed the need for a method that women could keep secret from their husbands and partners. Women’s ability to initiate or negotiate safer sex with female condoms was described as problematic. Education programs designed to sensitize women to female condom and teach partner negotiation skills went unfunded or underfunded.

Female Health Company response, 2001-2006

Invested in the development of FC2 Female Condom, which could be manufactured with the same cost-efficient methods used to make male condoms.

Commissioned cost-effectiveness study by Dr. David Holtgrave of Johns Hopkins University.

Partnered with University of the Witwatersrand to conduct effectiveness and acceptability comparison studies of FC2 and FC1 in Kwazulu Natal.

Introduced FC2 in 2005 at global forum on female condom sponsored by PATH and UNFPA in Baltimore.

Sought inclusion of FC2 in WHO’s Essential Products List for reproductive health commodities.

Engaged public relations counsel (Ogilvy PR) to raise visibility for FC2 among U.S. and international stakeholders Baltimore press release (unsuccessful) World AIDS Day 2005 media relations (more successful, indicating new strategy)

Engaged Musimbi Kanyoro, General Secretary of World YWCA as spokesperson Engaged six African national affiliates of World YWCA to issue Call to Action statement

Creating an advocacy movement:The launch of Prevention Now! in 2006

By 2006, FHC had all of the evidence it needed for effective policy advocacy.

Data on acceptability (~ 200 studies on four continents)

Data on cost effectiveness (Holtgrave et al.)

Data indicating that availability of FC in prevention programs diversifies prevention options, decreases unsafe sex, and decreases incidence of new STIs (Madagascar study)

So what was lacking?

We had plenty of evidence of NEED.

But the AP reporter convinced us that what we really needed was evidence of DEMAND for the female condom – not from study subjects, represented as data points – but from REAL WOMEN.

And that’s how was born.

CHANGE capabilities:• Relevant media & influencer contacts• Respect among policymakers and advocates• Staff dedicated to raising visibility and support for comprehensive programming of woman-initiated methods

Organization advocating for

universal access to prevention

options for women

Organization that is

recognized as an independent, credible voice

Organization with capacity to

engage and activate

reproductive health

advocates globally

Organization capable of

maintaining sustained

engagement

Building an effective advocacy NGO Partnership

Woman-initiated HIV prevention methods are essential to stopping HIV/AIDS.

The FC Female Condom has been proven safe, effective, and acceptable.

And the female condom is the only women-initiated method available NOW.

Women and men need access to

woman-initiated HIV and STI prevention.

The female condom remains

the only safe, effective, and

acccepted method

available NOW.

The development of

the second-generation FC

offers an opportunity to

drive down cost & increase

access.

Expanded access to the

FC, and training on its use, will

prepare women at risk of HIV for new methods as

they become available.

Creating clear, distinct, and credible messages

Developing a strong brand & 21st-century campaign platform

360° Communications

Coalition Building

Third-Party Initiatives (e.g.; School-based program)

Promotions and Special Events

Earned Media/Media Relations

Social/”New” Media Crisis Management

Issues Management

Family

Advocacy GroupsDigital

Influence

Friends

Neighbors

Faith Community

Local, State and Federal Agencies

Workplace (Employers,

Co-workers, Unions)

Community Leaders/Groups

Schools, Libraries, Other Community Resources

Partnership Support

Guerilla Marketing

Grassroots Outreach

Sports and Entertainment

Outreach

NGOs

Word-of-Mouth/ Social Media

Traditional Media(print and broadcast)

Advertising Direct Marketing

Key Decision-Makers at the International and Country Levels

Regional Organizations

Global Organizations

Country-Level Organizations

Individual Influencers /

KOLs

Think Tanks, Foundations

Name

Technical Assistance

Media OutreachResearch Reports

Leader Engagement

Events & Public Testimony

Strategic Approach

Prevention Now! policy advocacy

Prevention Now! Structure An initiative of the Center for Health and Gender Equity (CHANGE) U.S. and international campaign More than 215 organizational endorsers across 47 countries, including 9 regional/global networks Engages multiple audiences Key decision-makers, policymakers, funders Grassroots and grasstops advocates and partners Scientific/expert community Media

Prevention Now! Goal Expand global access to female condoms

How?• Network-building, information sharing, advocacy training• Consistent, evidence-based messaging• Demonstrate evidence of need/demand to key powerbrokers and constituencies• Informed advocacy at international and country level

Prevention Now! policy advocacy

International Advocacy Key partners: UNFPA, Universal Access to the Female Condom Initiative Key targets: UNAIDS, Global Fund for HIV/AIDS, TB, and Malaria Important events

International AIDS Conference in Toronto (2006) and Mexico City (2008) UN Special Session of the General Assembly on HIV/AIDS Commission on the Status of Women World AIDS Day (sign-on statement)

Country-Level Advocacy: Uganda Civil society support for Ministry of Health’s reintroduction of FC in 2009 Workshop trained 30 civil society leaders Working coalition formed Met with MoH, UNFPA, Health Development Partners Group (USAID, UNFPA, Danish & Swedish aid agencies)

Prevention Now! policy advocacy

U.S. Advocacy on U.S. Global AIDS Policy Researched and published Saving Lives Now report on female condom programming needs Advocacy for FC around PEPFAR reauthorization 2008 authorizing law replaced references to “condoms” with “male and female condoms,” a critical change in wording that will raise visibility for FC while allowing individual country programs more latitude in procuring FC for HIV/AIDS prevention USAID meeting in 2009 produced interest in scaling up FC2 promotion in Lesotho and development of FC fact sheet for circulation to all USAID missions

Support for FDA Approval of FC2 Female Condom CHANGE coordinated internal communication among advocates Preparation of supporting statements at hearing Sign-on statements from 170 organizations Unanimous vote to recommend FC2 for approval (14-0) Prevention Now! spokespersons prominently featured in follow up Reuters and AP coverage Co-chair of FDA panel remarked that the civil society presence at the hearing was the most organized and engaged of any he had seen in two decades of panel participation

Official launch of Prevention Now! Toronto IAC, 2006

Female Condom Rally Mexico City IAC, 2008

Year Positive

(%)

Balanced/

Neutral (%)

Negative

(%)

2004

(n = 409)

18 48 12

2008

(n = 413)

57 39 3

Difference

2004 > 2008

+39 -9 -9

Comparing 2004 and 2008, positive coverage of the female condom in global media increased from 18% to 57%. Comparing 2004 and 2008, positive or balanced coverage of the female condom in global media increased from 66% to 96%. Comparing 2004 and 2008, negative coverage of the female condom in global media decreased from 12% to 3%. While there was no significant increase in overall coverage between 2004 (n = 409) and 2008 (n = 413), the tone of media coverage of the female condom shifted significantly in favor of positive coverage.

Positive B/N Negative

2004 2008

Outcomes: The power of policy advocacy