FINAL REPORT March 15, 2010 This publication was produced for review by the United States Agency for International Development. It was prepared by Dr. Yagya Bahadur Karki, Team Leader, Mr. Khaagendra Adhikary, Team Member, Dr. Ashok Dev Pande, Team Member Evaluation of USAID/Nepal's Key Social Marketing and Franchising Project: AIDS, Reproductive Health, and Child Survival (N-MARC) Evaluation of USAID/Nepal's Key Social Marketing and Franchising Project: AIDS, Reproductive Health, and Child Survival (N-MARC) FINAL REPORT Submitted to: Office of Health and Family Planning USAID, US Embassy Bramha Cottage Maharajgunj Kathmandu By: Dr. Yagya Bahadur Karki, Team Leader Mr. Khaagendra Adhikary, Team Member Dr. Ashok Dev Pande, Team Member March 15, 2010 DISCLAIMER: The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. ii AED Academy for Educational Development AIDS Acquired Immune Deficiency Syndrome AMDA Association of Medical Doctors of Asia ASHA Advancing Surveillance, Policies, Prevention, Treatment, Care and Support to fight HIV/AIDS BBC British Broadcasting Corporation BCC Behavior Change Communication BCI Behavior Change Intervention CBO Community-Based Organization CDK Clean Delivery Kit CHD Child Health Division CHX Chlorhexidine COC Combined Oral Contraceptives CPIM Certificate Program in Inclusive Marketing CRS Nepal Contraceptive Retail Sales Company Ltd. CSED Centre for Social and Economic Development CYP Couple Years of Protection DG Director General DACC District AIDS Coordination Committee DHO District Health Office DoHS Department of Health Services DPHO District Public Health Office EC European Commission ECP Emergency Contraceptive Pill ELD Empowerment and Learning Development ENPHO Environment and Public Health Organization FCHV Female Community Health Volunteer FGD Focus Group Discussion FHI Family Health International FM Frequency Modulation FMI Full Market Impact ACRONYMS iii FP Family Planning FSW Female Sex Worker FY Fiscal Year GFATM Global Fund for AIDS, Tuberculosis and Malaria GIS Geographical Information System GoN Government of Nepal GPS Global Positioning System Gyn Gynecologist HFP Health and Family Planning HIV Human Immunodeficiency Virus HMIS Health Management Information System IDU Injecting Drug User IEC Information, Education and Communication INGO International Non-Governmental Organization IPC Inter-Personal Communication IQC Indefinite Quantity Contract IR Intermediate Result IUD Intrauterine Device IUCD Intrauterine Contraceptive Device KAP Knowledge, Attitudes and Practices KfW German Development Bank KTM Kathmandu LMD Logistics Management Division M&E Monitoring and Evaluating MER Monitoring, Evaluation and Research MARP Most-At-Risk-Population MCH Maternal and Child Health MIS Management Information System MMR Maternal Mortality Ratio MOHP Ministry of Health and Population MoU Memorandum of Understanding MSI Marie Stopes International MSC Matri Surakchhya Chakki (Safe Motherhood Pill) MSM Men Having Sex with Men MSH Management Science for Health NAC National AIDS Council iv NACC National AIDS Coordination Committee NCASC National Center for AIDS and STD Control NDHS Nepal Demographic and Health Survey NESoG Nepal Society for Obstetrics and Gynecologists NFCC Nepal Fertility Care Centre NFHP Nepal Family Health Project NFWLHA Nepal Federation of Women Living with HIV/AIDS NGO Non-Governmental Organization NHEICC National Health Education, Information and Communication Centre NHSP-IP National Health Sector Program-Implementation Plan NIBL Nepal Investment Bank Ltd. N-MARC Nepal Social Marketing and Franchising Project: AIDS, Reproductive Health and Child Survival NNR Neonatal Mortality Rate NTO Non-traditional Outlet NTV Nepal Television OB Obstetrics O/HFP Office of Health and Family Planning OCP Oral Contraceptive Pills ORS Oral Rehydration Salt PATH Program for Appropriate Technology for Health PSI Population Services International PPH Postpartum Hemorrhage PLWHA People Living with HIV and AIDS PPP Public Private Partnership PMP Performance Monitoring Plan PEPFAR President’s Emergency Program for AIDS Relief PSP Private Sector Program PSSN Pariwar Swasthya Sewa Network POPs Progesterone-only Contraceptive Pills POP Point of Purchase QA Quality Assurance RFR Rural Field Representative RH Reproductive Health SDIP Safe Delivery Incentive Program SFC Short Film Competition SM Social Marketing v SMD Social Marketing Distribution SMNHLTP Safe Motherhood and Neonatal Health Long Term Plan SOW Statement of Work SSDS Social Sector Development Strategies STI Sexually Transmitted Infection TO Task Order TOs Traditional Outlets TPM Team Planning Meeting TSV Technical Support Visit TVC Television Celebrities USAID United States Agency for International Development VSH Venture Strategies for Health vi Background USAID/Nepal has contracted with Academy for Educational Development (AED) for a program called Social Marketing and Franchising Project: AIDS, Reproductive Health (RH), and Child Survival (N-MARC), to support social marketing of family planning, maternal and child health, and HIV/AIDS prevention products and services. N-MARC promotes social marketing in Nepal by: 1) building the technical and organizational capacity of social marketing organizations such as the Nepal Contraceptive Retail Sales Company (CRS), 2) encouraging commercial players to expand sales of health products to reach a broader range of income segments within target populations, 3) promoting the appropriate use of maternal and child health, family planning and HIV/AIDS prevention products/services, and 4) ensuring the quality of family planning services and products in the social marketing sector. The commodities that are being sold through various partners of N-MARC include contraceptives, clean home delivery kits, oral rehydration salts and zinc for diarrhea, sexually transmitted disease treatment kits, emergency contraceptives pills, point of use water disinfectant (PIYUSH) and Virex® - a surface disinfectant. N-MARC aims to market subsidized quality health products to lower income groups willing and able to pay a small amount for valued health products, and to ensure they are available when and where they are needed. A strong, healthful behavior change component underpins product marketing in the N-MARC strategy. Goal The AED supports USAID/Nepal in meeting the goal of the PSP “N-MARC” project, which is to expand the depth, reach, and impact of the private sector in FP, MCH, and HIV/AIDS prevention products and services among low socio-economic populations through sustainable social marketing and social franchising programs. Purpose The purpose of evaluation of USAID/Nepal's key Social Marketing and Franchising Project: AIDS, RH and Child Survival (N-MARC) was to examine the key expected activities of N-MARC based on the project design and annual work plans. The evaluation focused on N-MARC's progress in meeting the program objectives and goals. Methodology The methodology of evaluation was guided by the Terms of Reference which included a wide range of methods and approaches for collecting and analyzing the information which were required to assess the evaluation objectives and answer the presented questions. The evaluation team reviewed the list of background reports and conducted key informant interviews with stakeholders from the government and N-MARC partners. A two-day team planning meeting (TPM) was conducted participated by USAID/Nepal officials, representatives from NFHP and FHI/ASHA. Data collection methodologies were drafted by the evaluation team, discussed in the TPM and approved by USAID/Nepal. The tools developed for evaluation were: Key Informant EXECUTIVE SUMMARY vii Interview Checklist for MoHP officials, Interview Checklist for key N-MARC staffs, Interview Checklist for key N-MARC Private Sector Program Partners, Interview Checklist for USAID/Nepal Social Marketing Team, Checklist for Observation of Service Sites, and Checklist for Observation of Commodity Outlets. The evaluation approach was primarily participatory. The evaluators also visited nine districts (Dhankuta, Sunsari, Morang, Chitwan, Tanahun, Kaski, Banke, Bardiya and Kailai) and conducted in-depth interviews with CRS and other N-MARC partners, observed Sangini service outlets and other TOs and NTOs selling RH products. Key Findings Some of the findings of the evaluation are presented as follows:  Initially N-MARC entered into partnership with EngenderHealth, CRS, and NFCC. Later N-MARC expanded its overall partnership with the addition of five new core partners MITRA Samaj, Urban Pixel, and three commercial sector condom distributors – Praxis Trade Link, Pioneer Trading, and Gayatra Store Enterprises.  At the outset, AED/N-MARC conducted a brief session on USAID population policies that included the Tiaahrt Amendment and the Helms Amendment for CRS and NFCC staffs.  Overall, N-MARC and its partners’ project activities have been effective in promoting and expanding RH/FP and HIV products and services and meeting the RH/FP needs of people.  Annual CYP based on five spacing methods distributed and marketed by N￾MARC partner organizations increased from the baseline CYP of 239,621 in 2005/06 to 289,835 CYP in the following year, further to 369,977 CYP in 2007/08 and 445,801 in 2008/09.  Sangini Network has been expanded to reach 2,784 providers in 69 of Nepal’s 75 districts.  N-MARC was successful in attracting and convincing Lomus Pharmaceuticals Pvt. Ltd. to manufacture, market, and distribute hormonal contraceptives namely Femicon (COC), Feminor (ECP), and Femitrone (POP).  CRS launched its new brand of emergency contraception, eCON replacing Postinor-2. It is popular among young population and some chemists think that they overdo it.  Sale of CDK has gone down especially in urban areas. Although in 2007/08 percent achieved was 102% against the target, in the following two years the achievement against the targets were much below 100 percent. From field observation it was found that CDK were not sold because of free delivery service and monetary incentives given to women delivering at health facilities. viii  Nava Jeevan ORS is now a self-sustaining social marketing product. The sale of Nava Jeevan has achieved the targets.  Although attempts have been made by N-MARC partners to promote and sell Virex and PIYUSH, these products are not found sold well.  A commendable item that N-MARC partners have marketed is Matri Surakchha Chakki MSC (Safer Motherhood Pills) as a pilot project in Bardiya district. Now the social marketing of MSC has expanded to Banke, Rupandehi, Nawalparasi, and Chitwan districts.  N-MARC has been successful in mobilizing private sector trade houses to promote and sell condoms of various brands in addition to social marketing of condoms mainly through CRS.  Annually about 21.4 million condoms are distributed by N-MARC partners which is about 52 percent of total market share is occupied by social and commercial marketing.  Some innovative approaches such as condom kiosks, healthy highway approach, mobile shops, tea shops, etc. have been adopted by N-MARC partners to market condoms in hard- to- reach areas.  N-MARC and the CRS Company's initiatives on social marketing practices in rural areas by recruiting Rural Field Representatives (RFR) marks a paradigm shift in retailing health and family planning products/service and to improve people's attitude towards condom usage and to increase its marketability in the hard-to reach villages.  Attractive packaging and high pricing of private sector condoms have motivated customers which encouraged the private sector to expand condom marketing.  Trainings on social marketing communication strategies, HIV-related institutional capacity building, organizational development and change, and logistics and warehouse management were provided to many staffs.  N-MARC also sponsored logistics training on social marketing for CRS central and regional staff in coordination with NFHP and USAID/Nepal.  With the objective of managing warehouse by CRS, a warehouse management consultant was hired by AED to provide on-the-job training to CRS warehouse staff.  N-MARC program helped strengthen PPP in health sector in Nepal. By sitting in different health committees of the government and regularly briefing about its own activities N-MARC has strengthened PPP in practice. This was appreciated by government officials. ix  In year two, N-MARC and NFHP collaborated on three key areas: chlorhexidine, misoprostol, and private sector sick child-care.  N-MARC collaborated with NFHP in logistics management training in social marketing sector during the first year of the project period and it also provided technical support to CRS in the development of their proposal to KfW.  N-MARC was successful in harnessing partnership of the Nepal Investment Bank Limited (NIBL) to sponsor top three directors of You Are No Exception short film competition. NIBL contributed Rs. 2 Million (approximately $27,000) to cover the costs of the top three directors to attend a 3-month long film course in Mumbai, India.  N-MARC project’s planned activity of creating policy incentive on mobilizing the private sector in year three could not be completed; it is perhaps too early to evaluate this activity as it was planned late in the project cycle.  Some private implementing partners have appreciated N-MARC program for providing them a platform to get involved in social development. Leveraging of resources from the private sector was highly encouraging.  Despite tremendous growth of Sangini Network in the country the quality aspects need to be further improved. This was the finding from the field visits to nine districts.  Many of Sangini providers do not have training to administer IUD and implant. This restricts clients’ choice for methods.  N-MARC faced high turn over of high level human resources. Recommendations Some major short-term and long-term recommendations are presented below: Short-Term Recommendations  All partners of N-MARC should work together to set targets for project implementation period. Proper targets setting enable achievements not to cross 100 percentage points.  Prepare PMP indicators in terms of residence, i.e., rural and urban which will reveal whether project implementation is progressing towards achieving equity.  N-MARC should strengthen monitoring of its partners’ activities to ensure that commodities are not expired and services do not derail from providing quality of care.  N-MARC should thoroughly check data before including in final reports. x  N-MARC should extensively promote pills.  The quality of Sangini service needs improvement.  N-MARC should train Sangini service providers to administer IUD and Implant/Jadelle; there is demand for training and IUD and Implant/Jadelle products.  CDK needs to be improved by adding CHX, a pair of gloves, scissors and clamp instead of string. CDK should be marketed in rural areas, not in urban or semi-urban areas.  Marketing of Matri Surakchha Chakki (Safe Motherhood Pill) should be focused more in rural areas.  N-MARC should select partners on the basis of relevancy, organizational strength, track records and through free competition. The evaluation team must also consist of external experts in addition to in-house members. Long- Term Recommendations  USAID should extend its support through US TA agency such as AED/N-MARC to the government of Nepal in formulating a national policy on social marketing.  In view of growing demand for condoms, it is now time for the CRS Company to consider manufacturing condoms in the country.  Jeevan Jal has become a generic name for ORS. Instead of changing the name of ORS and confusing the consumers the CRS Company should consider manufacturing it acquiring the brand name of Jeevan Jal.  N-MARC should encourage CRS to enter into commercial sector as well. However this step must not discourage the commercial sector already in business. The new wing can generate income which can be used to cross subsidize social marketing of health products and services and their expansion to rural areas.  Growth of CRS calls for quick assessment of its strength and weaknesses, its structure, rights and responsibilities of its Board Members and their composition. The Business Plan prepared by MART should be reviewed in this respect and some of its important recommendations should be taken into account for growth and strengthening of CRS.  The lessons learned were that when USAID/Nepal supported PSI it almost wiped out CRS but when this phase was over and N-MARC took over CRS began reviving. Perhaps USAID/Nepal should be clear on what strategies should be taken to help CRS sustain in future. More on recommendations are provided in the full evaluation report. xi Page ACKNOWLEDGEMENTS i ACRONYMS ii EXECUTIVE SUMMARY vi CONTENTS xi LIST OF BOXES AND FIGURES xiii 1 BACKGROUND 2 1.1 Introduction 2 1.2 Purpose of the Evaluation 2 1.3 Timeframe 2 1.4 Methodology 2 1.5 Limitations 3 2 AED Country Program Objectives and Relation to USAID/Nepal and National Policy 6 2.1 Country Context 6 2.2 The N-MARC Strategy 8 3 Assessment of the Effectiveness of the N-MARC Project 11 3.1 Overall Result Areas 11 3.1.1 Family Planning and Reproductive Health Products and Services: Scope, Coverage, Accessibility, Quality Assurance and Impact 11 3.1.2 Maternal and Child Health Products and Services: Scope, Coverage, Accessibility, Quality Assurance and Impact 13 3.1.3 HIV/STI Prevention Practices, Products and Services: Scope, Coverage, Accessibility, Quality Assurance and Impact 16 3.1.4 Social Marketing and Social Franchising: Leadership Development, Capacity Building, Sustainability 18 3.1.5 Public-Private Partnership in Family Planning, Maternal and Child Health Services, and HIV Prevention: Collaboration and Networking, Capacity Building, Market Impact 24 3.2 Monitoring, Evaluation, and Research 26 3.3 Management Systems: Project Management, Logistics Management, Financial Management 33 4 Evaluation Findings 37 4.1 Presentation of Results Towards Targets 37 4.2 Planning, Monitoring, Implementation, and Reporting 39 4.3 Management Systems 40 CONTENTS xii 5 The N-MARC Approach, Catalytic Effect, Best Practices and Lessons Learned 42 5.1 The N-MARC Approach 42 5.2 Catalytic Effect and Best Practices 42 5.3 Lessons Learned 45 6 Conclusions and Recommendations 47 6.1 Conclusions 47 6.2 Recommendations to Improve the Intended Impact of the Project 48 6.2.1 Short-Term Recommendations 48 6.2.2 Long-Term Recommendations for the Direction of USAID/Nepal's Social Marketing and Social Franchising Program. 49 Bibliography 51 Appendix I - Timeline 52 Appendix II - Statement of Work 53 Appendix III - Discussion Checklist 63 Appendix IV - List of Key Informants 73 xiii Page Box 1 Proportions of met and unmet need for family planning among currently married women, Nepal 2006 7 Box 2 Distribution of condoms by N-MARC partners, Nepal, 2007/08 and 2008/09 18 Figure 1.1 Trend in knowledge of modern contraceptive methods, Nepal, 1976-2006 6 Figure 1.2 Percent distribution of currently married women using contraceptives by most recent source of the method, Nepal 2001 and 2006 7 Figure 3.1 Annual CYP results based on five spacing methods distributed by N-MARC partners 11 Figure 3.2 Market share, condoms, by sector (August 1- July 31) 17 LIST OF BOXES & FIGURES 1  Introduction  Purpose of the Evaluation  Timeframe  Methodology  Limitations BACKGROUND 2 1. BACKGROUND 1.1 Introduction USAID's primary partner in Nepal for social marketing and social franchising technical assistance is currently Academy for Educational Development (AED). The existing social marketing program is national in scope and is a fully integrated program in which all components are coordinated, inter-linked and mutually supportive of USAID/Nepal's and Government of Nepal (GON) health goals. AED has been implementing this project since July 2006. USAID/Nepal has contracted with AED through a task order under the Private Sector Project indefinite quantity contract (IQC) for a project called N-MARC, to support social marketing of family planning, maternal and child health, and HIV/AIDS prevention products and services. N-MARC promotes social marketing in Nepal by: 1) building the technical and organizational capacity of social marketing organizations such as the Nepal Contraceptive Retail Sales Company (CRS), 2) encouraging commercial players to expand sales of health products to reach a broader range of income segments within target populations, 3) promoting the appropriate use of maternal and child health, family planning and HIV/AIDS prevention products, and 4) ensuring the quality of family planning services and products in the social marketing sector. The commodities that are being sold through N-MARC and its partners include contraceptives, clean delivery kits (CDK), oral rehydration salts (ORS) and Zinc for diarrhea, sexually transmitted disease (STD) treatment kits, emergency contraceptives pills, point of use water disinfectant (PIYUSH) and Virex® - a surface disinfectant. N-MARC aims to market subsidized quality health products to lower income groups willing and able to pay a small amount for valued health products, and to ensure they are available when and where they are needed. A strong, healthful behavior change component underpins product marketing in the N-MARC strategy. The N-MARC task order ends on June 30, 2010. 1.2 Purpose of the Evaluation The purpose of evaluation of USAID/Nepal's Key Social Marketing and Franchising Project: AIDS, Reproductive Health (RH), and Child Survival (N-MARC) was to objectively inform the USAID/Nepal Office of Health and Family Planning (O/HFP) about N-MARC's successes, weaknesses, best practices and lessons learned, with suggestions for future social marketing and social franchising programming needs inclusive of clear and appropriate program directions based on the Nepali context. 1.3 Timeframe The timeframe agreed upon by USAID/Nepal for the Evaluation of USAID/Nepal's Key Social Marketing and Franchising Project: AIDS, RH and Child Survival (N-MARC) is from January 4, 2010 to March 15, 2010 (Appendix I). 1.4 Methodology The design and methodology of evaluation is guided by the Terms of Reference (Appendix II: Statement of Work - SOW) which includes a wide range of methods and approaches for collecting and analyzing the information which are required to assess the evaluation objectives and answer the presented questions. The evaluation team has reviewed the list of background reports and conducted key informant interviews with stakeholders from the government, N-MARC partners and other social marketing organizations. 3 A two-day team planning meeting (TPM) was conducted in Kathmandu in which USAID/Nepal officials and representatives from Nepal Family Health Program (NFHP) and Family Health International (FHI/ASHA) participated. Data collection methodologies were drafted by the evaluation team which were discussed in the TPM and got approval from USAID/Nepal. The tools (see Appendix III for details) developed for evaluation, were as follows: 1. Key Informant Interview Checklist –MoHP relevant Department, Divisions and Centers 2. Interview Checklist for key N-MARC staffs 3. Interview Checklist for key N-MARC Private Sector Program Partners 4. Interview Checklist for other Social Marketing Organizations 5. Interview Checklist for USAID/Nepal Social Marketing Team 6. Checklist for Observation of Service Sites 7. Checklist for Observation of Commodity Outlets The evaluation approach was primarily participatory. The evaluators have also made site visits and conducted in-depth interviews with CRS and other N-MARC partners (see Appendix IV: List of Key Informants). Each of three evaluators took the responsibility of visiting three districts which were Dhankuta, Sunsari, Morang in the Eastern; Chitwan, Tanahun and Kaski in the Central and Western; and Banke, Bardiya and Kailali in the Mid-Western and Far-Western regions of the country (see Map below). Each evaluator spent eight days in the fields. 1.5 Limitations The evaluation report is based mainly on review of documents and reports made available by N-MARC and USAID/Nepal, key informant interviews with different stakeholders and field visits to nine districts by evaluation team members. Key informants included persons from 17 different organizations comprising of government high level officials of the Ministry of Health and Population, USAID/Nepal Social Marketing team, N-MARC and its implementing partners, and other key national and international social marketing agencies. 4 This evaluation is limited to the assessment of the effectiveness of the N-MARC project, documentation of how best the N-MARC approach is making a difference in the National Social Marketing and Social Franchising activities, documentation of best practices, informing and recommending on the future long-term Social Marketing and Social Franchising programming directions of USAID/Nepal. 5  Country context  N-MARC strategy AED COUNTRY PROGRAM OBJECTIVES AND RELATION TO USAID/NEPAL AND NATIONAL POLICY 6 2. AED COUNTRY PROGRAM OBJECTIVES AND RELATION TO USAID/NEPAL AND NATIONAL POLICY The Academy for Educational Development (AED) supports USAID/Nepal in meeting the goal of the Private Sector Program (PSP) “N-MARC” project, which is to expand the depth, reach, and impact of the private sector in family planning (FP), maternal and child health (MCH), and HIV/AIDS prevention products and services among low socio-economic populations through sustainable social marketing and social franchising programs. 2.1 Country Context USAID has been the first donor providing assistance in FP/MCH program since its inception in 1968. Up until 1978, most of Nepal’s contraceptives were provided free of cost through government family planning facilities. In 1978 the Contraceptive Retail Sales (CRS) project launched through AID/Washington as a social marketing effort to increase availability, distribution, promotion and use of temporary birth control measures. By promoting subsidized sale of contraceptives through retail outlets across the nation, the project was designed to complement the government FP program1 . A trend in contraceptive knowledge over the past 30 years shows that there has been a five-fold increase in the percentage of currently married women who know about modern contraceptive methods (Figure 1.1). This is so among men too. Source: Ministry of Health 1977, MoH/Nepal and Westinghouse Health Systems 1983, MoH 1987, 1993, Pradhan et al 1997, MoH, New ERA and ORC Macro 2002 and MoHP, New ERA and Macro International Inc., 2007. Although the knowledge of at least one method of contraception is universal, some methods are not universally known. Among women the method implants is known to 81 percent, Intrauterine Device (IUD) 67 percent and emergency contraception to only seven percent women2 . 1 Isaacson et al., 2001 2 MoHP, New ERA and Macro International Inc., 2007 7 Box 1 Proportions of met and unmet need for family planning among currently married women, Nepal 2006. FP need Spacing Limiting Both Unmet 66.2 26.0 33.9 Met 33.8 74.0 66.1 Total 100.0 100.0 100.0 Source: MoHP, New ERA and Macro International Inc., 2007 Knowledge of HIV/AIDS is high among men and women; 73 percent women and 92 percent of men age 15-49 have heard of HIV/AIDS and the corresponding figures among women and men age 15-24 are 80 percent and 96 percent3 . In Nepal, among currently married women of reproductive age the total demand for FP is 73 percent and only 66 percent of that demand is satisfied (Box 1). This is so because 48 percent women age 15-49 practice contraception while the unmet need for FP is 25 percent. Although of the total unmet need (24.6%), unmet need for limiting was higher (15.2%) than for spacing (9.4%) but if total demand for spacing and total demand for limiting are compared unmet need for spacing is very high (66 percent) compared to the proportion of unmet need for limiting methods (26 percent). This means that the potential for the expansion of the market for spacing methods such as injection, condoms, pills, IUD and Norplant (Jadelle) has been high as indicated by the last survey of 2006. The private sector is increasingly participating in fulfilling the need for family planning. In 2001, about eight percent women using family planning methods accessed services from the private sector which increased to 15 percent in 2006. If only five spacing methods namely injection, condoms, pills, IUD and Norplant are considered only 18 percent women in 2001 were found accessing family planning services from the private sector which increased to 30 percent by 2006 (Figure 1.2). Source: MoH, New Era and ORC Macro. April 2002 and MoHP, New ERA and Macro International Inc. 2007 3 ibid 8 The Nepal Contraceptive Retail Sales (CRS) company- major implementing partner of N-MARC, markets and promotes products that include two brands of condoms: Dhaal Deluxe and Panther Premium, two brands of pills: Nilocon White and Sunualo Gulaf, emergency contraceptive pill (eCON), Depo (Sangini - three monthly injectable), orange flavored Oral Re–hydration Salt (Nava Jeevan), long acting contraceptive methods IUD, and Norplant/Jadelle, clean delivery kit (CDK), Virex (bleach Powder), and water purifier (Piyush). It has been marketing CDK4 since March 1995 to prevent infection during delivery because a high percentage of deliveries take place at home5 . The NDHS 2006 showed that only 18 percent of home deliveries used CDK6 . However, there has been a significant increase in the use of CDK over the past 10 years from 2 percent in 1996 to 9 percent in 2001 and 18 percent in 2006. The CRS as a social marketing project started in 1978 distributes and promotes contraceptives and maternal/child health products. In August 1983, CRS acquired a corporate status by becoming a non-profit private company, incorporated under the Company Act, 2021 B.S. Its prime mandate is to increase awareness and use of health and FP products among the people of Nepal by using modern marketing tools and techniques. CRS further views this mandate to be more than just family planning as it relates to meeting overall public health challenges in Nepal, and the impact the company can have to the population. The second mandate of CRS Company is to fight the spread of HIV/AIDS in Nepal as well as other Sexually Transmitted Infections (STIs). It supplements larger HIV/AIDS initiatives in partnership with other INGOs and NGOs whose primary work is related to this issue. The company has launched “Matri Surakchha Chakki” (misoprostol) for postpartum hemorrhage in Bardiya district of Mid-Western Development Region. The product is distributed through existing Sangini Social Franchising Network. Marie Stopes International (MSI) also has a long history of social marketing of FP and MCH products and services in Nepal. CRS and MSI are both local leaders and have the potential to expand social and commercial marketing in the future. 2.2 The N-MARC Strategy The N-MARC strategy acknowledges the most recent social marketing and social franchising initiatives led by a U.S. institution – Academy for Educational Development. However, N-MARC recognizes USAID/Nepal’s desire for a transition to local leadership and sustainability. AED believes that the Nepali nonprofit and private commercial sectors are poised to provide that leadership. N-MARC’s core partner is the newly formed local “Partnership for Nepal Social Marketing” (the “Partnership”), which currently includes the Nepal CRS Company, NFCC, and other associate organizations. These partners have distinct, complementary roles. To complement social marketing efforts, N-MARC had a plan to team with a host of leading commercial companies to achieve sustainable health marketing initiatives. In addition, given the link of behavior change to sustainable health marketing and improved health outcomes, N-MARC had a plan to work with a range of NGOs, CBOs, and other USAID/Nepal projects in coordinated behavior change efforts. In addition, as no private sector health initiative can succeed without government cooperation, N-MARC had a plan to team up with the public sector to create and strengthen public-private partnerships (PPP). 4 This is a specially prepared kit, containing a razor blade, a curing surface, a plastic sheet, a piece of soap, a string and pictorial instructions, assembled by Maternal Child Health Product Pvt. Ltd., and marketed commercially by the Contraceptive Retail Sales (CRS) Company. 5 In the five years preceding the survey of 2006, 81 percent deliveries took place at home (MoHP, New ERA and MEASURE DHS ORC Macro. 2007). 6 Ibid, p. 151, Table 10.10 9 AED’s philosophy of partnership, teamwork, and capacity building is central to its Full Market Impact™ (FMI) approach, its key methodology for achieving N-MARC objectives. FMI addresses the four P’s of marketing, (product/supply, price/affordability, place/distribution, and promotion/demand and appropriate use) and has three expected outcomes – equity, commercial viability, and sustainable public health impact. AED’s FMI strategies are expected to increase accessibility and affordability of health products and services, behavior change and demand creation, and health marketing and franchising systems to achieve equity and sustainable public health impact. AED is committed to restoring leadership of Nepal’s social marketing and social franchising movement to local organizations, with quality technical and management support from the AED team. For this project AED has been assigned to work as a facilitating and capacity-building, not a marketing organization. AED lets local partners take the lead under it supervision and support. AED believes that through partnership, experience sharing and capacity building expected results can be achieved with sustainable impact. 10  Overall result areas  Monitoring, evaluation and research  Management systems ASSESSMENT OF THE EFFECTIVENESS OF THE N-MARC PROJECT 11 3. ASSESSMENT OF THE EFFECTIVENESS OF THE N-MARC PROJECT 3.1 Overall Result Areas 3.1.1 Family Planning and Reproductive Health Products and Services: Scope, Coverage, Accessibility, Quality Assurance and Impact (IR-1) The FP/RH products marketed by N-MARC partner organizations include mainly spacing methods such as injectable popularly known as Sangini marketed by the CRS Company, various brands of condoms and pills, IUD and Implant. The CRS Company markets Panther (Premium), Dhaal (Deluxe) and Number 1 condoms. However, since December 2009 Number 1 condoms are not anymore distributed. The emergency contraceptive pill Postinor 2 was introduced in 2004/05 but since 2007/08 another brand of EC named eCON replaced Postinor 2. According to N-MARC project reports the annual CYP results of five spacing methods distributed and marketed by partner organizations increased from the baseline CYP of 239,621 in 2005/06 to 289,835 CYP in the following year, further to 369,977 CYP in 2007/08 and 445,801 in 2008/09 (Figure 3.1). Overall, the results are positive as the CYP increased steadily over the years. According to N-MARC annual report 2006/07 sales of FP/RH products through CRS were impressive during the reporting period, resulting in 289,835 CYP (Figure 3.1), or 102% of the annual forecast. The CRS Company has had strong sales for its oral contraceptive brands, Sangini (103% achieved against the target), IUD (110% achieved), and Norplant (94% achieved). During this period CRS with support from N-MARC made efforts to revitalize promotional activities for all of its brands; it formed a family planning communications working group composed of representatives from N-MARC, NFCC, USAID/Nepal, NFHP, and GoN. CRS initiated the re-establishment and expansion of its Sangini Social Franchise Network (1,801 outlets), which is primarily composed of pharmacy-based health providers (midwives, nurses, and paramedics). During FY 2007/08, N-MARC exceeded the CYP target of 312,481 with an actual value of 369,977 (Figure 3.1). This success had much to do with the increase in sales of condoms and Sangini. Multimedia approach was used to promote newly designed Panther Premium and Dhaal Deluxe condoms and also due to the scale up of Sangini training activities by NFCC. The number of Sangini outlets was added by 737 which increased the total number of outlets to 2,060. 12 N-MARC continued its support for its three commercial sector condom partners, and executed a contract with Lomus Pharmaceuticals Pvt. Ltd. which committed to manufacture market and distribute POPs, COCs, and ECPs. During the 2008/09 fiscal year, N-MARC achievement in CYP growth was 115 percent against the target. This achievement was due to the growth in contribution from N-MARC’s commercial partners. CRS launched eCON, its new brand of emergency contraceptive. Method-wise, among the spacing methods, pill was most popular in use until 1986, by 1991 injection became most popular followed by condom but in 1996 and later, condom use surpassed pill use. The proportion of pill users has remained at 4 percent or less until 20067 . Among the N-MARC partners it is only the CRS Company that promotes and distributes pills and the pills they sell are branded as Nilocon White and Sunaulo Gulaf. OCP KAP study conducted by N-MARC8 shows that pill use can be raised by comprehensive communication campaign. During the three-year project period no major promotional activity was conducted by N-MARC to promote OCP use. Nevertheless, sale of OCPs steadily increased over the project period from 744,329 cycles of oral contraceptives in 2006/07 to 912,699 units in 2007/08 and further to 1,197,012 cycles in 2008/09. In order to extend accessibility in hard-to-reach areas, CRS expanded its Sangini Network to Dhading, Doti, Kailali, Bardiya and Pyuthan districts. All together, NFCC trained and certified 91 individuals to provide Sangini in these districts. According to the CRS MIS, the Sangini Network has increased to 2,784 providers in 69 districts by July 2009. One of the most successful network programs in South Asia in providing FP services is the Sangini Network. The Network keeps growing as time passes, the backbone of social marketing. Additionally, CRS continued its efforts to extend reach beyond Sangini providers through the Sangini Didi Chhar Chhimek (Sangini Didi Neighborhood) Program in Bardiya district. This initiative has become a platform for CRS to explore new rural social marketing approaches, and has been instrumental for the social marketing of misoprostol tablet. Efforts were made by N-MARC partners to improve the quality of care which resulted in development of quality assurance (QA) strategy and new QA monitoring tools and systems and training materials. Additionally, N-MARC renewed activities of the Pariwar Swasythaya Sewa Network (PSSN) in major cities of 15 districts and the Sewa midwife and paramedic network in Rupandehi district,9 under the leadership of NFCC in 2006/07. Network services included hormonal contraceptive counseling and management, IUD insertions/removals, voluntary surgical contraception (VSC), and STI management. Network providers were trained in promoting FP benefits, side-effects counseling and management, client-provider interaction (CPI) skills using evidence-based information, and infection prevention. The network activities also included assessment of PSSN members, establishment of Advisory Committee, Professional Talk Program on RH, and membership drive. In order to provide more access to rural population, NFCC expanded membership from 54 to 91 members in Rupandehi district. CRS successfully conducted Jadelle testing in Kathmandu valley with technical assistance from EngenderHealth and NFCC. Also in June 2008, N-MARC 7 MoHP, New ERA and Macro International Inc., 2007 8 N-MARC. 2009. OCP KAP Market Research Baseline Survey. 9 The current franchised regime (SQH) simply co-opted much of the PSSN’s innovative franchising and marketing concepts (membership fees, recognition programs, “medical missions,” health fairs at temple sites during religious holidays, clinic “open houses,” “Dial-a-Doc” radio information programs, etc.) 13 established a MoU with NESOG with the objective of broadening the role of private sector OB/GYNs in the delivery of quality FP/RH services. After significant work with the NESOG Secretariat to design project, conduct provider attitude research towards the organization, and lay out society priorities for the coming year, NESOG leadership changed in April 2009 and subsequently due to political challenges within NESOG and ongoing internal hurdles, N-MARC prudently decided not to proceed further with this partner for the time being. The clinics that the evaluation team visited in nine districts, the Sangini providers were quite enthusiastic to get training on IUD and Jadelle insertion. They said that the public has demand for long acting methods. Also they said it would be cost effective because they have been trained to administer injection (Depo) and more skills will expand choice for clients. N-MARC achieved a significant milestone for Nepal through its support to Lomus Pharmaceuticals Pvt. Ltd. in the manufacturing, marketing, and distribution of hormonal contraceptives. Lomus launched a new portfolio of contraceptives: Femicon (COC), Feminor (ECP), and Femitrone (POP). In June 2009, CRS launched its new brand of emergency contraceptive pills, eCON. This product replaced Postinor-2, and offers consumers a high quality, locally branded emergency contraceptive pills. CRS used an international tender process to procure this product, and it is fully cost-recoverable. The eCON product represents a step forward for CRS in terms of product diversification and increased profitability. In all the districts the evaluators visited, eCON was found widely available and popular especially among young population. Chemists/pharmacists have two opinions on eCON: some say that it is good because it helps to fulfil the demand of young people to plan their reproductive life while others say that it is perverting the society because young people use it as a regular birth control method which is not the intention of its promotion. High level officials in Kathmandu found the consumption of eCON unexpectedly high; they reported that one year stock of eCON was exhausted in three months. Assessment of the effectiveness of the N-MARC Project under IR-1 indicates that overall N-MARC and its partners were effective in achieving the intended results in the three-year project period. The CYP trend based on five spacing methods that the project has distributed was increasing over the years despite strikes by repackaging workers and externalities such as strikes (banda), ethnic unrest in the Terai, weakening law and order, intermittent shortage of fuel and load shedding up to 16 hours per day and The Koshi River flooding in the eastern Terai affecting project implementation. 3.1.2 Maternal and Child Health Products and Services: Scope, Coverage, Accessibility, Quality Assurance and Impact (IR-2) N-MARC partners particularly CRS Company markets MCH products to contribute to achieving GoN’s goals of reducing morbidity and mortality of mothers and children which are high by the world standards. The Safe Motherhood and Neonatal Health Long Term Plan (SMNHLTP 2006- 2017)10 has set the goals of reducing the MMR from the current 281 per 100,000 live births11 to 134 per 100,000 by 2017 and of reducing the NNR from the current 33 per 1,00012 to 15 per 1,000 by 2017. The Government of Nepal has launched Safe Delivery Incentive Programme (SDIP) as a Priority 1 Program since 2005 under which a woman delivering at a government health facility is provided with a cash payment. 10 MoHP. 2008. Annual Report. 11 MoHP, New ERA and MEASURE DHS ORC Macro. 2007. 12 ibid 14 One of the factors contributing to high maternal and child mortality in Nepal is the practice of delivery and according to the NDHS 2006 the proportion of births that were delivered at home was 81 percent. This was much more so in 1990s when home delivery was 92 percent. It is argued that the use of clean delivery kit (CDK)13 at delivery can reduce the risk of mortality of both, the mother and the infant. With a view to addressing the maternal and child health problems during delivery the CRS Company first marketed CDK only in March 1995. Prevalence of diarrhea among children under five is a major health problem in Nepal. It is however lower now than it was several years ago. The prevalence of diarrhea has decreased steadily from 28 percent in 1996 to 20 percent in 2001 and 12 percent in 200614. In order to prevent the serious consequences of diarrhea among children CRS has been marketing Nava Jeevan - oral rehydration salt (ORS). Nava Jeevan is now an entirely self-sustaining social marketing product. CRS initiated the procurement of low-osmolarity ORS using its own revenue. CTL Private Limited Company was awarded the contract to supply ORS through a competitive bidding process. The actual sale of Nava Jeevan at the baseline was nearly 3.2 million packets whereas the targets set for 2006/07 and 2007/08 were fixed at 2.6 million packets. The achievements were 93 percent and 122 percent in the first and second year, respectively. In the third year, i.e., 2008/09 the target was to sell 3 million packets and the achievement was 99 percent. It appears that the consumption of Nava Jeevan is constant. From the field visits it is gathered that Nava Jeevan is widely available particularly in pharmacies but many said that it is sold mostly in the rainy season when children have diarrhea. In June 2009, N-MARC facilitated private sector participation in the national response to the outbreak of diarrheal disease at both the national and district levels (Jajarkot and surrounding districts). MITRA Samaj – one of the implementing partners of N-MARC, played a key role in leading this effort. Sale of 815,453 Zinc tablets is reported but this was perhaps the response to the outbreak and the target was not set at the beginning. MITRA Samaj, one of the implementing partners of N-MARC conducted community-level orientation programs among healthcare providers and mothers and caregivers in 26 districts. Thirty-nine detailing programs in 22 districts, resulting in 785 chemists, druggists, and pediatricians detailed on the rationale treatment of diarrhea. MITRA Samaj also conducted twenty trainings in 22 districts to orient 107 doctors. Ninety-three activation programs held in 22 districts to orient 3,218 caretakers on rationale treatment of diarrhea. Inquiry was made about Zinc sale and use in Dhankuta, Tanahun and Banke districts. The DHO of Tanahun is not aware of any NGO involved in Zinc promotion or sale. The DHO of Tanahun said that Zinc is heavily promoted by the government. Pharmacies in Dhankuta and Tanahun sell Zinc especially in the rainy season. Apparently the public at large is not well aware of the value of taking Zinc because pharmacy owners said that people do not prefer Zinc. The shopkeepers said that taking 10 tablets for 10 days is too long for the clients. They want something that prevents diarrhoea immediately; therefore Zinc is found not popular. N-MARC in 2006/07 established the CDK Advisory Committee to guide the reinvigoration of the CDK within the country, with a particular focus on expanding marketing and distribution 13 This is a specially prepared kit, containing a razor blade, a curing surface, a plastic sheet, a piece of soap, a string and pictorial instructions, assembled by Maternal Child Health Product Pvt. Ltd., and marketed commercially by the Contraceptive Retail Sales (CRS) Company. 14 MoHP, New ERA and MEASURE DHS ORC Macro. 2007. 15 activities in hard-to-reach areas. N-MARC and its partner CRS Company’s sales data show that the sale of CDK increased from 66,189 units in 2006/07 to 111,017 units in 2007/08 but in 2008/09 the number declined to 102,562 units. Of the nine districts visited by the evaluation team only in Bardiya district CDK was found sold and the informants said that product should be focused in rural and remote areas rather than in urban areas where health facilities are available for institution delivery. The area officers of CRS in the districts mentioned that they sell CDKs to government facilities but they said the sale of CDKs is plummeting. One of the Directors, MoHP, Kathmandu said that CDK contents and quality have to be improved; a pair of gloves and scissors (instead of blade) should be included in the packet. Also it was suggested to replace string by a clamp to save time and for convenience. During FY 2008, N-MARC established a contract with ENPHO to expand marketing and distribution efforts of PIYUSH, its point-of-use chlorine solution. ENPHO established collaboration with CRS for distribution of PIYUSH to rapidly expand product coverage nationally. N-MARC enhanced to not only treat but also prevent diarrhea by introducing PIYUSH. About 317,000 PIYUSH bottles (point-of-use chlorine solution) were recorded sold in 2008/09 by N-MARC partners. Field observation, however, shows challenge in the effort to expand the use of PIYUSH as of now it is not that popular. In year 2005/06 nearly 88,000 units of Virex - a surface disinfectant, were sold and in 2006/07 this number increased to 98,000 but it declined to 78,000 in 2007/08 and again increased to 83,000 in 2008/09. In the nine districts visited by evaluators virex was found sold in some pharmacies to institutions only. N-MARC supported the redesign of Sutkeri Samagri (CDK) packaging to include Chlorhexidine (CHX) in CDK for which it worked with Family Health Division (FHD), NFHP, Lomus Pharmaceuticals, and CRS to design a pilot program to introduce CHX in four districts. In order to address the problem of postpartum haemorrhage among women, CRS with a grant from Venture Strategies for Health (VSH), initiated introduction of misoprostol under the brand name Matri Surakchha Chakki (Safer Motherhood Pills). It was a pilot project in Bardiya district, in coordination with FHD, NFHP, NFCC, and N-MARC. Subsequently, social marketing of Matri Surakchha Chakki (MSC) has expanded to Banke, Rupandehi, Nawalparasi, and Chitwan. This has resulted in the product being available at 116 Sangini outlets across the five districts. This product and diversification is expected to contribute to greater sustainability for CRS. From the field visit by the evaluation team it is also learned that MSC is in high demand in rural areas than in urban areas. Overall, activities undertaken to achieve results under IR-2 were relatively effective. During the project period Nava Jeevan sales met the targets. N-MARC’s partners provided product and behavior change support to the MoHP’s response to the outbreak of diarrhea in Jajarkot and surrounding districts. N-MARC designed and implemented a public-private partnership for the rationale treatment of diarrhea under the leadership of Child Health Division (CHD). CDK sales were lower than expected, it is said that because of the government policies of monetary incentives to women delivering in a health facility and free maternal health service increasing number of women deliver at a health facility which contributes to lowering sale of CDK. However, it is suggested that CDK should be promoted in rural areas but it should be improved. Introduction of CHX in four districts for testing should help improve the kit and also create demand for it. Piloting of Matri Surakchha Chakki (Safer Motherhood Pills) in Bardiya district is showing good results and it is hoped that it will contribute to improving maternal health in the long run. 16 3.1.3 HIV/STI Prevention Practices, Products and Services: Scope, Coverage, Accessibility, Quality Assurance and Impact (IR-3) Since the detection of the first AIDS case in 1988, the HIV epidemic in Nepal has evolved from a low prevalence to concentrated epidemic. HIV/AIDS is not just a public health challenge but also socio-developmental challenge affecting the most economically productive population 15-49 years. Given Nepal’s location (China and India which are fast affected by HIV/AIDS epidemic) and its mobile uneducated youth with virtually no access to Adolescent Sexual and Reproductive Health services, Nepal is posed for potential HIV/AIDS epidemic. As of 2007, national estimates indicate that approximately 70,000 adults and children are infected with the HIV in Nepal, with an estimated prevalence of about 0.49 percent in the adult population. As of October 2009, a total of 14,787 cases of HIV including 2,627 AIDS cases had been reported to the National Centre for AIDS and STD Control (NCASC). The sex ratio among HIV positive cases is nearly 2:115. Nepal is categorized as a “concentrated” epidemic country as HIV prevalence rates in some of the sub population groups (IDUs, migrants) are more than 5 percent. According to NCASC most cases of HIV occur among labor migrants (41 percent) and increasing number occurs among their wives (a combined 27 percent of HIV cases in low-risk women in rural and urban areas). Clients of sex workers account for 16 percent of HIV infections, IDUs 10.2 percent, MSM 3.9 percent, and female sex workers 1.8 percent. Nepal was quick to respond to HIV/AIDS problem. A number of policies and protocols have been prepared and implemented. Recent efforts include “New National HIV/AIDS Strategic Plan 2007-2011 and “National HIV/AIDS Action Plan 2006-2008”. In 1995 the government formed a national structure to coordinate activities at various levels. At the centre a National AIDS Coordination Committee (NACC) and at district level District AIDS Coordination Committee (DACC) were formed to guide and coordinate the response. The Minister of Health chaired NACC comprising of members from different walks of life. In 2002 a National AIDS Council (NAC) was established, chaired by the Prime Minister, to raise the profile of HIV/AIDS. In order to contribute to government’s efforts to preventing HIV infection N-MARC invests in subsidized and fully-priced locally owned brands of condoms and the current environment is conducive as very high proportions of women and men are aware of HIV/AIDS. Seventy three percent women and 92 percent men age 15-49 have heard of AIDS. Among the youth population age 15-24 the corresponding figures are even higher (80 percent young females and 96 percent young males)16. For HIV prevention N-MARC and its partners promote and distribute condoms both through social marketing and private commercial channels. The Nepal CRS Company is the main partner distributing and marketing condoms using social marketing approach. Dhaal Deluxe and Panther Premium are the two condoms distributed and sold by CRS. The N-MARC commercial partners such as Gayatra, Pioneer, Praxis trade houses and other organizations and some trade houses not affiliated with N-MARC market male and female condoms. In the market there are over 25 different brands of condoms17. Another partner organization namely Centre for Social and Economic Development (CSED) promotes and distributes commercial and regular CRS condoms. CSED entered into partnership with N-MARC in May 2008. CSED implemented Healthy Highway Project along the East-West 15 MoHP. 2009. NCASC. 16 MoHP, New ERA and MEASURE DHS ORC Macro. 2007. 17 In Chitwan and Kaski districts the brands of condoms found in pharmacies and shops were Black Cobra, Black King Kong, Black Python, Bull, Cobra, Dhal, Durex Performa, Durex Superthin, Fire ecstacy, Game, Inspiral, Jodi, Kamasutra, Kohinoor, Max herbal, Max strawberry, Maya, Nightlight, Okamato, Okamato crown, Okamato DotHot, Okamato French Kiss, Panther, Safe, Skinless Skin, Stad, Touch Convenience Patent, Trishna and Vibrating condoms. 17 highways from Jhapa to Kanchanpur district. The goal of the project is to ensure proper and consistent use of condoms among MARPs to prevent HIV/AIDS and STI’s among transport workers and local communities through increased awareness about and accessibility to condoms. Behavior Change Communication (BCC) and social mobilization activities were conducted in areas inhabited by people of low socio-economic status such as urban slums. With the objective of increasing access to condoms for most-at-risk-population (MARP), N-MARC partner, MITRA Samaj completed a thorough mapping of areas in Kathmandu valley, other major districts and all along highways where high-risk sexual activities take place. The mapping of these ‘high-risk’ areas used a systematic process developed over the past four years under USAID/Nepal-funded private sector health programs. First, N-MARC and MITRA Samaj identified hot spots, or places where sex negotiation takes place or sexual activity takes place. From each hot spot they measured a 100 meter catchment area – or the average distance a person might walk to get a condom - and connected overlapping hot spots, creating ‘hot zones’. Identifying “hot zones” helped better supply condoms to most-at-risk groups (FSWs and their clients) to prevent transmission of HIV. In order to promote the use of condom among MARP in Nepal a communications campaign ‘You Are No Exception’ program was launched. The campaign aimed at addressing social taboos, hesitation, myths and other problems associated with purchase and use of condoms and establishing condom use as a normative behavior among at-risk groups. The communication campaign launch included Short Film Competition (SFC), Celebrity Advocacy (artists, TV hosts) through involvement in SFC and publicity activities, special use of media – local FMs, Print, and Television and Partnerships with business community (banks and hotels). The campaign reached a large audience and contributed to demand creation of condoms. The annual demand for condoms in the country is estimated at 40 million. In FY 2007/08 the public sector distributed 19.8 million condoms18 and the private sector distributed 21.4 million condoms19 resulting in total condom distribution of 41.2 million. This implies that the distribution of condoms outside the government is 52 percent. Using retail market survey data from A. C. Nielsen, N-MARC reports total annual sales of condoms of 17.9 million for 2005/06, 17.7 million for 2006/07, 21.4 million for 2007/08 and 23.5 million for 2008/09. Furthermore, N-MARC reports increase in market share of commercial condoms from 6 percent in 2006 to 22 percent in 2009 (Figure 3.2). Source: N-MARC, 2010 18 MoHP. 2009. Annual Report 2007/08. 19 A. C. Nielson data reported by N-MARC. 18 However, if N-MARC partners’ reported sales data alone are used, one cannot support the argument that the market share of commercial condoms increased over the years. In 2006/07 N-MARC had no commercial partner engaged in promoting and marketing of condoms but in 2007/08 and 2008/09 the private business houses such as Gayatra Store Enterprises, Pioneer Trading and Praxis Trade Link were engaged in this business. N-MARC Annual Reports show that the commercial sector condom sales were nearly eight million in 2007/08 which increased to nearly 8.5 million units in 2008/09. Although in terms of absolute number the share of both sectors has increased in 2008/09 compared to the previous year but in terms of percentages it has remained constant (Box 2). CRS re-launched Panther as Panther Premium and Dhaal as Dhaal Deluxe with new packaging designs and promotional campaigns in 2007/08; the revamped media and inter-personal communication (IPC) activities were the first in nearly 10 years. CRS put significant focus on developing and implementing new BCC activities focused on MARPs and ‘hot zones’. Additionally, Praxis Trade Link used its own resources to launch the V-AMOUR latex female condom. For the first time, the commercial sector partners were allowed to promote and market highly erotic condoms. CRS launches condom social marketing through retail shops (TOs and NTOs) such as pharmacies, pan shop, groceries, departmental stores, mobile kiosks, local CBOs and NGOs and through rural field representative in rural areas. In the nine districts visited by members of evaluation team, commercial marketing of condoms was found quite vibrant. In towns and cities over 25 different types of commercial featured condoms are available. The commercial brands far outnumber the CRS brands which are only two – Dhaal and Panther. In every district Cobra, Jodi and Skinless Skin brands topped the list. The price of commercial condoms ranged from Rs. 30 per pack to Rs. 63 whereas the price of Dhaal is Rs. 5 and that of Panther is Rs. 10. It was also found that Number 1 condom is still popular and sold. However, in some places expired Number 1 condoms were also found being sold. For that matter, expired condoms of other brands are also sold in different places. The retailers think that commercial condoms have a high market potential because they are dotted and are satisfying to use than normal/plain condoms marketed by CRS. They recommend that CRS should also market dotted condoms. Activities undertaken under IR-3 gave good results overall. It is said that N-MARC and its partners were particularly successful in encouraging the commercial sector to promote and market condoms which resulted in increasing the share of the commercial sector in the overall market. However, data reporting from both CRS and N-MARC were not found consistent. 3.1.4 Social Marketing and Social Franchising: Leadership Development, Capacity Building, Sustainability (IR-4) One of the prime partners of N-MARC in implementing social marketing project in Nepal, the CRS Company is considered as the leading social marketing (SM) organization. The Nepal CRS Company over the years has successfully attained a position of social marketing leadership, Box 2 Distribution of condoms by N-MARC partners, Nepal, 2007 and 2008 Sector 2007/08 2008/09 Pvt social marketing 13,881,346 63.7 14,839,908 63.7 Commercial sector 7,923,434 36.3 8,473,107 36.3 Grand Total 21,804,780 100.0 23,313,015 100.0 Source: N-MARC. Annual Reports 2007/08 and 2008/09. 19 founded on an aggressive marketing and sustained use of FP, MCH, and HIV/STI prevention products and services in the country. With continued support from USAID/Nepal, KfW and VSH, CRS marketing strategies have been successful in earning and maintaining the followings:  a definite corporate image and social marketing leadership, creating an image of quality products; a product pricing at affordable level;  a strong distribution and sales system (motivated and supported by attractive mark-ups to distributors, wholesalers, and retailers);  a promotion mix of communication for persuasion through publicity at possible places and occasions, advertising, information, education and training/orientation programs; and  extensive market research conducted to determine brand names, prices, package designs, and promotional message content before a product is released on the market. Population Services International (PSI), Marie Stopes International (MSI), and Social Marketing and Distribution (SMD) are the other social marketing players in Nepal. The General Operational Plan 2009 of PSI for a public-private partnership aims to improve rural demand and access to quality, long-term contraceptive family planning services (intra-uterine devices, and implants). Marie Stopes International (MSI) operates through their locally registered NGO, Sunaulo Pariwar Nepal. MSI markets their own brand of oral contraceptive pills and Jodi® brand condoms. They expect the sale of Jodi® condoms will be profitable, with eventual cost-recovery. They aim to use the revenue generated to cross-subsidize their clinical services. MSI's oral contraceptive pills (Feminyl) are at a middle level price range, with good primary sales. Social Marketing and Distribution (SMD) founded in 1998, offers marketing expertise to other organizations and distributes products for sale. SMD distributed and sold subsidized condoms for PSI to most-at-risk populations in designated hot zones. Sangini Didi Network developed by N-MARC/CRS in Nepal is an example in social franchising for health services. In the Nepalese context social franchising has been used to deliver Depo￾Provera (Sangini) and other FP and MCH services throughout the country. The Sangini Network is the biggest network; it has 2,784 members in 69 districts. Activities of the Network are focused on training and quality monitoring and attempts are being made to expand it to uphill and mountain districts. Three Social Franchising Networks PSSN, SEWA paramedic and Sangini pharmacy are managed jointly by CRS and Nepal Fertility Care Center. Under PSSN there are currently 132 OB/GYN members in 15 districts. The PSSN will eventually be aligned with NESOG and all future OB/GYN support to go through NESOG. The SEWA paramedic network has currently 91 members in one district and activities are focused on training and quality monitoring and NFCC with CRS is exploring opportunities to expand the model. The components of social marketing and franchising of N-MARC project include leadership development, capacity-building, and sustainability. Having a mission of "Partnership for Nepal Social Marketing," N-MARC, during its inception phase of the project, had planned to engage CRS and NFCC as key local partners, to undertake social marketing, franchising, and behavior change programs, and to create partnerships among multiple players in the commercial, NGO, and public sectors to facilitate growth of the "total market" for an extensive range of health products and services. N-MARC and its another core partner, EngenderHealth, had also planned to manage capacity-building, and management and technical support using local resources for "south-to-south" ("Nepal-to-Nepal") capacity building and technical assistance. Similarly, N-MARC has been sensitive since the beginning of the project to ensure long-term survival, "life 20 after N-MARC". It had also planned to help the partnership develop a comprehensive marketing strategy in N-MARC's final year with a clear plan to achieve adequate revenue. In order to increase capacity of local partners to design, implement, and manage the state-of-the￾art social marketing and social franchising projects the partner organizations required to perform seven activities which include: i. Preparation and submission of semi-annual and annual performance reports, and other report deliverables on time and meeting quality standards (accuracy, presentation, quality of writing) ii. Completion of work plan activities on time iii. Training of staffs to make them capable to develop and implement social marketing communication strategies iv. Arrangement of technical assistance for strategic information activities v. Provision of technical assistance for HIV-related institutional capacity-building vi. Provision of training to individuals in strategic information (includes M&E, surveillance, and/or HMIS) and vii. Imparting training to individuals in HIV-related institutional capacity-building. During the first year of the project, N-MARC held routine meetings with leadership from CRS and NFCC to discuss program achievements and challenges, project strategy development, and to conduct coaching sessions. It also organized workshops with CRS senior staff on topics related to social marketing, appreciative inquiry and change management; and N-MARC staff routinely made field visits with both the partners, CRS and NFCC to provide on-the-job training. Besides holding routine meetings with leadership from all key partners to discuss program achievements and challenges, program strategy development, and to conduct coaching sessions, these ditto activities were found carried out during the second year of the project too. In order to provide organizational development and change technical assistance to CRS, N-MARC contracted the services from Social Sector Development Strategies (SSDS) for a five-week reviewing sessions on the existing organizational structure and business processes of CRS. During this period, SSDS held a series of workshops with CRS staff and consultations with key stakeholders. N-MARC also collaborated with NFHP to initiate organizational development technical assistance for NFCC. N-MARC encouraged its partners to accept the challenges for taking calculated risks in program implementation so as to enhance project results and to also support in organizational decision-making process and growth. A three-day executive leadership program was supported and facilitated by N-MARC for senior staff from its partner organizations focusing on strengthening inter-personal soft communication skills to stimulate greater personnel performance. The N-MARC work plans for 2007/08 and 2008/09 show that N-MARC and its partners had a plan to implement 29 activities. N-MARC implemented nearly half of its planned activities by involving CRS which is commendable on the part of N-MARC. Among several partners of N-MARC, CRS as a key partner had the opportunity to develop its leadership which carried out several core activities such as warehouse management; development of five-year business plan, revenue utilization plan; logistics management; information management; distribution system upgrade, etc. As a vital part of N-MARC project, N-MARC has provided technical assistance and cooperation to its local partner organizations and individuals for building their capacity in the relevant areas. In the beginning of the project, N-MARC sponsored "professional development forum", a quarterly forum that brought together partners like FHI, AMDA, Constella Futures, NFCC, 21 CRS, and NFHP to share innovative ideas and approaches to the delivery of health products and services, among other things. It started in January 2007. N-MARC also sponsored logistics training for the social marketing sector to CRS central and regional staff in coordination with NFHP and USAID/Nepal. Furthermore, a number of social marketing workshops including Consulting and TA Technique Workshop; Use of “SIVA Theory” for understanding the CDK, “Devil’s Alternative”, “Who Moved My Cheese”, and change management. With the objective to accelerate the transition of warehouse responsibility to CRS, a warehouse management consultant hired by N-MARC provided on-the-job coaching to CRS warehouse staff. A week-long workshop was also sponsored by N-MARC on professional writing skills conducted by Empowerment and Learning Development (ELD) for the senior executives from CRS and NFCC. During the first year of the project, one of the main partners of N-MARC, EngenderHealth took the lead on conducting capacity-building workshops on QA with partners, including NFCC, CRS, NFHP, GON, and others. The workshops included one-day STI orientation to all NFCC staff working on N-MARC by a senior OB/GYN, a four-day long meeting on "Standardization on Facilitative Supervision" for all N-MARC partners organizations, update on the latest scientific research related to Intrauterine Contraceptive Devise (IUCD), and contraceptive technology updates. With the expertise of a warehouse management consultant, N-MARC transferred warehouse management responsibility to CRS by the end of the year two period of the project. The consultant also facilitated some logistics management workshops with CRS’s logistics management officer for CRS field staff and CRS distributors, and also provided similar trainings for N-MARC's commercial partners. N-MARC supported for professional development trainings to CRS staff on financial management, strategic communications, and interpersonal HIV/AIDS communications which was held in Singapore and to two more staff at the British Council. CRS has re-emerged as the leading social marketing organization in Nepal, with strong sales figures and assumption of commodity management responsibilities. N-MARC initiated the design of a series of workshops to enhance knowledge of partners in marketing, communications, and research. Choice of these three areas was based on outcomes of a research carried out by an external consultant in identifying gaps in partners’ knowledge to achieve their business goals. In FY 2008, workshop sessions on GIS, logistics management, presentation skill, developing marketing and communication plans, and launching new products were held to improve specific skills of implementing partners. N-MARC initiated a seminar series to transfer cutting-edge business and marketing approaches to partners’ staff especially focusing on topics like audience segmentation, global economic crisis, and the value of branding. N-MARC conducted a number of social marketing training sessions for individuals and organizations by utilizing the expertise of CRS, MITRA Samaj, and CSED to provide trainings in order to push the concept of social marketing to organizations working at the community level. During the second and third year of the project regular coaching on procurement, contracts, and finance was provided to partners' finance and administration staff to ensure compliance with USAID and N-MARC guidelines. N-MARC conducted routine one-on-one coaching in information management and reporting with all partners. Anticipating greater operational efficiencies, evidence-based business decision-making, and increased transparency, enhanced overall public profile of CRS, N-MARC supported in the upgrading of CRS’s management information system (MIS), which included a comprehensive electronic logistics management component, online sales input and reporting system, and multi-user online access to key information elements for CRS. Following international standards for procurement with the support from N-MARC, CRS successfully completed two important product procurements: OCPs and ECPs. Historically, CRS 22 has used a local tender approach for product procurement; thus, this activity represents a shift towards CRS using international competitive bidding process as its standard procurement approach. Two CRS staff and one staff from MITRA Samaj participated in the Certificate Program in Inclusive Marketing (CPIM), organized by the Birla Institute of Management Technology and MART. N-MARC has made commendable efforts in managing and carrying out capacity building activities for its local partners. However, in response to evaluation team’s inquiry to N-MARC officials, not all training programs prepared or training curricula developed. Similarly, result package indicators and targets are not known about the trainings conducted to particular target groups or individuals at the field level. The evaluation team found that there was no baseline information in the first year of the project period on trainings provided to local partner organizations and individuals. In the subsequent years targets were set but the achievements exceeded them. Upon the evaluation team’s enquiry about this issue the N-MARC responded that because of security reason the place planned for training was changed and as a result the number of individuals to train also increased because of higher demand for training in the new place. This also resulted in higher achievements than the targets. This is a learning experience which should help N-MARC to plan better in the next phase. N-MARC had planned to ensure long-term survival of its partnership in social marketing and social franchising with the development of comprehensive marketing strategies for its partners. In the first year of the project there were no activities carried out on sustainability aspects although there was a plan to help N-MARC partners establish linkages with other donors and funding sources. But the second and third year of the project had a 'cheer' in this regard having contracted with MART, a rural-focused consulting firm from India, to work with partners to identify areas in which each could enhance rural marketing and distribution efforts. As a result of this effort together with CRS, N-MARC initiated the development of a long-term business plan that was expected to give CRS a clear direction for its sustainability. MART prepared a draft of five-year business plan and one-year operational plan which are currently being adapted for submission to the Board of Directors of CRS. The following excerpt is derived from the draft of five-year business plan on sustainability: "Sustainability for CRS has three-fold implications-  Building relationships with multiple donors – national and international. It has to be attractive to donors and be their first choice partner in the health sector. Donors partner with the organization because it delivers, has a wide ranging credibility and a record of performance.  Create and upgrade the CRS bouquet of products to enable internal generation of cross subsidy for socially driven products  Build and integrate benchmark efficiencies on costs and productivity - to deliver efficient utilization of donor funds and build robust processes and operation in CRS" One of the milestones added to the sustainability of CRS was the MoU between USAID/Nepal, CRS, and N-MARC to release the revenue generated from sales of contraceptives from July 1, 2006 to September 30, 2009 totaling approximately Rs. 100 million which can be utilized for the procurement of contraceptive commodities and management. This is a step towards CRS achieving greater organizational independence and becoming a more sustainable social marketing organization. 23 The initiative taken by N-MARC to encourage the private sector to get involved in commercial marketing of health products is very commendable. Bringing the private sector such as Lomus Pharmaceuticals Pvt. Ltd. on board for the production of pills and three trade houses such as Gayatra, Praxis, and Pioneers for marketing of condoms is a good initiative towards sustainability of product accessibility and services. This is in line with the PPP of the Government of Nepal. However, at this juncture the Government of Nepal should develop a mechanism for a long-term partnership that will complement and supplement social marketing program and contribute to achieving health goals. N-MARC should now with the first hand experience in commercial marketing of health products using matching fund approach initiate more interaction with the government. Following its mission of "Partnership for Nepal Social Marketing", N-MARC has engaged its local partners in the project with responsibilities. It is worth to note here that for all the seven indicators set for IR-4, no baseline indicators were present whereas monitoring plans should be based on the baseline data. As seen in the N-MARC Annual Performance Monitoring Plan, the number of individuals trained in strategic information and number of individuals trained in HIV￾related institutional capacity building, IR 4.6 and IR 4.7, respectively, have been found the same in both the years, year one and year two of the project, differing only in year three. It could be assumed that these individuals trained were the same people. The number of participants in different N-MARC sponsored training programs/workshops has been found missing in the report. Some of such significant trainings include Professional Writing Skill Workshop, Logistics Training for the Social Marketing Sector and one-day STI orientation. As social franchising consists of creating networks of private medical practitioners and other health providers offering a standard set of services under a shared brand, franchisees receive subsidised equipment, drugs and contraceptives, sometimes clinic space; training; brand and commodity advertising; technical support and opportunities for professional advancement. However, in districts where evaluation team members visited, the quality of Sangini Social Franchise Network service has been found needing more attention; the Sangini providers have been found not strictly following the protocol. Technical support visits to the outreach are found not sufficient. Sangini providers were found less interested in following the protocol because they said it is time consuming and the incentive is too low. Some providers said that some clients visit the clinic with the mindset just to get the injection; they do not like to spend time for counseling. Some clients do not like to get exposed that they have got the injection. In some Sangini outlets, the team also found that the providers have not been trained for Sangini injection administration. Implementation of activities for and by partner organizations far exceeded the targets set in year 2007/08 and also in 2008/09. For instance, the actual number of staffs trained on development and implementation of social marketing communication strategies exceeded the number planned by about 50 percent in 2007/08 and 2008/09. Similarly the actual number of individuals trained on HIV-related institutional capacity-building exceeded by 260 percent. The CRS Company had managed Central Warehouse for many years but PSI took it over from CRS for the period from 2002-2006. However, it was very commendable on the part of N-MARC that the warehouse management responsibility was transferred back to CRS. Discussions with the Director General of Department of Health Services and The Technical Adviser of KfW, clearly revealed that the CRS Company is the only leading organization in social marketing in Nepal. However, the DG expressed the concern that despite the existence of PPP, the government of Nepal does not have a clear policy on social marketing. He also mentioned that the Planning Commission has to consider this issue. 24 Knowledge management aspect of the project is another cornerstone as there was regular on-the￾job coaching from N-MARC. NFCC and EngenderHealth regularly conducted sessions on contraceptive updates to the staffs of local partners. N-MARC was effective in regard to IR-4 because the level of achievements in almost all the stated indicators was high. 3.1.5 Public Private Partnership in Family Planning, Maternal and Child Health Services, and HIV Prevention: Collaboration and Networking, Capacity Building, Market Impact (IR-5) Nepal Health Sector Implementation Plan (NHSP-IP) 2003-2007 has clearly identified eight outputs in health sector reform including three program outputs and five sector management outputs. While summarizing these outputs one can draw a clear picture of the importance of the role of private sector in health sector forming public private partnerships for efficient and effective healthcare delivery. Out of the five intermediate results of the N-MARC program, the IR 5 is intended to increase collaboration between private sector, USAID/Nepal partners and Government of Nepal public sector health services in family planning, maternal and child health, and HIV/STI prevention. In the beginning N-MARC executed sub-contracts with its three core partners, EngenderHealth, CRS, and NFCC. N-MARC expanded its overall partnership with the addition of five new core partners MITRA Samaj, Urban Pixel, and three commercial sector condom distributors – Praxis Trade Link, Pioneer Trading, and Gayatra Store Enterprises. Another significant step taken at the start was holding briefing meetings with the Director-Generals of the Ministry of Health and Population and also with the Directors of relevant Divisions/Centers. The aim of briefing was to provide details on the N-MARC mission, objectives and strategies. N-MARC also coordinated project activities with USAID/Nepal project partners’ programs such as ASHA and NFHP. In order to increase collaboration between private sector, USAID/Nepal partners and GON public sector health services in FP/MCH and HIV prevention and services the partner organizations required to perform three activities which include: i. Establishment, expansion or strengthening of new private sector interventions that increase the supply of quality FP, MCH, and HIV/AIDS/STI products and services to target populations. ii. Creation of policy incentives to increase private sector participation in RH/FP service delivery. iii. Leverage resources from the private sector as a result of public/private partnership agreements. The above activities were monitored through performance monitoring plan of the N-MARC program. Some of the major collaboration activities that N-MARC carried out through CRS included supply of condoms to ASHA project areas and the development of standardized guidelines in line with GoN national medical standards for use in private sector FP/RH services. In the first year, N-MARC ensured GoN involvement in the QA activities implemented by NFCC. In year two ASHA continued its technical inputs into the HIV/AIDS section of Sangini provider network training module as well as communication activities. ASHA also supported in the implementation of the You Are No Exception HIV/AIDS prevention campaign. It shows that 25 there was a strong collaboration between ASHA and N-MARC – an example of working together with USAID/Nepal funded project partners. N-MARC developed its networking by participating in public sector’s health technical groups and committees such as National Family Planning Subcommittee, National Safe Motherhood Subcommittee, Working Group for National FP/RH Guidelines Review, Chlorhexidine Technical Advisory Group, National Commodity Forecasting meetings, and various HIV/AIDS and STI Control Board meetings. With an objective to form strategic relationships and collaboration with the agencies engaged in similar program areas, CRS led the formation of communication working groups for each of the products areas: FP/RH, HIV/AIDS, and MCH. These groups comprised of CRS, N-MARC, USAID/Nepal, NFHP, NFCC, relevant GoN divisions/centers, and the media partners. To strengthen social networking, N-MARC also held consultations with numerous partners regarding collaboration and for partnership opportunities. These were PATH, MSH, MSI, Blue Diamond Society, Youth Power Nepal, and others. N-MARC initiated its collaboration with commercial sector partners, which included engagement of commercial sector condom traders to expand their marketing and distribution activities in ‘hot zones’. In year one, Nepal CRS Company also started the formation of its own strategic partnership with several INGOs, civil societies, USAID/Nepal partners and projects, commercial sector, and government agencies engaged in similar activities. N-MARC staff participated in a series of meetings with KfW regarding their support for CRS in the areas of ORS and oral contraceptives as well as expanding resources in the area of social franchising and voucher schemes. N-MARC supported CRS by providing technical assistance in preparing and developing technical proposal to submit to KfW. In year two, N-MARC and NFHP collaborated on three key areas: chlorhexidine, misoprostol, and private sector sick child-care. In product areas, NFHP provided technical leadership and N￾MARC provided product introduction, sustainability, and private sector leadership. As a part of capacity building program, N-MARC collaborated with NFHP in logistics management training in social marketing in the first year of the project and it also provided technical support to CRS in the development of their proposal to KfW. Similarly, N-MARC also organized a five-day long training program entitled “Pictures and Words” for television journalists which was led by Mr. Daniel Lak, a seasoned BBC reporter. PPPs are seen as ‘win-win’ arrangements in which different actors with varied motivations and philosophies work together, and are able to contribute to health development. In line with the PPP objectives, N-MARC has involved ‘for-profit’ and ‘not-for-profit’ organizations together in the health sector. During the first year of the project, intensive efforts were made for collaboration and networking with public as well as private sectors. N-MARC established partnership with Nepal Investment Bank Limited (NIBL) to sponsor awards given to the top three directors in the You Are No Exception short film competition. NIBL provided Rs. two million (approximately $27,000) to cover the costs of the top three directors to attend a three-month long film course in Mumbai, India. Additionally, NIBL donated Rs. 500,000 to the NFWLHA. N-MARC’s efforts in multi-sectoral partnership include partnership with Sagarmatha Television for a health news section on TV which was initiated by CRS Company and leveraging beneficiary groups by using revenue generation model that MITRA Samaj linked with a number of groups such as commercial sex workers and PLWHA, intending to promote and distribute commercial brands of condoms in the Terai. 26 The private sector has been found very encouraging. During discussions with some private implementing partners, they gave credits to N-MARC project for providing them a platform to get involved in social development. The most successful example can be cited as the leveraging of resources from the private sector which exceeded by 363 percent in year two and 259 percent in year three. The target of partnering with one private sector entity to increase the supply of quality FP, MCH, and HIV/AIDS/STI products and services to target populations in year two and partnering with five entities in year three have been achieved as against the set targets. This is a good example of N-MARC’s collaboration with the private sector. Public private partnership can be viewed as an agreement between the government (public sector) and non-government (private sector, for-profit and non-profit) for the purpose of delivering health services cost effectively and equitably. The N-MARC project made efforts to achieve FMI by involving the commercial sector as well. Under IR-5 one of the activities the N-MARC project listed to carry out was “number of policy incentives created to increase private sector participation in RH/FP service delivery”. However, no new policy incentives were created during the reporting period as mentioned in the PMP. 3.2 Monitoring, Evaluation, and Research N-MARC has adopted the ‘Monitoring, Evaluation, and Research Plan’ for recording and reporting of project activities. The main purpose of the monitoring was to provide information on key aspects of program performance and of learning lessons to guide strategic and programmatic decisions. The aims of evaluation function were two-fold: (1) to assess changes in the market and progress toward increasing the supply of products and services expanded distribution, greater demand, increased access and use of high-quality health products and services, and sustainable public health impact, and (2) to determine the extent to which N-MARC and its partners have contributed to these changes. The project progress was specifically monitored and evaluated in seven of its key areas following its FMI approach: product/supply; price/affordability; place/distribution; promotion/demand and appropriate use: equity; commercial viability; and sustainable public health impact. N-MARC selected key indicators from the PMP that are used for reporting to USAID/Nepal. The indicators were derived from PEPFAR and Operational Plan indicator manuals, and standard FP/RH indicators contained in the Compendium of Indicators for Evaluating Reproductive Health Programs. N-MARC also tracked indicators that refer to the specific seven areas of results that reflect N-MARC’s FMI model. In the beginning of the project, the N-MARC core project team provided technical assistance to the implementing partners to upgrade standards in data collection, analysis, and use. These partners were encouraged to tailor their own MIS to their needs, provided certain standards are met. N-MARC has subscribed to a retail market audit conducted by A. C. Nielsen to understand overall product category market dynamics. Maintaining quality in the delivery of FP/RH, MCH, and STI/HIV prevention products and services has been critical to the success of N-MARC, particularly as it relates to maintaining compliance with US population policies. N-MARC has developed an extensive monitoring and evaluation plan and manual for its private provider networks entitled Quality of Care Monitoring 27 and Evaluation for Health Network Outlets, which acts as the guiding document for quality assurance monitoring under the project. During the site visits by the evaluation team, the quality of care protocol was found not well followed by Sangini providers. CRS and NFCC also admitted this. The discussion with them indicated that there is a need for a wide strategy in order to address issues such as strictly following up of protocol, incentive to providers, occasional administration of injection by untrained provider, client awareness about the value of counseling, etc. The evaluation team found at some sites expired Number 1 condoms being sold through both TOs and NTOs. Most retailers said that Number 1 condoms are popular and are in high demand. Some retailers told that when selling condoms they hardly notice the date of expiry or so do the consumers. The retailers said that the supplier should monitor the market well. N-MARC submits its semi-annual and annual reports to USAID/Nepal regularly as part of external monitoring requirements. These reports were found to have two shortcomings: i. The reports contain more quantitative information and little qualitative information explaining data discrepancies. In some reports, training contents, target groups and duration of training are found not reported. ii. Inconsistencies are found in data presentations. For example, under IR 4.5, for year three Annual Report mentioned ‘target 8, achievement 9, percent achieved 113’, whereas in the Annual PMP of the same year different data have been mentioned such as ‘target 8, achievement 85, percent achieved 1,063’. After eight months of the project, N-MARC selected MITRA Samaj as its MER partner to provide management, technical support, and capacity building for MER activities. The selection of the organization also included the placement of a full-time MER Advisor on the N-MARC team. The report of N-MARC mentioned delay in MER activities had become a challenge for it. The evaluation team recommends that there should be some staff trained in qualitative monitoring and reporting. In-house monitoring allows the involvement of staff for monitoring activities from the beginning of the program to keep planned activities on track. However, project evaluation can be outsourced to minimize biases. N-MARC has made commitment to support feasibility and pricing studies for new FP/RH services, and MCH and HIV/AIDS/STI products and services; BCI and brand campaign formative research, testing and tracking; and retail audits using GIS/GPS. It is mentioned in the agreement made between USAID and N-MARC that N-MARC’s research staff have years of experience in working with the commercial sector on willingness-to-pay, market research, monitoring of TS programs, and measuring FMI. N-MARC recognizes the importance of monitoring, evaluation, and research (MER) in designing effective strategies and interventions, providing program managers with the feedback they need, and assessing progress toward goals. ‘You Are No Exception’ Endline Survey In the 2006/07 to 2008/09 project period N-MARC carried out as well as commissioned several research activities. Following N-MARC’s ‘You Are No Exception’ communication campaign in 2008, an endline survey was conducted to find out about the level of awareness about HIV. The communication campaign appears partially successful because less than 10 percent MARPs heard 28 about “You are No Exception”20. Most preferred outlet to buy condoms was reported to be pharmacy and second most preferred outlet was shop. Most respondents recalled Number 1 condom followed by Dhaal, Panther, Cobra/Black Cobra in that order. The research was, however stereotyped; it dealt too much on background information of the respondents. GIS Mapping GIS Mapping, another study, however, reports Dhaal having biggest coverage followed by Panther, Number 1, Jodi, Black Cobra and Skinless Skin in that order. It should be recalled that CRS condoms are highly promoted. The study also reports availability of 64 different brands of condoms in the country through some 22 different outlets21. These outlets appear only transitory because in the nine districts the evaluation team members visited condoms were found selling mostly in chemist/pharmacy, pan bidi shop, supermarket, departmental and mini stores. The N-MARC project has introduced “hot spot” and “hot zone” in Nepal. By “hot spot” it means a place where sex negotiation for money or sexual activity for money takes place and by “hot zone” it indicates a cluster of “hot spots” within 100 meters radius. The project also talks about condom coverage meaning an outlet has condoms stocked in the visible location. It also means the outlet has promotional materials at point of purchase (PoP), have no incidence of condom stock-out last month and outlets sell condoms even at night. The GIS Mapping study reports overall condom coverage from the first round of data collection to the third round has increased from 69 percent to 90 percent. The quality of coverage showed the following features: • Condom stock availability has fluctuated up and down over the three rounds • Condom stock at visible location over the time has improved • Proportion of outlets with condom promotional items at visible location remains persistently low • Condom stock out experienced by outlets has lowered • Proportion of outlets operating at night over the period has improved substantially Clients’ access to condoms within 100 meter radius improved in the third round compared to the first round of study. The number of condom brands available in ‘hot zones’ increased from 41 to 64. Featured male condoms and female condoms are now available in hot zones. The types of outlets selling condom increased from 12 to 22, increasing number of outlets allows more choice to customers. The challenge for the project is how to maintain overall condom coverage figure at 90 percent or higher. To improve the quality of coverage there is a need to further prioritize product visibility and POP materials at outlets, ensure that the improved current minimum number of outlets reporting ‘out of stock’ situation is maintained and focus more on improving the night-time condom availability. The research report recommends to focus on opening outlets near ‘hot spots’, continue to re￾evaluate appropriate radius for measuring access indicator (e.g. 60-80m instead of 100m) and increase the types of outlets selling condom in hot zones so that customers have more choices, and leads to index of saturation (availability of condom in all types of outlets). 20 New ERA. 2009. 21 N-MARC. 2009. Levels and trends in condom coverage. 29 The GIS Mapping of Franchising Network Product Service Performance and Coverage Study The GIS Mapping of Franchising Network Product Service Performance and Coverage in Nepal study22 was conducted to estimate and monitor service coverage and quality of service coverage of RH products in Nepal. Each RH/FP and MCH product and service outlet was assessed to determine the availability of the following products at time of survey: – Condoms (Dhaal, Panther, and Number 1) – Oral contraceptive pills (Nilocon White and Sunaulo Gulaf) – 3-month injectable contraceptive (Sangini – Depo-Provera) – Emergency contraceptive pills (Postinor 2) – Oral rehydration salts (e.g. Nava Jeevan) – Clean delivery kit (Sutkeri Samagri) – STI treatment kit for male urethritis Quality of coverage was measured using two types of indicators such as the “stock at visible location” and “promotional materials of the products at outlet” indicators measured the promotion aspects and the “out of stock last month” indicator measured the performance of distribution. In all 249 outlets selected from among the total 2,327 outlets from 55 districts were audited with pre-structured retail audit tool. Key Findings At the time of survey, 2,327 Sangini outlets operated in 55 of 75 districts, most outlets were found located in the Terai, with minimal coverage in mountain and hill districts while in Kathmandu valley 25 percent outlets were located. Product Availability • Condom availability was high, with Dhaal and Panther outperforming Number 1. – However, about 10% of the outlets reported not having product • Oral contraceptive availability was high, with Nilocon White outperforming Sunaulo Gulaf • Sangini was expected to be available in all 100 percent of the outlets, but only 90% of outlets reported to have Sangini available in their outlet. • Postinor 2 availability was poor. • Nava Jeevan was available in 90% of the outlets. • 45% of outlets stocked CDK • Very few shops reported to have sold STI treatment kits Quality of Product Coverage Product visibility • Among the three condom brands, Dhaal and Panther performed well, while Number 1 visibility was low. • Product visibility of Nilocon White was better as compared to Sunaulo Gulaf 22 AED/NMARC. No date 30 • Sangini was placed in a visible location in 80% of outlets and Nava Jeevan in only 78% of the outlets. Stock status • Out stock situation was relatively high for Number 1, Postinor 2, CDK, and STI kits. Promotional material at visible location • Promotional materials of all products were found to be poor although the situation of Dhaal, Panther and Sangini was relatively better. Other Quality Aspects • 83% of outlets reported to maintain log book of Sangini clients • Average number of Sangini clients per outlet per month was 31 (min=0; max=300) • Condition of facility in terms of cleanliness, separate room for counseling, hand washing facility, have clean hand towel and proper light ranged between 55-72% • 5% of the providers reported to put needles in the puncher proof container after re￾capping them, which is a hazardous practice. • Various BCC/IEC materials were found in 65% of the outlets. • 53% of the outlets had Sangini painting or on-shop board. • 62% of the shops reported to operate during night that is after 8:00 PM. Other Aspects of Study Child Health Service • On average, 7 children under 5 years come to Sangini outlets for treatment every day. • The average number of such client flow is highest in the mid and far western regions compared to other regions, possibly because of limited number of other places to seek care in these regions. Program Implications Product: The study recommends that N-MARC partners should initiate efforts to increase all range of product coverage to 95% of the outlets Place/distribution: The study recommends that it should • emphasize product distribution in outlets reporting to have out of stock; • open new outlets in those districts with limited or few outlets; • increase activities to improve quality services focusing outlets that showed poor performance; and • explore other products/services that can be delivered through the Sangini outlet; Promotion: The study recommends that it should ensure • promotional materials visibility in and around outlets; and • the informed choice poster, client register poster and sangini painting or board placed in all outlets Price: Not examined The evaluation team thinks that this type of research study is good for the project to improve and design project activities better. However, in the fields it was found that many of the recommendations have not been implemented, for instance, products are not placed in visible places, informed choice posters are not properly hanged, several outlets do not have boards or paintings and so on. Another critical issue is price; since N-MARC products are not free, a good study on pricing of products should have been conducted. 31 OCP KAP Baseline Market Research Survey This baseline study on OCP was conducted in 200923. The rationale for conducting this study was that the use of pill has remained low for many years and it was necessary to explore why the pill is not a popular spacing method in Nepal. A total of 1,074 married women age 18-30 from 25 urban and peri-urban areas were interviewed. It was a quantitative questionnaire survey; the field work took place from April 24 – May 23, 2009. The primary objective of the survey was to explore: media habits, awareness of and attitudes towards contraception especially pill, recall of family planning and OCP messages, and relevant behaviors, including OCP purchasing and usage behaviors. The sample design was a multi- stage, stratified cluster sample selected with principles of probability. Key Findings Knowledge of at least one modern method of family planning was found universal among women. Ninety percent have heard about OCP and five main sources of information on OCPs were the radio (85%) and TV (82%), followed (much lower) by shop (56%), poster/hoarding board (54%), and newspapers/magazines/brochure (36%). Almost all respondents (95%) heard/saw something about Sunaulo Gulaf followed by information on contraceptive in general (87%), Nilocon White (68%) and ECP (26%). Radio Nepal is listened to most by all groups, with Kantipur FM being the 2nd most listened-to station; remaining radio stations are listened to by less than 10%. Nepal Television is the most popular television station, followed by Kantipur and Star Plus. Tito Satya, Meri bassai, and Jire Khursaani are the most popular TV programs across all users. The three main responses of what was understood from the messages heard/seen about the pill were: pills prevent pregnancy; woman can conceive when she stops using pills and pills help to space births. Most popular modern method was found to be injection (18%) followed by pill (17%), condom (8%), female sterilization (7%), and male sterilization (4%). Slightly over half of all women did not use any method because of absentee husbands (two in three among former pill users), one in three wants to have children (four times higher among never users), 15% are postpartum and 8% currently pregnant. Most important source of contraceptives supply is the government facilities (53.6%), 2nd important source is pharmacy (23%), and private sector third important (15.1%). NGOs role appear the least (7%). Three in 4 women said pill is very effective to prevent pregnancy, two in three said it is easy to use and one in three dislikes other methods. The main reason given by former pill users for quitting (n=125) was side effects (42%), followed by difficulty to remember to take (33%), bleeding (27%), and husband getting sterilization (26%). 12%-14% each said they wanted to become pregnant, heard about health risk, and husband likes other method. An additional 8% said they became pregnant while using pill. A great portion of current pill users (86%, n=181) said they were very satisfied with the pill and none said "not satisfied". Important reasons mentioned for this were: pill is effective, easy to take, inexpensive and helps regulate menstruation. The two brands mentioned by most current users were Nilocon White (53%) and Sunaulo Gulaf (41%). The main place OCP users would like to 23 N-MARC. 2009. OCP KAP BASELINE MARKET RESEARCH SURVEY 32 obtain their current OCPs was pharmacy (83%), followed by food store (32%), and FCHV (21%). The four advantages of OCPs mentioned are that pill helps to regulate menstruation, easy to use, reliable, and can be stopped any time. In 2006, the Government remained the primary source of supply, though the private sector assumed a greater share of supply for the richest (36%) and richer quintiles (13%), with modest gains in the others. In the 2009 N-MARC KAP survey, the private sector is the source of supply for nearly 50% of the top three quintiles, and increased its share in the poorer (35%) and poorest (25%) quintiles substantially which implies that FMI approach of reaching the low income group is working in Nepal. The research report contains nine recommendations which can help promote pill use effectively. The evaluation team thinks that N-MARC should design pill promotion program along the recommendations of this study. Zinc Campaign Impact Assessment The “Zinc Promotion Campaign”, a comprehensive and generic communication campaign24 was undertaken by N-MARC. ANS Creation Pvt. Ltd. was the communication and advertising partner for the campaign. This five-month long campaign has worked to significantly improve and promote increased acquisition of Zinc through the public and/or private sector. Key Findings The Zinc Promotion Campaign has been very effective in creating awareness among the target groups. Although the practice of use of Zinc is not at the desired level, there is an increasing trend, through increased awareness. Radio and Television have once more proved to be the strongest mass communication media. Also, in the area surveyed, the local pharmacists have been playing a very positive role in disseminating the communication and encouraging the use of baby Zinc. Using popular Television celebrities in the TVC has been a good strategy, as many of the respondents were able to name their favorite celebrity from the TVC and even sing the jingle when prompted. However, these statements are not supported by data. In order to assess such a big communication campaign it would have been better if the tasks were outsourced to make objective assessment of the campaign. The title of the work is a misnomer; it is actually a monitoring report rather than an assessment report. It lacked proper methodology and the sample size of 100 cases was too small. Overall research studies were found supportive to the project although several recommendations are yet to be implemented such as promotion of OCP activities. The research works that are worth mentioning are GIS and OCP studies. The GIS study was good in indentifying locations to increase access to commodities and services for high-risk populations. The OCP study gave recommendations to strengthen IEC activities that would help increasing number of women to learn about the advantages of pills and accept it. 24 N-MARC. Zinc promotional campaign. 33 Peter Oyloe Resident Advisor Arinita Shrestha Program Manager Anjeeta Shrestha Finance & Admin Director Rajeeb Satyal PPP Advisor CP Bhandari Senior Accounts Officer Hema Shrestha Administrative Assistant Prabin Subba Admin Assistant/Receptionist Sujata Lama Compliance Officer Pradip Adhikari Driver Satya Manandhar Driver Bhim Osti Utility Worker Karuna Shakya Quality Assurance Advisor Prakash Pant MER Adivsor Reed Ramlow Project Director Program/Technical Operations AED/DC AED/KTM EngenderHealth/KTM MITRA Samaj/KTM Balaram Joshi Finance Officer Chad Blain Senior Operations Manager Yehwoub Geadion Program Associate 3.3 Management Systems: Project Management, Logistics Management, Financial Management In the beginning, N-MARC carried out start-up activities that included office set-up, establishment of operational procedures, staff hiring, warehouse management, and execution of project sub-contracts with its key implementing partners – Nepal CRS Company, Nepal Fertility Care Center and EngenderHealth. Simultaneously, N-MARC also managed the USAID/Nepal commodities and assets. Compliance with USAID population policies was found given top priority while beginning the project activities. As soon as the program began, CRS and NFCC staffs were briefed about the USAID population policies that included the Tiaahrt Amendment and the Helms Amendment. Although N-MARC had faced operational challenges during its first year of operation due to the deteriorating security situation especially in Terai area, it was able to manage the activities by developing and disseminating security reports, conducting regular security meetings, and developing partner contingency plans which helped lessen the situational impact on the program. Workplans and PMP for all three years were well prepared and approved from USAID/Nepal, as mentioned in the annual reports, however the workplan for the year one was not made available to the evaluation team. Not all the activities stated in the workplans were found recorded in PMP. The recruitment process of N-MARC is in place and has been followed too. Since the inception phase of the project, human resource planning was initiated. Some of the top level manpower for the project were already involved during the proposal submission period. The project began in July 2006 and in four months time the technical director resigned and a new director took the charge as marketing and communication director after a year. The marketing and communication director also left the organization after 15 months. High level human resources turnover was high. The following figure shows the N-MARC Organizational Structure as of February 4, 2010. The figure shows that program activities are implemented in collaboration with the Headquarter at Washington, D.C., N-MARC, MITRA Samaj and EngenderHealth. The total number of staff in Kathmandu office is eleven including three supporting staffs. N-MARC Organizational Structure (as of February 4, 2010) 34 N‐MARC ASHA NFHP Government Communication / Research NFCC CRS ENPHO MITRA Samaj CSED Gayatra Pioneer Praxis Lomus FP/MCH Condoms USAID Project Partners USAID Projects Government of Nepal Commercial Companies National NGOs USAID During the program period, most of the senior staff of N-MARC often traveled abroad to attend different meetings and workshops to share their experiences of N-MARC program with international participants. Some of the senior staffs were also provided opportunities to participate in academic courses abroad as part of human resource development program. The project system followed the following N-MARC Partnership dynamics that included ASHA and NFHP- the USAID project partners; and CRS, NFCC and MITRA Samaj as core N-MARC partners. MITRA Samaj worked as a mediator for commercial partners and CSED. The partnership dynamics shows the combination of public sector, USAID, NGOs and the private sector. N-MARC Partnership Dynamics For the N-MARC project, the major logistics management activities carried out during the program period can be summarized as follows:  Transfer of USAID-funded assets from PSI project to N-MARC  Management of these assets  Distribution of all those remaining usable assets to N-MARC partners  Disposal and disposition of unusable packaging/promotional materials and PSI/Nepal assets  Distribution of existing PSI-branded commodities to prevent unnecessary expiry  Transfer of warehouse management responsibility to CRS to independently manage USAID-donated commodities Although N-MARC faced some challenges in maintaining stocks of some KfW-donated commodities like ECPs and Sunaulo Gulaf, N-MARC and CRS were able to carry on with the delivery from an Indian manufacturer. 35 N-MARC has policies, mechanisms and guidelines for an efficient and effective financial management of its program. Some of the principal policies and guidelines are corporate inventory policy for monitoring inventory and their utilization, and policy for financial controls. For the N￾MARC project, there are procurement processes and procedure guidelines, public private partnership policies, and guidelines for using N-MARC matching funds. During the entire project period N-MARC’s collaboration with organizations for different expertise has been high. Implementing a national program with only a few project staff is definitely an efficient management system. However, human resource management was challenging for N-MARC because one high level post was vacant for a year in the beginning of the project period after the resignation of the Deputy Advisor. The evaluation team found that experienced social marketing and social franchising personnel were working for N-MARC. However, human resource turnover was a problem with N-MARC. The technical director stayed only for four months and the position was vacant for a year. The person who filled the vacant position also left after 15 months. The present N-MARC organization structure is without the position of Deputy Advisor although this position was regarded as crucial for the organization in the beginning. Nevertheless the strength of N-MARC program was that USAID provided adequate financial resources for the program. The market leadership is the another strength of the program since the Full Market Impact (FMI) approach is regarded as a breakthrough in social marketing and social franchising sectors in Nepal. Third strength of N-MARC is the high-quality products being made available in the market through CRS Company and other private implementing partners. N-MARC has faced several challenges during its implementation period. One of such challenges is the human resource turnover as mentioned above. Another challenge was the shortage of human resources for supervision and monitoring of the program activities from the beginning because only after eight months of the project period the MER activities started taking place. It was observed that large inventories also caused some problems while managing the USAID/Nepal funded assets and distributing the PSI-branded left over commodities. Some less than optimal procedures are noticed in the selection of some of the sub-partners. The following suggestions are made for the future:  Selecting sub-partners through an open competition instead of restricting competition to pre-selected bidders would guarantee wider participation.  The sub-partner selection team should consist of not only in-house employees but also external experts. A plan should have been developed to monitor field activities by the N-MARC and accordingly necessary staffs should have been recruited on time. There are many instances of international visits by the staff from time to time, but very few visits to the project implementation sites. Overall, although in the beginning, the project was implemented under difficult circumstances because there was unrest in the country especially in Terai region, efforts made to collaborate and coordinate with core partners and local partners were commendable in order to achieve the goals of N-MARC project in Nepal. 36  Presentation of results towards targets  Planning, monitoring, implementation, and reporting  Management systems EVALUATION FINDINGS 37 4. EVALUATION FINDINGS The findings of evaluation are broadly presented along three main headings: presentation of results towards targets; planning, monitoring, implementation, and reporting; and management systems. 4.1 Presentation of results towards targets  The N-MARC project was unique in Nepal as it functioned as a facilitating organization rather than an implementing one while USAID/Nepal funded its predecessor, viz., PSI was an implementing organization. Therefore PSI did not create an environment for partner organization to grow while N-MARC has created ample space for growth.  The estimated annual CYP based on five spacing methods distributed and marketed by N-MARC partner organizations increased from the baseline CYP of 239,621 in 2005/06 to 289,835 CYP in the following year, further to 369,977 CYP in 2007/08 and 445,801 in 2008/09. Yearly percent achievement against the targets was 102%, 118% and 115%, respectively.  Distribution and sale of Sangini were over 100 percent against the targets in all three years.  The Sangini Network was expanded to reach 2,784 providers in 69 of Nepal’s 75 districts.  Except for IUD in 2006/07 achievements against targets in year 2007/08 and 2008/09 for IUD and implant were below the targets by a margin of 15% to 25%.  SURE home pregnancy test kits did not sell well in 2006/07 (only 3% achievement against the target) and in the subsequent two years it was stopped.  N-MARC project achieved a milestone for Nepal through its support to Lomus Pharmaceuticals in the manufacturing, marketing, and distribution of hormonal contraceptives namely Femicon (COC), Feminor (ECP), and Femitrone (POP).  In June 2009, CRS launched its new brand of emergency contraceptive pills, eCON replacing Postinor-2. There are, however, mixed reactions to eCON use. It is popular among young population and some chemists think that they overdo it.  Sale of MCH product CDK was not found encouraging because the achievement against the targets were much below 100 percent except in 2007/08 when it was 102%. Respondents in the districts the evaluation team members talked to also gave the impression that it is not sold well primarily because of free delivery service and monetary incentives given to women delivering at a health facility.  Nava Jeevan ORS is now an entirely self-sustaining social marketing product. The sale of Nava Jeevan has achieved the targets. However, the sale of Nava Jeevan is found seasonal.  The target set for the sale and distributions of Virex – a surface disinfectant, was met in 2006/07 but not in the following two years. In the nine districts visited by evaluators, Virex was found sold in some pharmacies to institutions only. 38  Although N-MARC got credit in supplying Zinc tablet to diarrhea affected districts in the West but it is not found appealing to the general public and therefore the sale of Zinc tablet is not achieving results. Several pharmacies told evaluation team members that taking 10 Zinc tablets in 10 days is too long time for children affected by diarrhea; the parents/guardians of sick children want medicine that can cure diarrhea soon after taking the medicine.  PIYUSH, a point of use water disinfectant, was introduced in 2007/08 but sales data are not reported for that year and in the following year, sale was reported good. However, the evaluation team did not find PIYUSH that promising in the fields. The pharmacists that the evaluation team members talked to about the sale and use of PIYUSH mentioned that people in general are not used to taking water after adding anything extra. This is an age old habit which takes time to change.  CRS initiated introduction of misoprostol for PPH under the brand name Matri Surakcha Chakki ‘MSC’ (Safer Motherhood Pills) as a pilot project in Bardiya district. Now the social marketing of MSC has expanded to Banke, Rupandehi, Nawalparasi, and Chitwan. This product diversification is expected to contribute to greater sustainability for CRS.  It is estimated that about 41.2 million condoms are distributed and/or sold in the country annually and of that 21.4 million condoms were distributed by N-MARC partners. This means that 52 percent of market share goes to the private sector.  N-MARC and its partners were particularly successful in encouraging the commercial sector to promote market condoms which resulted in increasing the share of the commercial sector in the overall market.  N-MARC project reported increase in market share of commercial condoms from 6 percent in 2006 to 22 percent in 2009. However, when condom sales data from N-MARC partners alone are used no growth in market share of private sector is noticed.  Some innovative approaches have been adopted by N-MARC partners to market condoms in hard-to-reach areas and population such as condom kiosks, healthy highway approach, mobile shops, tea shops, etc.  Branding and packaging of condoms have also been made attractive to customers. The commercial sector now sells condoms packaged in attractive and featured packets.  The actual number of individuals trained on HIV related institutional capacity-building exceeded by 260 percent among several partners of N-MARC.  Routine meetings with leadership from all key partners were held to discuss program achievements and challenges and program strategy development.  In order to provide organizational development and technical assistance to CRS, N￾MARC contracted the services from SSDS for a five-week reviewing session on the existing organizational structure and business processes of CRS.  N-MARC project has provided technical assistance and cooperation to its local partners and individuals to build their capacity. N-MARC sponsored "professional development forum", a quarterly forum that brought together partners like FHI, AMDA, Constella 39 Futures, NFCC, CRS, and NFHP to share innovative ideas and approaches to the delivery of health products and services.  N-MARC project sponsored logistics training on social marketing for CRS central and regional staff in coordination with NFHP and USAID/Nepal.  With the objective of managing warehouse by CRS, a warehouse management consultant was hired by N-MARC project to provide on-the-job training to CRS warehouse staff.  N-MARC collaborated with NFHP in logistics management training in social marketing sector during the first year of the project period and it also provided technical support to CRS in the development of their proposal to KfW.  By sitting in different health committees of the government and regularly briefing about its own activities N-MARC has strengthened PPP in practice.  Despite progress made in strengthening PPP it appears that certain policies are lacking - no policy incentive created to increase private sector participation in RH/FP service delivery. Nevertheless, private sector has been found very encouraging. Some private implementing partners have given credits to N-MARC for providing them a platform to get involved in social development. Leveraging of resources from the private sector was highly encouraging.  Initially, N-MARC entered into partnership with EngenderHealth, CRS, and NFCC. Later N-MARC expanded its overall partnership with the addition of five new core partners MITRA Samaj, Urban Pixel, and three commercial sector condom distributors – Praxis Trade Link, Pioneer Trading, and Gayatra Store Enterprises.  In year two, N-MARC and NFHP collaborated on three key areas: chlorhexidine, misoprostol, and private sector sick child-care.  N-MARC by partnering with the Nepal Investment Bank Limited (NIBL) sponsored awards to top three directors in the You Are No Exception short film competition. NIBL contributed Rs. 2 million (approximately US$27,000) to cover the costs of the top three directors to attend a 3-month long film course in Mumbai, India. 4.2 Planning, Monitoring, Implementation, and Reporting  Monitoring of project activities in the project areas are found weak. The N-MARC staffs were found hardly visiting field activities except for research. Also weak monitoring was found in project reports.  A number of project related research were conducted such as GIS Mapping, baseline and endline surveys. Some researches were found not in line with project objectives. However, most research studies guided project activities.  Reporting of achievements were heavily based on A. C. Nielson market research but no report was made available to the evaluation team to verify the validity of data.  At the outset, CRS and NFCC staffs were briefed about the USAID population policies that included the Tiaahrt Amendment and the Helms Amendment. 40  Workplans and PMP for the project period were well prepared and approved by USAID/ Nepal. 4.3 Management Systems  N-MARC faced human resource problem especially of high level human resources. The turn over of human resources was high.  N-MARC developed a partnership dynamics and followed it that included government agencies, international and local partners such as EngenderHealth, CRS, NFCC and MITRA Samaj.  The strengths of the management system included internal control of finance, cost advantages, and rules and regulations in place.  There was shortage of human resources for supervision and monitoring of the program activities from the beginning of the project.  There were problems in handling large inventories while managing the USAID/Nepal funded assets and distributing the PSI-branded left over commodities.  Selection of some partners by management was not clear in documents given for review. 41  The N-MARC approach  Catalytic effect and best practices  Lessons learned THE N-MARC APPROACH CATALYTIC EFFECT BEST PRACTICES AND LESSONS LEARNED 42 5. THE N-MARC APPROACH, CATALYTIC EFFECT, BEST PRACTICES AND LESSONS LEARNED 5.1 The N-MARC Approach N-MARC uses N-MARC’s Full Market Impact™ (FMI) model as a framework to achieve its objective. The FMI approach in Nepal has engaged multiple partners from the private commercial sector such as Nepal CRS Company, Gayatra Store Enterprises, Pioneer Trading, Praxis Trade Link, , Lomus Pharmaceuticals, CTL Private Limited, ANS Creation Pvt. Ltd, New ERA, and A. C. Neilson; (I)NGOs such as MITRA Samaj, ENPHO, and CSED; professional bodies such as EngenderHealth, FHI/ASHA, NFHP, NFCC; and the public sector including the DOHS, NCASC, LMD, CHD and NHEICC in comprehensive efforts that aim to increase the practice of healthy behaviors, and generate and fulfill demand for an affordable and accessible range of public health products and services. The leveraging of resources and expertise from partners of N-MARC has contributed to increased use of new products such as eCON and featured male and female condoms and existing health products such as Dhaal and Panther, CDK, Nava Jeevan, and Sangini services that have improved the condition of health of at-risk, economically deprived, hard-to-reach, and the most vulnerable people. The OCP 2009 research has clearly shown that increasingly more (35%) poorer section of the population has benefitted from the private sector franchising of health products and services compared to only 5 percent in 2006. 5.2 Catalytic Effect and Best Practices During meetings with key stakeholders that included government officials, project implementing partners (for-profit & not-for-profit), some social marketing organizations, and some donor agencies, the evaluation team did hardly hear directly of specific catalytic effects the N-MARC program has had so far. However, based on observations and discussions with these key stakeholders and key players in the sites, the evaluation team was able to note the beginning of several catalytic effects and some best practices set by the N-MARC program: a. Reaching ‘Hard-to-Reach’ Through Social Marketing N-MARC and the CRS Company's initiatives on social marketing practices in rural and remote mountain areas by recruiting Rural Field Representatives (RFR) marks a paradigm shift in retailing health and family planning products/services and to improve people's attitude towards condom usage and to increase its marketability in the hard-to reach villages. The RFR in the Lukla area follows the trekking trail to the Everest Base Camp via Namche Bazar, the gateway to Mount Everest for opening NTOs and also to educate people on HIV and AIDS. Similarly, distribution activities are being carried out simultaneously with the distributors and users motivational activities in the rural villages of some of the hill districts. They also use the word-of￾mouth approach in recruiting NTOs and attempt is also made by RFRs to ensure that false rumors are countered mitigated. Frequent revisits and resupply of the products is another major responsibility of RFRs. Besides interpersonal communication (IPC), several external motivational activities are undertaken, e. g. film showing, village posters, promotional activities in village market (Hat Bazaar) and local festivals, and distribution of give-aways (cap, umbrella, raincoat, t-shirts, key-chain, ball-pen, etc.) and promotional items (posters, stickers, flyers, booklets, etc.). 43 Expansion of social marketing in hard-to-reach areas is a strong step towards reaching out to the vulnerable and marginalized populations. It needs to be further strengthening by developing standard guidelines for BCC, product distribution and incentives as people have found out time and again that family planning can, indeed, be relevant to their needs. ‘Hard-to-reach’ approach has been introduced by N-MARC program in order to mobilize social marketing experts and volunteers in such areas where rural social marketing activities are needed to cater for underprivileged and unreached populations. b. Condom Kiosks run by Women N-MARC prioritized increasing access to condoms through opening NTOs and creating novel condom selling points. One example is woman-managed condom kiosk in Kailali. CRS has launched a new mobile condom-selling kiosk in Dhangadi with the hope of increasing accessibility to condoms. The kiosk moves around hot zones selling a variety of subsidized and commercial brands of condoms. CRS brands each kiosk with Panther imagery, and connects the kiosk owner to a commercial distributor. Women primarily are responsible for the kiosks, so this business opportunity offers them a chance to earn income. CRS has anecdotal evidence that more and more women are purchasing condoms from these mobile units. CRS has continued its innovative use of kiosks and mobile kiosks to expand accessibility to condoms in hot zones. In many areas of the country, CRS has created income-generating opportunities for women through the establishment of condom kiosks. Besides condoms, the women running kiosks sell noodles, shampoo, soap, and other household items. The uniqueness of N-MARC program is such an NTO having two objectives simultaneously – to empower women with income-generative activities such as selling condoms through the kiosk, and to create a platform to more women to purchase condoms at a convenient NTO. c. “You Are No Exception” Communication Campaign You Are No Exception short-films premiered in over 150 cinema theatres covering 70% of the country in the year 2008. This was followed by a promotional tour and Cinema on Wheels, a series of open-air screenings, where each film crew (including the celebrities involved) traveled to 22 high-risk districts along Nepal's east-west highway to interact with audiences and media. Overall it is estimated that nearly 200,000 individuals watched the films in person, with significantly more watching through television. N-MARC established a partnership with Nepal Investment Bank Limited (NIBL), a private financial institution, to sponsor the awards given to the top three directors in the You Are No Exception short film competition. NIBL provided Rs. two million (approximately $27,000) in funding to cover the costs of the top three directors to attend a three-month long film course in Mumbai, India. This short film competition can be considered as a milestone in private intervention for a social cause and a corporate social responsibility in fulfilling a social marketing need. 44 d. Local Manufacturing of Oral Contraceptives and Emergency Contraceptive In 2008, the project selected Lomus Pharmaceuticals to develop and introduce the first-ever oral contraceptives manufactured in Nepal. The Nepali manufacturing company provided the funds for product development and manufacturing, and received co-investment from USAID/Nepal for marketing and distribution. The products represent a new era of family planning in Nepal, as Nepali companies take up leadership roles to address the country’s family planning needs. Lomus launched a new portfolio of contraceptives: Femicon (COC), Feminor (ECP), and Femitrone (POP). N-MARC has also secured representation from Lomus Pharmaceuticals on both the National Safe Mother Subcommittee and National Family Planning Subcommittee, the first time a pharmaceutical company has represented to these national subcommittees. N-MARC has achieved a significant milestone for Nepal by supporting Lomus Pharmaceuticals in the manufacturing, marketing, and distribution of hormonal contraceptives. e. Sangini Network and Sangini Neighbourhood Program CRS, in partnership with NFCC, scaled up activities for its Sangini Social Franchise Network, which is primarily, composed of pharmacy-based health providers (midwives, nurses, and paramedics). CRS made a strategic choice against promoting the Sangini Network independently, and instead extended its product-focused communications activities with Sangini to do network promotions. Shop boards promoting the availability of Sangini were placed on outlets offering the service, with a particular focus on areas outside Kathmandu. Additionally, CRS developed a broad range of useful POP materials that would help to promote the concept of ‘quality’. These materials included a branded sharps container, logbook, and water bucket. Additionally, CRS developed new posters for ‘informed choice’ and ‘clients rights’ in Nepali for display at outlets. In order to extend accessibility of RH products and services in hard-to-reach areas, CRS has been expanding its Sangini Network in the country. The Sangini Network has increased to 2,784 providers in 69 districts by July 2009. f. “Healthy Highway” Program Partnering with N-MARC and its commercial partners, Center for Social and Economic Development (CSED) ensures proper and consistent use of condoms to prevent HIV/AIDS and STI’s among the MARPs of the East-West Highway from Jhapa to Kanchanpur with the main objective of increased awareness and accessibility of condoms in the project areas mostly at the hot zones. The program is launched focusing on two segments of target populations. The primary target groups includes males age 15-40 from lower to middle income groups comprising of mobile populations such as transport workers, whereas the secondary target groups comprise of sex workers and their clients. The Program conducts IEC/BCC activities in collaboration with indigenous local clubs, NGOs/CBOs to increase awareness on HIV/AIDS and STIs to educate the target groups for correct and consistent use of condom to prevent STIs and HIV and to ensures the amiability of condoms (socially marketed and full priced) using basket sales approach. 45 Some of the following promising results from CSED indicate that private sector organizations can also greatly contribute to the improvement of health sector in Nepal. During the project period the following major activities were carried out by CSED:  Established 4,500 Non Traditional Outlets (NTOs) to supply various brands of condoms to transport workers and the general population across the East-/West Highway.  Educated 5,000 transport workers (through group and IPC approaches) on HIV/AIDS stressing correct and consistent use of condoms.  Distributed 600,000 units of condoms of which 72 % comprised of social marketing and 28 % commercial sector products. 5.3 Lessons Learned N-MARC has learned a great deal about working with the private sector and the applicability of commercial marketing techniques for promoting social products and services. The following lessons are entirely based on available reports, site visits, discussions with key stakeholders and major social marketing players. 1. There is the need of redefining the goals of Social Marketing. Nepal's demographic imperatives call for addressing RH needs of growing adolescents and youth. Fast increasing demand for eCON indicates that marketing of FP products alone is not sufficient; there is a need to include diverse health products along with the expansion of basic RH products like contraceptives. 2. The purpose of distributing products through multiple partners was filling the existing demand in the market. For instance, expansion of commercial sector increases choices for consumers and helps them to satisfy their varied needs. The lesson learned is that the engagement of multiple partners contributes to increasing choice and fulfilling consumer varied demands. This is also supported by the increased share of commercial sector over the years in the total sales of condoms. 3. Expanding distribution to include commercial outlets (TOs and NTOs) increases accessibility and product use. Introduction of the concept of “hot zones” by N-MARC has brought RH products closer to consumers particularly the high-risk groups. This approach has addressed the need of the most-at-risk populations. 4. Attractive packaging, product image and improved product attributes such in case of condoms dotted and flavored features are important in generating demand for RH products. This is true regardless of product price. The commercial marketing of condoms is the case in point. 5. In urban and semi-urban areas the sales of RH products increase through TOs and NTOs but in the rural areas sales do not increase without any special approach; it needs different approaches and strategies than in the urban areas. Therefore need exists to balance focus on increasing sales with reach into remote areas. The Rural Field Representative mobilized by CRS is a step in the right direction. 46  Conclusions  Recommendations to improve the intended impact of the project CONCLUSIONS AND RECOMMENDATIONS 47 6. CONCLUSIONS AND RECOMMENDATIONS 6.1 Conclusions USAID/Nepal entrusted N-MARC to meet the goal of the PSP N-MARC project through social marketing and social franchising programs in Nepal. The goal of N-MARC was to expand the depth, reach, and impact of the private sector in family planning (FP), maternal and child health (MCH), and HIV/AIDS prevention. N-MARC teamed up with PSP partner EngenderHealth to provide the technical assistance and capacity-building necessary to make these health achievements sustainable through local institutions. N-MARC, however, did recognize USAID/Nepal’s desire for a transition to local leadership and sustainability. The N-MARC project partnership dynamics included ASHA and NFHP- the USAID project partners; and CRS, NFCC and MITRA Samaj as core N-MARC local partners. MITRA Samaj worked as a mediator for commercial partners and CSED. The partnership dynamics is the combination of public sector, USAID/Nepal, NGOs and the private sector. These partners have played complementary roles. The private sector or the commercial companies teamed up with N-MARC to achieve sustainable health marketing initiatives. The partnership dynamics is the manifestation of N-MARC FMI approach. The FMI approach addresses four components of a cross-sectoral, integrated implementation plan, and has three areas of expected impact. The first component i.e., product/supply has to do with the increase in the supply of FP, MCH, and HIV products by helping partners in the private, NGO, and public sectors introduce new products and brands. N-MARC strongly supported the Nepal CRS company and at the same time stimulated the commercial sector to invest in health products and services on a competitive basis. The second component, i.e., price/affordability has been well addressed by N-MARC because through social marketing some RH commodities and services are subsidized to ensure that the poor are not barred from accessing products and services while at the same time the commercial sector has made full priced commodities widely available in markets to meet the choice of people who can afford them. Place/distribution of commodities and services is the third component which has ensured that the NGOs and the private sector reach key groups including hard-to-reach group to access RH products and services. The fourth component, i.e., promotion/demand approach has been addressed by using BCC (communication strategies and activities) approach to reach specific target groups. Also, N-MARC used “matching funds” approach to encourage the commercial sector to expand its market to the poorly served areas. The three areas of expected impact include equity, commercial viability and sustainable public health impact. The social marketing approach implemented by the CRS Company has contributed to ensuring equity as the products are subsidized and increasing number of socially disadvantaged section of the society benefit from these products; one of the research studies has also shown that of late N-MARC and its partners’ activities have increasingly benefitted the poor now compared to five years ago. However, it is not known which section of the society whether rural or urban section benefitted more from this. N-MARC project activities have shown that RH products and services are commercially viable; the “joint risk, joint investment” from the commercial sector has been successful. Implementation of integrated program addressing each of the above components has helped to meet the needs of varied sections of the populations including the neediest group. Assessment of the effectiveness of the N-MARC project indicates that overall N-MARC and its partners were effective in achieving the intended results in the four-year project period. The CYP was increasing over the years despite some turbulent times. Other RH products such as Nava 48 Jeevan sales met the targets. N-MARC’s partners provided product and behavior change support to the MoHP’s response to the outbreak of diarrhea in Jajarkot and surrounding districts. N-MARC designed and implemented a public private partnership for the rationale treatment of diarrhea under the leadership of CHD. Sales of CDK were however lower than expected because of the government policies of monetary incentives to women delivering in a health facility. Piloting of Matri Surakcha Chakki (Safer Motherhood Pills) in Bardiya has been successful. N-MARC and its partners were successful in encouraging the commercial sector to promote and market condoms which resulted in increasing the share of the commercial sector in the overall market. Following difficult times working with PSI, CRS is now back on track in its social marketing of RH products and services after the implementation of N-MARC project. PPP is seen as ‘win-win’ arrangement in which different actors with varied motivations and philosophies work together, and are able to contribute to health development. In line with the PPP objectives N-MARC has involved ‘for-profit’ and ‘not-for-profit’ organizations together in the health sector. The project made intensive efforts for collaboration and networking with public as well as private sectors. Despite good achievements overall, there are certain issues that need to be mentioned here. N-MARC’s good intention of stimulating the commercial sector to engage in health sector development activities has encouraged the trade houses to engage in marketing of health products but at the same time the social marketing sector finds it uncomfortable to see this happening. This situation could not have arisen should N-MARC have made efforts for better coordination among its social and commercial marketing partners. Results data over the project period show good achievements nevertheless some of the data shown in various reports and documents lack consistency, uniformity and conformity. The selection process of some organizations for partnership was not found accountable in terms of organizational strength, track records, relevancy of organization and composition of evaluators. Monitoring and supervision of partners’ activities in the fields by N-MARC has been found weak. Despite the shortcomings observed during field visits, monitoring and supervision of field activities, and some lapses in management and reporting, it was found that the N-MARC program has been found effective in achieving its expected results. Some of the achievements such as PPP, social franchising and support to CRS in its social marketing efforts are noteworthy of N-MARC project. USAID/Nepal’s contribution to strengthen PPP policy in health sector in Nepal through N-MARC for the development of local leadership is commendable and USAID/Nepal should further continue such endeavor. 6.2 Recommendations to improve the intended impact of the project Based on the analysis of information from project reports, research studies, key informant interviews, field visits the following sets of short and long-term recommendations are made to improve the intended impact of the project: 6.2.1 Short-term recommendations  All partners should work together to set targets for project implementation period. Targets should be set in such a way that achievements do not cross 100 percent and if they do reasons should be found.  One of the main objectives of N-MARC project is to increase access to low income groups. Current PMP do not tell whether project implementation is progressing towards 49 achieving this goal. Therefore it would be wise to prepare PMP by stratifying by residence, i.e. rural and urban.  N-MARC should strengthen its monitoring activities to ensure that expired products are not sold by its partners. Expired condoms need to be withdrawn from the market particularly Number 1 condom and some other condom brands marketed by the commercial partners.  N-MARC should thoroughly check data for consistency and correctness while reporting, and uniformity in reference periods.  N-MARC should extensively promote pills. Research has shown that pills are liked by young women as they help to address anemia and can be stopped any time children are wanted.  Despite a lot of training GoN into Sangini Network providers the quality of service does not seem to have improved much; women take Sangini even at the cost of low quality service because it has become popular. N-MARC should address this issue immediately.  Inquiring with the Sangini service providers in TOs in the nine districts the evaluation team members visited, most said that they are interested to administer IUD and Implant/Jadelle and they also mentioned that the local women demand IUD/Jadelle. Therefore, it is urgent that these demands are met and these two methods are also made locally available. Simultaneously, promotional activities should be considered for IUD and implants (Jadelle).  There is a need to improve the quality of CDK. In addition to new packaging design and proposed addition of CHX, CDK should include a pair of gloves and scissors (instead of blade) and clamp instead of string. CDK should be marketed in rural areas, not in urban or semi urban areas where birthing is possible in health facilities.  Matri Ssurakchha Chakki (Safe Motherhood Pill) should be focused more in rural areas.  Any intended implementing partner should be selected on the basis of but not limited to, relevancy, organizational strength, track records and through free competition. The proposal evaluation team must consist of not only in-house members but also external experts. 6.2.2 Long-term recommendations for the direction of USAID/Nepal's social marketing and social franchising program  It is recommended that USAID/Nepal extend its support through US TA agency such as N-MARC to the government of Nepal in formulating a national policy on social marketing.  Given that demand for condoms is ever increasing and it is met from external assistance, it is now time for CRS Company to consider manufacturing condoms in the country.  Demand for ORS is high and Jeevan Jal is the patent of The Nepal Drug Company which does not manufacture it anymore but Jeevan Jal has become a generic name for ORS. Instead of changing the name of ORS from time to time it would better for a company 50 like CRS to consider manufacturing Jeevan Jal by seeking permission from the concerned Ministry.  N-MARC should encourage CRS to enter into commercial sector as well. However this step must not discourage the commercial sector already in business. The new wing can generate income which can be used to cross subsidize social marketing of health products and services and their expansion to rural areas.  Growth of CRS calls for quick assessment of its strength and weaknesses, its structure, rights and responsibilities of its Board Members and their composition. The Business Plan prepared by MART should be reviewed in this respect and some of its important recommendations should be taken into account for growth and strengthening of CRS.  In order to monitor achievements or failure of a program over time and to offer actionable recommendations on all aspects of management for the improvement of program, annual management audit is highly recommended for future technical assistance programs supported by USAID/Nepal.  The lessons learned were that when USAID/Nepal supported PSI it almost wiped out CRS but when this phase was over and N-MARC took over CRS began reviving. Perhaps USAID/Nepal should be clear on what strategies should be taken to help CRS sustain in future. 51 N-MARC. No date. “GIS Mapping of Franchising Network Product Service Performance and Coverage in Nepal: Nepal Social Marketing and Franchising Project: AIDS, Reproductive Health, and Child Survival (N-MARC)”. Kathmandu. _____________________. 2010. “Nepal Social Marketing and Franchising Project: AIDS, Reproductive Health, and Child Survival (N-MARC)”. Presentation by Peter Oyloe. Kathmandu. January. _____________________. 2009. “N-MARC Zinc Promotion Campaign”. Kathmandu. December. _____________________. 2009. “OCP Market Research Survey”. Kathmandu. _____________________. 2009. “Levels and trends in condom coverage in HIV risk zones of Nepal. A GIS study for measuring product performance and strategic planning”. Kathmandu. December. _____________________. 2009. “Annual Report 2008/09”. Submitted to USAID/Nepal. _____________________. 2008. “Annual Report 2007/08”. Submitted to USAID/Nepal. _____________________. 2007. “Annual Report 2006/07”. Submitted to USAID/Nepal. Contraceptive Retail Sales Private Ltd. “Data Sheet”. 2010. Kathmandu. Isaacson, J. M., Christa A. Skerry, Kerry Moran and Kay M. Kalavan. 2001. “Half-a-Century of Development: The History of U.S. Assistance to Nepal - 1951-2001”. USAID, Kathmandu, Nepal. New ERA. 2009. “A Follow-up Study on ‘You are No Exception’ Campaign among Most at Risk Groups in Hot Zones in Nepal. Final Report”. Submitted to AED. Kathmandu. October. Ministry of Health and Population (MoHP). 2009. “Let’s Know Our Epidemic”. National Centre for AIDS and STD Control. Government of Nepal, Teku, Kathmandu. _____________________. 2008. “Annual Report 2006/07”. Department of Health Services. Government of Nepal, Kathmandu, Nepal. _____________________. 2007. “Nepal Demographic and Health Survey 2006”. New ERA and Macro International Inc. Ministry of Health (MoH). 2002. “Nepal Demographic and Health Survey 2001”. Kathmandu, Nepal and Calverton, New ERA and ORC Macro, DHS+, Maryland, USA. _____________________. 1993. “Nepal Fertility, Family Planning and Health Status Survey, 1991”. Kathmandu, Nepal. _____________________. 1987. “Nepal Fertility and Family Planning Survey Report 1986, First Report.” Family Planning and Maternal Child Health Division, Planning Research and Evaluation Section, Kathmandu, Nepal. _____________________. 1983. “Nepal Contraceptive Prevalence Survey Report, 1981”. Nepal FP/MCH Project, HMG and Westinghouse Health Systems. _____________________. 1977. “Nepal Fertility Survey 1976. First Report”. Nepal Family Planning and Maternal and Child Health Project, World Fertility Survey. Kathmandu. Pradhan, A, Aryal, R. H., Regmi, G., Ban , B. and Govindasamy, P. 1997. “Nepal Family Health Survey 1996”. Kathmandu Nepal and Calverton, Maryland. USA. BIBLIOGRAPHY 52 The Timeline agreed upon by USAID/Nepal for the Evaluation of USAID/Nepal's Key Social Marketing and Franchising Project: AIDS, Reproductive Health, and Child Survival (N-MARC) is as follows: Date Program January 04, 2010 Signing Ceremony at USAID/Nepal January 05, 2010 Documents to be made available January 06-10, 2010 Document Review January 11-12, 2010 Team Planning Meeting Preparation January 13-14, 2010 Team Planning Meeting January 15, 2010 Preparation for Interviews and Field Studies January 17-19, 2010 Interviews & Discussions with Key Stakeholders (AED, CRS, NFCC, MITRA Samaj and some government agencies) January 20-27, 2010 Field Studies at Project Implementation Sites January 28-Feb 01, 2010 Interviews & Discussions with Partners (USAID/Nepal Social Marketing Team, KfW, ASHA, CSED, PSI, MSI, Gayatra Store Enterprises, Praxis Trade Link, Pioneer Trading and some government agencies) January 31- February 10, 2010 Compilation of Interview Reports & Field Study Reports February 11, 2010 USAID/Nepal Debriefing February 15-19, 2010 Draft Reporting Writing February 22, 2010 Draft Report Submission March 08, 2010 Feedback/Comments from USAID/Nepal March 09-14, 2010 Draft Report Revision March 15, 2010 Final Report Submission APPENDIX I TIMELINE 53 Title: Evaluation of USAID/Nepal's Key Social Marketing and Franchising Project: AIDS, Reproductive Health, and Child Survival (N-MARC). Statement of Work (SOW): Purpose: This is a Statement of Work (SOW) for the final evaluation of USAID/Nepal's key Social Marketing and Franchising Project: AIDS, Reproductive Health, and Child Survival (N-MARC). The evaluation will focus on N-MARC's progress in meeting the program objectives and goals. The SOW evaluates the key expected activities of N-MARC based on the project design and annual work plans. The results of this evaluation will then inform the USAID/Nepal Office of Health and Family Planning (O/HFP) about N-MARC's success and weaknesses and beast practices and lesson learned. Additionally, the evaluators must provide suggestions for future social marketing and social franchising programming needs inclusive of clear and appropriate program directions based on the Nepali context. Background: USAID's primary partner in Nepal for social marketing and social franchising technical assistance is currently Academy for Educational Development (AED). The existing social marketing program is national in scope and is a fully integrated program in which all components are coordinated, inter-linked and mutually supportive of USAID/Nepal's and Government of Nepal (GON) health goals. AED has been implementing this program since July 2006. USAID/Nepal has contracted with AED through a task order under the Private Sector Project indefinite quantity contract (IQC) for a program called N-MARC, to support social marketing of family planning, maternal and child health, and HIV/AIDS prevention products and services. N-MARC promotes social marketing in Nepal by: 1) building the technical and organizational capacity of social marketing organizations such as the Nepal Contraceptive Retail Sales Company (CRS), 2) encouraging commercial players to expand sales of health products to reach a broader range of incomes segments within target populations, 3) promoting the appropriate use of maternal and child health, family planning and HIV/AIDS prevention products, and 4) ensuring the quality of family planning services and products in the social marketing sector. The commodities that are being sold through N-MARC include contraceptives, clean home delivery kits, oral rehydration salts and Zinc for diarrhea, sexually transmitted disease treatment kits, emergency contraceptives pills, pint of use water disinfection and Virex® - a surface disinfectant for surgical instruments used in voluntary surgical contraception. N-MARC aims to market subsidized quality health products to lower income groups willing and able to pay a small amount for valued health products, and to ensure they are available when and where they are needed. A strong, healthful behavior change component underpins product marketing in the N-MARC strategy. The N-MARC task order ends in June 30, 2010. APPENDIX II STATEMENT OF WORK 54 N-MARC Project's result areas:  IR-1 Increase the use of high-quality family planning products and services by target groups through private sector health providers.  IR-2 Increase the quality, supply and use of maternal and child health products and services among target groups.  IR-3 Increase HIV/STI prevention practices, products and services among the most-at-risk groups.  IR-4 Increase the capacity of local partners to design, implement, manage and sustain state￾of-the-art social marketing and social franchising programs.  IR-5 Increase the collaboration between private sector, USAID partners and Government of Nepal (GON) public sector health services in family planning, maternal and child health and HIV/STI prevention. Other Major Social Marketing Players in Nepal: Since mid- 2006, Population Services International (PSI) has focused on implementing a GFATM malaria project in conjunction with the Epidemiology and Disease Control Division of the Department of Health Services/MOHP. PSI has recently received funding from a large anonymous donor to implement social marketing, which they are planning to do through their branded Sun Quality Network, a social franchise network created by PSI with USAID funding. In March 2009, PSI presented their General Operational Plan for a public-private partnership with the MOHP. They aim to improve rural demand and access to quality, long-term contraceptive family planning services (intra-uterine devices, implants, comprehensive abortion care and medical abortion) through public and private providers. Specifically, PSI plans to improve remote areas services for intra-uterine devices and implants. Currently, PSI does not intend to re￾introduce their No.1® condom brand or other short-term family planning products in Nepal. Marie Stopes International (MSI) is a social marketing organization that operates through their locally registered NGO, Sunaulo Pariwar Nepal. MSI supports clinics and mobile camp operations where they offer voluntary surgical contraception, comprehensive abortion care, medical abortion, Depo-Provera®, their own brand of oral contraceptives and Jodi® brand condoms. They expect the upward sales trends of Jodi® condoms, targeted to an upper middle class market, will reach profitability in the medium-term, with eventual cost-recovery. Their goal is to use the revenue generated to cross-subsidize their clinical services. Jodi® condoms are sold from 61 MSI clinics, mobile camps, youth-friendly service centers and six kiosks on the border with India. Over 600 sales promoters are reaching traditional and on-traditional outlets in over 65 districts. MSI's oral contraceptives are at a middle level price range, with good primary sales and unknown secondary sales. MSI is interested in diversification and is examining the possibility of adding voluntary HIV/AIDS counseling and testing services at their clinics. MSI has one clinic in the remote mountain district Jumla. Otherwise, to-date their clinics are all in more accessible hill and Terai districts. MSI plans a gradual extension into remote locations. Social Marketing and Distribution (SMD) was formed in 1998, by an ex-member of the Contraceptive Retail Sales Company (CRS) management, to offer marketing expertise to other organizations and to distribute products for sale. It has filled a niche as a small and maneuverable social marketing organization. During its history it has worked with UNICEF and national Salt Trading in distribution of iodized salt and again for UNICEF in the distribution of soap and support to the hand-washing component of the Hygiene Improvement Project. They were also involved in the production or distribution of peace stickers, during the conflict period. SMD distributed and sold subsidized condoms for PSI to most-at-risk populations in designated hot zones. 55 Commercial companies: N-MARC mentored three companies, Gayatra Enterprise, Praxis Tradeline and Pioneer, in the incorporation of social marketing principles into their commercial marketing strategies. They achieved successful condom sales, possibly in part due to their sensitization to social marketing principles. Another two companies are engaged in the sale of health products and are aware of social marketing principles. Lomus is marketing three types of family planning contraceptive pills, including two oral contraceptive pill brands and one emergency contraceptive pill. Hukum is preparing to market an ORS product. All five of these companies are expressly commercial have no known interest to reorient their identities from commercial to social marketing. Methodology: The evaluator must use a wide range of methods and approaches for collecting and analyzing the information with will be required to assess the evaluation objectives and answer the presented questions. The evaluators must review the suggested background list and perform key informant interviews provided in this purchase order. The evaluators must perform site visits and conduct team planning meetings. Data collection methodologies must be discussed with and approved by USAID prior to the stat of the evaluation. To the extent possible, the approach taken to the evaluation must be positive and participatory. The outcome of the evaluation must be three-fold 1) present results towards targets 2) provide a set of recommendations to improve the intended impact of the project and 3) present long-term recommendations for the direction of USAID/Nepal's Social Marketing and Social Franchising program. The team must conduct a tow-day team planning meeting (TPM) before starting the evaluation. The TPM must review and clarify any questions on the SOW, draft an initial work plan, develop a data collection plan, finalize the evaluation question, develop the evaluation report table of contents, clarify team members' roles and responsibilities, and assign drafting responsibilities for the evaluation report. TPM outcomes must be shared with USAID/Nepal and the health team will participate in sections of the TPM, as appropriate. Team Planning Meeting: The evaluation team leaders, assisted by the two evaluation members, must facilitate and conduct a two-day team planning meeting before starting the evaluation. USAID/Nepal's focal person will participate in the two-day team planning meeting. The agenda will include, but not be limited to the following items;  Clarify team members' roles and responsibilities;  Establish a team atmosphere, share individual working styles, and agree on procedures for resolving differences of opinion;  Finalize a work plan for the evaluation;  Review and develop final evaluation questions;  Review and finalize the assignment timeline and share with USAID;  Finalize data collection plans and tools;  Review and clarify and logistical and administrative procedures for the assignment;  Develop a preliminary draft outline of the team’s report; and  Assign drafting responsibilities for the final report. Team Compositions: The evaluation team consists of three experts, including one team leader. The team leader is responsible for selecting the additional two local experts and has consulted with the USAID/Nepal health team. 56 Team Leader: The team leader for this evaluation work is Dr. Yagya Bahadur Karki a local senior level evaluator with experience in the Asia region. Particular expertise and experience includes the following:  Strong monitoring and evaluation experience in public health activities;  Strong knowledge of Social Marketing and Social Franchising and public/private partnerships;  Prior experience as the leader of an international project evaluation;  Expertise in program monitoring and evaluation;  Strong team management and supervisory skills working with diverse populations with differing opinions;  Demonstrated strong cross-cultural communication skills;  Demonstrated lead writer with strong technical writing (in English) skills;  Experience working with a range of government officials, local NGOs, private and public sector enterprises in project implementation and management;  Experience implementing activities in a post-conflict setting;  Ability to travel and work for short durations in challenging environments; and  The team leader must supervise the local experts. Local Expert (first): The first team member of this evaluation work is Mr. Khagendra Adhikary having sound knowledge and expertise of Social Marketing and the Social Franchising situation in Nepal and in the region. Particular expertise and experience includes the following:  Having strong behavioral communication initiative expertise and will be required to take special attention to branding/marking and communication activities implemented by N￾MARC. Extensive experience and in-depth local knowledge of Social Marketing and the Social Franchising in Nepal in a plus;  Demonstrated strong technical and analytical skills;  Strong monitoring and evaluation experience;  Strong team skills working with diverse populations with varying opinions;  Strong written and verbal communication skills (in English);  Responsible for organizing meeting/site visits with key commercial sector partners and government counterparts;  Ability to manage general logistics;  Ability to translate select documents and interviews;  Ability to travel and work for short durations in challenging environments; and  The local expert must work under the supervision of the team leader Local Expert (second): The second team member of this evaluation work is Dr. Ashok Dev Pande also having sound knowledge and expertise of Social Marketing and the Social Franchising situation in Nepal and in the region. Particular expertise and experience includes the following:  Having extensive marketing skills required to pay special attention to marketing and public/private partnership activities implemented by N-MARC;  Extensive experience and in-depth local knowledge of Social Marketing and the Social Franchising in Nepal;  Strong monitoring and evaluation experience;  Demonstrated strong technical and analytical skills;  Strong team skills working with diverse populations with varying opinions; 57  Strong written and verbal communication skills (in English);  Responsible for organizing meeting/site visits with key commercial sector partners and government counterparts;  Manage general logistics;  Translate select documents and interviews;  Travel and work for short durations in challenging environments; and  The local expert must work under the supervision of the team leader Scope of Work: The overall objective of this evaluation is to assess the effectiveness of the N-MARC project, document how best the N-MARC approach is making a difference in the National Social Marketing and Social Franchising activities, document best practices, inform and recommend on the future long-term Social Marketing and Social Franchising programming directions of USIA/Nepal. The evaluation team must consider, but not be limited to the following illustrative questions: 1. Overall result areas:  Was N-MARC effective? If so, how and why? And if not, how and why?  To what extent did the N-MARC project achieve results?  Describe shortcomings and why they happened and what could be done in the future to prevent them?  Where there achievements outside of result areas? If so, what are they?  In terms of future programming, are there result areas that are not longer relevant? If so, please elaborate.  Are there new or emerging result areas that USAID/Nepal should consider adding to a future social marketing program? If so, what is USAID/Nepal’s comparative advantage in these result areas, and with what other organizations would USAID/Nepal collaboration to address them?  What are these specific result areas and what illustrative measurable indicators should USAID/Nepal use to monitor and evaluate impact? 2. Planning, implementation, monitoring and reporting:  Were the monitoring and evaluation framework and indicators relevant to the program objectives and in-line with USAID/Nepal standard indicators? If not, what would be more relevant?  Were all of the annual work plans, relevant to the approved N-MARC program description?  Are work plan activities sufficiently reported in the semi-annual and annual technical reports?  Are key activities missing or under-reported? Is there sufficient monitoring and reporting of compliance with USG regulations concerning activities?  Were N-MARC’s monitoring systems sufficiently robust to adequately monitor the quality of activities conducted by sub-recipients and their compliance with USG regulations? How could they be strengthened without compromising the reach of the program? 58 3. Management systems:  What are the strengths and weaknesses in the project management structure and systems? What could have been done to make them stronger and build capacity of Nepali staff to manage technical and administrative functions?  Were the structure and management systems of the technical units relevant to the overall program objectives and results? How could they be improved?  Was the management of USAID assets strong and compliant with USG regulations?  Was there adequate understanding and compliance with branding and marking regulations?  In terms of financial management, are internal controls strong, transparent and accountable?  Was the management and oversight of awards to sub-recipients strong, accountable and compliant with USAID regulations?  Was the management of core sub-recipients strong, accountable and effective? N-MARC project evaluation team must: 1. Review N-MARC project documents; 2. Work plans; 3. M & E plan; 4. Annual and semi-annual reports; 5. Performance monitoring plan; 6. Demobilization plans; 7. Marketing plan; 8. Capacity building and collaboration plans; 9. BCI plans, campaigns and other N-MARC related technical documents and studies; 10. Interview key stakeholders, donors, government counterparts and implementing agencies; 11. Interview N-MARC key staff; 12. Interview USAID/Nepal Social Marketing team; 13. Conduct specific field visits and observe the activities in action; 14. Organize a preliminary presentation to USAID/Nepal Social Marketing team; 15. Review additional documents/reports made available by the Health Team; and 16. Submit a draft and final report to be reviewed by USAID/Nepal. Timeline and Level of Effort (LOE): USAID/Nepal anticipates that the preparation days, in-country work including site visits, as well as drafting and finalizing the evaluation report is completed according to the following illustrative level of effort (LOE). A 6- day work week is authorized. The LOE for this assessment must not to exceed the number of days as stated below: Task LOE (days) Document review/preparation 4 Team planning meeting (in KTM) 2 Interviews and discussion with key stakeholders 6 Field studies at project implementation sites-possible 2-3 flights and car rental involved 8 USAID/Nepal debriefing 1 Draft report writing 5 Report revisions, based on Mission comments 2 Total consultation LOE 28 (team leader) 28 (first team member) 28 (second team member) 59 The above tasks are to include adequate time for consultations, exchanges of findings, team planning, report preparation and discussion with USAID/Nepal staff. The evaluation must be completed in and around 6 weeks, including preparation days, all in-country work, report writing and finalization. Then the evaluation team must do the final editing and formatting and submit the final report to USAID/Nepal in additional three weeks time. Terms and Conditions of the Consultancy: The evaluation team must sign a non-disclosure agreement, inclusive of not being part of any potential future bid related to this work, with USAID/Nepal. Logistics: This evaluation team must make all logistical arrangements such as flight reservations for in￾country travel, airport pick-up/drop, lodging and meetings and as per the associated costs that the evaluation team submitted on 24 November 2009. The valuation team must arrange and pay for their own transportation, communication and administrative support. The evaluation team must travel to the districts and project sites to visit in consultation with USAID/Nepal staff. The evaluation team must arrange and pay for their air tickets, hotels and food that is included in the total amount of this PO. The team leader must arrange and pay for all logistics for the first and second tam members that are included in the total amount of the PO. The team leader must pay the first and second team member’s remuneration according to their daily rates for their evaluation work. USAID/Nepal HFP Office will provide key documents and background materials for reading and help arrange the in-briefing and debriefing. Exact participation of USAID/Nepal will be determined after the selection of the consultants, but someone from USAID/Nepal may accompany in key meetings with Senior GON officials and select stakeholders and possibly attend some field visits. The USAID/Nepal HFP staff will provide contacts for meetings and a list of the suggested site visits for the team to arrange meetings. Deliverables: The outcomes must be a full written report, a summary of progress to-date, a set of recommendations to improve performance and overall project impact for the current activity, and recommendations for possible future directions for USAID/Nepal’s social marketing activities. All deliverables mentioned below shall be received, inspected, and accepted by the assigned USAID/Nepal Activity Manager. The evaluation team is responsible for the following deliverables: 1. Two-day planning meeting documents: The team leader must submit to USAID/Nepal for approval on day two of the tow-day initial planning meeting a finalized work plan for the evaluation, finalized data collection plans and tools, finalized format of the draft final report including table of contents, defined roles and responsibilities of team members, including agreed upon writing responsibilities for the final report. 2. Mission in-briefing and final debriefing: The evaluation team must conduct an in-briefing with USAID/Nepal Social Marketing mangers as part of the two-day initial planning meeting, and a final debriefing. The evaluation team must conduct a final debriefing with USAID/Nepal and include the presentation of main findings and recommendations. The presentation must include an oral presentation and discussion with all team members, a CD-ROM with the Power Point presentation, a hard copy of the presentation and a hard 60 copy draft final report. The debriefing must also include a separate ‘sensitive but unclassified’ annex that contains sensitive information that must not be published in an open, public document, but must contain important information for USAID/Nepal’s internal use. 3. Draft Report: The first draft of the final evaluation report is due after the full team’s debriefing at USAID/Nepal so that comments and feedback can be incorporated into the draft report that will be left with USAID/Nepal. The draft must conform to the agreed upon format and include findings, conclusions and recommendations, as well as annexes with additional reports, copies of data collection tools, lists of key informants, etc. USAID/Nepal will review and provide one set of comments to the draft report within 10 working days upon receipt of the draft report. 4. Final Report: The final evaluation report must be submitted within 5 working days after the evaluation team receives comments from USAID/Nepal. Once the report is reviewed and accepted, a print-ready version must be reviewed in final before publication. Any procurement sensitive information or future directions recommendations will be removed from the public report and provided to USAID/Nepal as an Internal Memo for USAID/Nepal Use only. Payment The payment will be made upon successful completion, submission, revision and acceptance of the required deliverables by HFP Office of USAID/Nepal Payment will be processed by the Mission Controller, USAID/Nepal on submission of SF-1034 voucher and completed receiving and inspection reports by the HFP. The payment shall be made in equivalent local currency. List of Preparatory Materials: USAID’s Private Sector Program IQC Performance Monitoring Plan (PMP), USAID/Nepal’s PMP, USAID/Nepal’s Combined HIV/AIDS work plan, national strategies, guidelines and reports for Nepal’s national health programs are available through the following links. They include: “Private Sector Program IQC Performance Monitoring Plan.” Please refer to the following URL for this document: http://www.pspiqc.org/ “USAID/Nepal’s PMP for Health and Family Planning.” Please refer to the following URL for this document: http://www.pspiqc.org/ “His Majesty’s Government of Nepal’s National HIV/AIDS strategy.” Please refer to the following URL for this document: http://www.ncasc.gov.np/ Selected Publications and Reports “National Estimates of Adult HIV Infection 2003.” Please refer to the following URL for this document: http://www.ncasc.gov.np/ Select Publications and Reports. “National STI Case Mangement Guideline.” Please refer to the following URL for this document: http://www.ncasc.gov.np/ Select Publications and Reports. “The National Action Plan for HIV/AIDS Control (2005-2006).” Please refer to the following URL for this document: http://www.pspiqc.org/ 61 “USAID/Nepal’s HIV/AIDS Strategy- Updated 2004.” Please refer to the following URL for this document: http://www.pspiqc.org/ “The National Reproductive Health Strategy 1998.” Please refer to the following URL for this document: http://www.pspiqc.org/ “The National Medical Standards for Reproductive Health, Vol. 1. “Contraceptive Service,” (2001) and Vol. II “Other RH Services” (2003).” Please refer to the following URL for this document: http://www.pspiqc.org/ “The National Reproductive Health Clinical Protocols 1999.” Please refer to the following URL for this document: http://www.pspiqc.org/ “The National Behavior Change Communications (BCC) Strategy for Family Planning and Maternal and Child Health.” Please refer to the following URL for this document: http://www.pspiqc.org/ List of Key Stakeholders and Partners: SN Organization Person to interview Designation Contact 1 DOHS Dr. Yasho Vardhan Pradhan DG dg@dhs.gov.np Tel. 4261436 2 NCASC Dr. Krishna Kumar Rai Director Tel. 4261653 3 FHD Dr. Naresh Pratap K.C. Director Tel. 4262155/4262273 4 CHD Dr. Shyam Raj Upreti Director Tel. 4261660 5 LMD Dr. Mingmar G. Sherpa Director doctor_mingma@hotmail. com Tel. 4261653 6 KfW Ms. Shanker Raj Pandey Local Expert kfwnepal@wlink.com.np Tel. 5523228 7 FHI/ASHA Ms. Jacqueline McPherson Country Director Jackie@fhi.org.np Tel. 4437173 8 CRS Company Mr. Krishna B. Rayamajhi Managing Director kbr@crs.org.np Tel. 4362097 9 NFCC Dr. Tika Man Vaidhya Executive President tmv@mos.com.np Tel. 5523885/5527377 10 MITRA Samaj Mr. Deepak Bajracharya Executive Director mitranepal@wlink.com.np Tel. 5013027/5521715 11 CSED Mr. Rajendra Rimal Project Coordinator info@csed.org.np Tel. 4353538 12 PSI Mr. Andrew Boner Country Representative Andrew@psi.org.np Tel. 4377471/4377472 13 MSI Ms. Kamala Thapa Tel. 4419371 14 Gayatra Enterprise Mr. Bhaskar Chapagain Managing Director info@gayatrastore.com Tel. 4434380 15 Praxis Mr. Himal Nath Adhikari Chairperson info@praxistrade.com Tel. 2160217 16 Pioneer Mr. Punit Sarda Director Tel. 021-530935 62 Purchase Order Clauses: This purchase order incorporates one or more clauses by reference, with the same force and effects as if they were given in full text. Upon request, the Contracting Officer will make their full test available. Also, the full text of a clause may be accessed electronically at this/these address(es): http://www.arnet.gov/ Executive Order on Terrorism Financing (Feb. 2002): The Contractor/Recipient is reminded that U.S. Executive Orders and U.S. law prohibits transactions with, and the provision of resources and support to, individuals and organizations associated with terrorism. It is the responsibility of the contractor/recipient to ensure compliance with these Executive Orders and laws. This provision must be included in all subcontracts/ sub awards issues under this contract/agreement. Part 52- Solicitation Provisions and Contract Clauses: Type of Contract ……………………………......... 52.216-1 Drug-Free Workplace ……………………………….. 52.223-6 Availability of Funds …………………….. 52.232-18 Prompt Payment ……………………………………….. 52.232-25 Changes-fixed-price ………………………………… 52.243-1 Termination for Convenience of the Government (Fixed-price) ………… 52.249-2 Excusable Delay ………………………………….. 52.249-14 63 Dr. Yasho Vardhan Pradhan, Director General, DoHS, MOHP, Teku Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to DG. Issues to discuss:  Government policy on private sector development  N-MARC  Level of involvement of government in implementing projects/programs of N-MARC and partner organizations  How is the government involved and to what extent  What level of contribution is N-MARC project making in achieving government health goals o In contraceptive distribution o Child health service products o Maternal health service products o STI/HIV/AIDS  Would you say that N-MARC project is effective in meeting the needs of target groups in FP, child health, maternal heath/products, HIV/AIDS? o If yes, how? o If no, why?  What about child survival? Are N-MARC products effectively reaching the target group such as the children suffering from diarrhea?  Are the channels of distribution effective in bringing products to the children in need?  What about maternal health products? Are these products effectively distributed to women when they need them?  And what about STI/HIV/AIDS products – particularly condoms?  Do you think N-MARC and its partners through social marketing and franchising helping increasing access of target groups (MRP) to condom use?  One of the objectives of N-MARC project is to promote PPP and in this respect it has partnered with a private manufacturing company. The Private Company – Lomus manufacturer’s OCs. What do you think of this initiative?  Do you get regular information about N-MARC / social marketing activities? o If yes, how? o If no, how would you like get informed?  What would be the best direction for social marketing activity?  Roles and contribution of govt sector  Public/private partnership  Do you have any particular suggestions to make social marketing/N-MARC project activities more effective?  Which aspects of N-MARC activities – social marketing, private sector strengthening, CBO capacity building …. Do you think there is a need of strengthening in the next phase of N-MARC in Nepal? Thank you. APPENDIX III DISCUSSION CHECKLIST 64 Dr. Naresh Pratap K. C. Director, FHD, Teku Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Director. Issues to discuss:  Government policy on private sector development  N-MARC  Partners of N-MARC/AED project such as CRS, NFCC, other NGOs and INGOs  Level of involvement of government in implementing projects/programs of N-MARC and partner organizations  How is the government involved and to what extent  What level of contribution is N-MARC project making in achieving government health goals o In contraceptive distribution o Child health service products o Maternal health service products o STI/HIV/AIDS  Would you say that N-MARC project is effective in meeting the needs of target groups in FP, o If yes, how? o If no, why?  What is the share of N-MARC and its partners’ in FP products (pills, condoms, and long acting spacing methods) in the country?  Does FHD promote EC?  If yes, since when?  If no, do you think it needs to be introduced in the country?  What about the private and NGO sectors? Do they have EC outlets? If yes, which organizations are doing it?  What about N-MARC and its partners? Are they promoting EC? If yes, how?  Which target groups are benefiting from EC?  We hear that Nepal CRS Company is promoting “Matri Surakchya Chakki” to prevent post partum haemorrhage? Can you elaborate on this? In what places is it promoting and distributing “Matri Surakchya Chakki”? Is it part of N-MARC project activities?  What is the rationale for introducing this tablet in Nepal?  N-MARC and its partners also promote Clean Delivery Kits and it is said that NCRS does it quite extensively?  Do communities like CDK; how extensively is it used? The last 2006 NDHS showed only 18% of non-institutional deliveries using CDK? Would you have something to say in this context?  How can the use of SDK be increased? Any suggestions?  What about child survival? Are N-MARC products effectively reaching the target group such as the children suffering from diarrhea?  Are the channels of distribution effective in bringing products to the children in need?  What about maternal health products? Are these products effectively distributed to women when they need them?  Do you think N-MARC and its partners through social marketing and franchising helping increasing access of target groups (MRP) to condom use?  What is the share of N-MARC and its partners’ in condom distribution in the country? o Would you say that it has the largest share – if so what percentage? o Or would you say that it needs to increase its share? o Which target group in particular is benefiting from condom distribution network? (poor/middle class/rich) o What do you think of the N-MARC partners’ capability in meeting the needs of increasing consumers of condoms?  Are you aware of N-MARC and its partners’ condom promotion activities? o If yes, what are they? o Are they effective in reaching the target groups? o What about costs of condoms? Are they affordable by the lower socio-economic groups? 65  What would be the best direction for social marketing activity?  Roles and contribution of government sector  Public/private partnership  Do you have any particular suggestions to make N-MARC project activities more effective?  Which aspects of N-MARC activities – social marketing, private sector strengthening, CBO capacity building …. Do you think there is a need of strengthening in the next phase of N-MARC in Nepal? Thank you. Dr. Mingmar G. Sherpa, Director, LMD, Teku Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Director. Issues to discuss:  Government policy on private sector development  N-MARC  Partners of N-MARC/AED project such as CRS, NFCC, other NGOs and INGOs  Level of involvement of government in implementing projects/programs of N-MARC and partner organizations  How is the government involved and to what extent  What level of contribution is N-MARC project making in achieving government health goals o Child health service products o Maternal health service products o STI/HIV/AIDS  What is the relationship of your Centre with N-MARC and its partners?  How are RH, child survival and STI/HIV/AIDS health products of N-MARC are distributed in the country?  Do they acquire commodities from your centre?  Would you say that N-MARC project is effective in meeting the needs of target groups in FP, o If yes, how? o If no, why?  What is the share of N-MARC and its partners’ in FP products (pills, condoms, and long acting spacing methods) in the country?  What about child survival? Are N-MARC products effectively reaching the target group such as the children suffering from diarrhea?  Are the channels of distribution effective in bringing products to the children in need?  What is the share of N-MARC and its partners’ involvement in child survival activities of the government?  Are these activities effectively contributing to government’s child health goals?  If yes, how?  If no, why?  Do you think N-MARC and its partners can do more in future to child health program of the government?  What specific suggestions would you have to N-MARC for future programming on child health?  What about maternal health products? Are these products effectively distributed to women when they need them?  N-MARC and its partners also promote Clean Delivery Kits and it is said that NCRS does it quite extensively?  Do communities like CDK; how extensively is it used? The last 2006 NDHS showed only 18% of non-institutional deliveries using CDK? Would you have something to say in this context?  How can the use of CDK be increased? Any suggestions?  We hear that Nepal CRS Company is promoting “Matri Surakchya Chakki” to prevent post partum haemorrhage? Can you elaborate on this? In what places is it promoting and distributing “Matri Surakchya Chakki”? Is it part of N-MARC project activities? 66  What is the rationale for introducing this tablet in Nepal?  Do you think N-MARC and its partners through social marketing and franchising helping increasing access of target groups (MRP) to condom use?  What is the share of N-MARC and its partners’ in condom distribution in the country? o Would you say that it has the largest share – if so what percentage? o Or would you say that it needs to increase its share? o Which target group in particular is benefiting from condom distribution network? (poor/middle class/rich) o What do you think of the N-MARC partners’ capability in meeting the needs of increasing consumers of condoms?  Are you aware of N-MARC and its partners’ condom promotion activities? o If yes, what are they? o Are they effective in reaching the target groups? o What about costs of condoms? Are they affordable by the lower socio-economic groups?  Public/private partnership  Do you have any particular suggestions to make N-MARC project activities more effective?  Which aspects of N-MARC activities – social marketing, private sector strengthening, CBO capacity building …. Do you think there is a need of strengthening in the next phase of N-MARC in Nepal? Thank you. Dr. Krishna K. Rai, Director, NCASC, MOHP, Teku Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Director. Issues to discuss:  Government policy on private sector development  N-MARC  Level of involvement of government in implementing projects/programs of N-MARC and partner organizations  How is the government involved and to what extent  What level of contribution is N-MARC project making in achieving government health goals o In contraceptive distribution o Child health service products o Maternal health service products o STI/HIV/AIDS  Would you say that N-MARC project is effective in meeting the needs of target groups in FP, o If yes, how? o If no, why?  What about child survival? Are N-MARC products effectively reaching the target group such as the children suffering from diarrhea?  Are the channels of distribution effective in bringing products to the children in need?  What about maternal health products? Are these products effectively distributed to women when they need them?  And what about STI/HIV/AIDS products – particularly condoms and related activities?  Are there any events that NCASC and N-MARC or its partners conduct jointly?  If yes, what are they? What is N-MARC or its partners’ level of involvement?  Do you think N-MARC and its partners through social marketing and franchising helping increasing access of target groups (MRP) to condom use?  What is the share of N-MARC and its partners’ in condom distribution in the country? o Would you say that it has the largest share – if so what percentage? o Or would you say that it needs to increase its share? o Which target group in particular is benefiting from condom distribution network? (poor/middle class/rich) 67 o What do you think of the N-MARC partners’ capability in meeting the needs of increasing consumers of condoms?  Are you aware of N-MARC and its partners’ condom promotion activities? o If yes, what are they? o Are they effective in reaching the target groups? o What about costs of condoms? Are they affordable by the lower socio-economic groups?  Public/private partnership  Do you have any particular suggestions to make N-MARC project activities more effective?  Which aspects of N-MARC activities – social marketing, private sector strengthening, CBO capacity building …. Do you think there is a need of strengthening in the next phase of N-MARC in Nepal? Thank you. Dr. Shyam Raj Upreti, Director, CHD, Teku Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Director. Issues to discuss:  Government policy on private sector development  N-MARC  Partners of N-MARC/AED project such as CRS, NFCC, other NGOs and INGOs  Level of involvement of government in implementing projects/programs of N-MARC and partner organizations  How is the government involved and to what extent  What level of contribution is N-MARC project making in achieving government health goals o Child health service products o Maternal health service products o STI/HIV/AIDS  Would you say that N-MARC project is effective in meeting the needs of target groups in FP, o If yes, how? o If no, why?  What is the share of N-MARC and its partners’ in FP products (pills, condoms, and long acting spacing methods) in the country?  What about child survival? Are N-MARC products effectively reaching the target group such as the children suffering from diarrhea?  Are the channels of distribution effective in bringing products to the children in need?  What is the share of N-MARC and its partners’ involvement in child survival activities of the government?  Are these activities effectively contributing to government’s child health goals?  If yes, how?  If no, why?  Do you think N-MARC and its partners can do more in future to child health program of the government?  What specific suggestions would you have to N-MARC for future programming on child health?  What about maternal health products? Are these products effectively distributed to women when they need them?  N-MARC and its partners also promote Clean Delivery Kits and it is said that NCRS does it quite extensively?  Do communities like CDK; how extensively is it used? The last 2006 NDHS showed only 18% of non-institutional deliveries using CDK? Would you have something to say in this context?  How can the use of CDK be increased? Any suggestions?  We hear that Nepal CRS Company is promoting “Matri Surakchya Chakki” to prevent post partum haemorrhage? Can you elaborate on this? In what places is it promoting and distributing “Matri Surakchya Chakki”? Is it part of N-MARC project activities? 68  What is the rationale for introducing this tablet in Nepal?  Do you think N-MARC and its partners through social marketing and franchising helping increasing access of target groups (MRP) to condom use?  What is the share of N-MARC and its partners’ in condom distribution in the country? o Would you say that it has the largest share – if so what percentage? o Or would you say that it needs to increase its share? o Which target group in particular is benefiting from condom distribution network? (poor/middle class/rich) o What do you think of the N-MARC partners’ capability in meeting the needs of increasing consumers of condoms?  Are you aware of N-MARC and its partners’ condom promotion activities? o If yes, what are they? o Are they effective in reaching the target groups? o What about costs of condoms? Are they affordable by the lower socio-economic groups?  What would be the best direction for social marketing activity?  Roles and contribution of government sector  Public/private partnership  Do you have any particular suggestions to make N-MARC project activities more effective?  Which aspects of N-MARC activities – social marketing, private sector strengthening, CBO capacity building …. Do you think there is a need of strengthening in the next phase of N-MARC in Nepal? Thank you. Academy for Educational Development/N-MARC Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Resident Advisor. Issues to discuss:  Programs/ Planning  Goal and objectives of NMARC (reach low socioeconomic group)  Programs implementation mechanism (PSP, network, experts, matching fund-sustainability)  Monitoring and evaluation plan/system (MER, PMP, Marketing Plan, Demobilization Plan, Collaboration Plan, BCI Plan/Strategy)  Capacity Building, Training, Orientation, BCC, guidelines, etc  Results  Achievements  Effectiveness  Anything special about N-MARC approach (strength)  Problems faced (constraints)  Steps taken to solve the problems  What strategies have you to work with govt and to report to them?  What strategies worked and what strategies did not work?  Do you ever engage govt officials in preparing work plans/programs at national and /or district level?  Lessons learned  Have you brought in any lessons learned/experience from another country for N-MARC here in Nepal?  What experience/lessons learned would you take from here to another country?  How do you envision social marketing continuing without external support?  Recommendations you have for future sustainability of social marketing in Nepal  Any other matters you think have been left out? Thank you. 69 Nepal CRS Company Pvt. Ltd. Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Managing Director. Issues to discuss:  Types of support from N-MARC  Goal and objectives of CRS (reach low socioeconomic group)  Programs implementation mechanism and strategies (PSP, network, experts)  Monitoring and evaluation plan/system (MER, PMP, Marketing Plan, Collaboration Plan, BCI Plan/Strategy)  Capacity Building, Training, Orientation, BCC, guidelines (QOC, protocols), etc  Number and types of products and distribution mechanism  Coverage – district, urban, rural  Results/ Impact, share (different products) of market  Innovations regarding brands, prices, promotion of products  Achievements  Effectiveness  Anything special about CRS approach (strength)  Problems faced (challenges/constraints)  Steps taken to solve the problems  What strategies have you to work with govt and to report to them?  What strategies worked and what strategies did not work?  Do you ever engage govt officials in preparing work plans/programs at national and /or district level?  Lessons learned  Recommendations you have for future sustainability of social marketing in Nepal  Any other matters you think have been left out? Thank you. USAID/Nepal Social Marketing Team Fix an appointment  Social marketing programs: past/present/future  Monitoring and evaluation mechanism  Comparative advantage in N-MARC program  Logistic management  Compliance with USG regulations Thank you. MITRA Samaj Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Executive Director. Issues to discuss:  Types of support from N-MARC  Capacity Building, TA, Training, Orientation  Zinc program  Research (GIS, Hot zones, Sangini, other) o Support in evidence based research for program development  Monitoring on training provided and commodity distribution  Achievements 70  Effectiveness  Anything special about MITRA Samaj approach (strength)  If you are given same opportunity again what would you do differently?  Problems faced (constraints)  Steps taken to solve the problems  What strategies have you to work with govt and to report to them?  What strategies worked and what strategies did not work?  Do you ever engage govt officials in preparing work plans/programs at national and /or district level?  Lessons learned  Recommendations you have for future  Any other matters you think have been left out? Thank you. KfW, Kathmandu Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to KfW Local Expert, Mr. Shanker Raj Pande. Issues to discuss:  Since when have you been funding CRS?  In what areas do you fund CRS?  What is the level of support in terms of funding x amount of Euro/dollars a year, etc? Any document that shows some details of support to CRS?  What sort of agreement do you have with CRS? Is government of Nepal part of it?  What is the rationale for supporting CRS in Nepal?  Link of KfW with N-MARC…  Results  Achievements  Effectiveness  Anything special about CRS approach (strength)  Problems faced (constraints)  Steps taken to solve the problems  What strategies have you to work with government and to report to them?  What strategies worked and what strategies did not work?  Do you ever engage government officials in preparing work plans/programs at national and /or district level?  Lessons learned  How do you envision social marketing continuing without external support?  Should N-MARC phase out its support to CRS what then will be the role of KfW?  Recommendations you have for future sustainability of social marketing in Nepal  Any other matters you think have been left out? Thank you. Nepal Fertility Care Center Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Managing Director. Issues to discuss:  Types of support from N-MARC  Capacity Building, Training, Orientation, guidelines (QOC, protocols), etc  Monitoring (TSV) 71  Achievements  Effectiveness  Anything special about NFCC approach (strength)  Problems faced (weakness)  Steps taken to solve the problems  What strategies have you to work with government and to report to them?  What strategies worked and what strategies did not work?  Do you ever engage government officials in preparing work plans/programs at national and /or district level?  Whether NFCC foresee the possibility of future government involvement in private sector family planning quality control and if so, what could be done now to encourage that in the future?  Lessons learned  Recommendations you have for future  Any other matters you think have been left out? Thank you. Population Services International Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to PSI Country Representative. Issues to discuss:  Current activities in social marketing in Nepal?  If yes, what are your funding sources?  Past experience in social marketing in Nepal especially with CRS company?  Strength of CRS  Constraints of CRS  Your link with USAID/N-MARC?  Any noticeable differences between PSI and N-MARC approaches to social marketing?  Does USAID support you in any activity?  Lessons learned from working with CRS in past?  How do you envision CRS social marketing continuing without external support?  Recommendations you have for future sustainability of social marketing in general?  Any other matters you think have been left out? Thank you. Marie Stopes International Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Country Director. Issues to discuss:  Partnership with N-MARC  What areas do you work with N-MARC program?  Achievements  Effectiveness  Anything special about your approach (strength)  Problems faced (constraints)  Lessons learned  Recommendations you have for future  Any other matters you think have been left out? Thank you. 72 ASHA/FHI Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to Country Director. Issues to discuss:  Partnership with N-MARC  What areas do you work with N-MARC program?  Achievements  Effectiveness  Anything special about N-MARC approach (strength)  Problems faced (constraints)  Lessons learned  Recommendations you have for future  Any other matters you think have been left out? Thank you. Private Commercial Partners Gayatra Store Enterprises, Praxis Trade Link, Pioneer Trading Fix an appointment, Explain about the purpose of visit, Hand over a copy of letter given to Evaluation Team from USAID/Nepal to the respective Executive Directors. Issues to discuss:  Partnership with the Program  Coverage and distribution  Sustainability  Matching fund for production (Lomus) o Which area they got supported from N-MARC? o What they have liked to do?  Effectiveness of N-MARC program o Benefits from the program  Recommendations Thank you. 73 Central Level 1. Dr. Yasho Vardhan Pradhan, Director General, Department of Health Services 2. Dr. M. G. Sherpa, Director, Logistics Management Department, DoHS, GoN 3. Dr. Krishna Kumar Rai, Director, National Center for AIDS and STD Control, GoN 4. Dr. Sagar Dahal, Family Health Division, DoHS, GoN 5. Mr. Pangday Yonzone, Social Marketing and Logistics Specialist, USAID/Nepal 6. Ms. Linda Kentro, Health Development Specialist, USAID/Nepal 7. Mr. Peter Oyle, Resident Adviser, AED/Nepal 8. Mr. Rajib Lal Satyal, AED/Nepal 9. Ms. Arinita Maskey Shrestha, AED/Nepal 10. Ms. Anjita Shrestha, AED/Nepal 11. Mr. Shanker Raj Pandey, Technical Adviser, KfW 12. Ms. Jacqueline McPherson, Country Director, FHI/ASHA 13. Mr. Andrew Boner, Country Representative, PSI/Nepal 14. Mr. K. P. Upadhaya, PSI/Nepal 15. Mr. K. B. Rayamajhi, Managing Director, Nepal CRS Company Pvt. Ltd. 16. Mr. Rohit Shrestha, Nepal CRS Company Pvt. Ltd. 17. Mr. Uttam Raj Regmi, Nepal CRS Company Pvt. Ltd. 18. Mr. Mahesh Pokharel, Nepal CRS Company Pvt. Ltd. 19. Mr. Jyoti Shrestha, Nepal CRS Company Pvt. Ltd. 20. Dr. Tika Man Vaidhya, Executive President, Nepal Fertility Care Center 21. Dr. Mahendra Bahadur Shrestha, Nepal Fertility Care Center 22. Ms. Kamala Thapa, Country Director, Marie Stopes International/Nepal 23. Mr. Ashok Kharel, Marie Stopes International/Nepal 24. Mr. Prabin Shakya, Marie Stopes International/Nepal 25. Mr. Dipak Bajracharya, Executive Director, MITRA Samaj 26. Dr. Prakash Dev Pant, MITRA Samaj 27. Mr. Chandra B. Thapa, MITRA Samaj 28. Dr. Pranita Bhatta, MITRA Samaj 29. Mr. Parishkrit Shrestha, MITRA Samaj 30. Mr. Nilesh Man Joshi, MITRA Samaj 31. Mr. Uttam Situala, Chairman, Center for Social Economic Development 32. Mr. Rajendra Rimal, Center for Social Economic Development 33. Mr. Suraj Karki, Center for Social Economic Development 34. Mr. Ashesh Khanal, Center for Social Economic Development 35. Mr. Bhashkar Chapagain, Managing Director, Gayatra Store Enterprises 36. Mr. Dinesh Chapagain, Gayatra Store Enterprises 37. Mr. Himal Nath Adhikari, Chairperson, Praxis Trade Link 38. Mr. Utsav Udas, Pioneer Trading District Level Dhankuta 1. Mr. Purna Shanker Shrestha, Data Officer, District Health Office, Dhankuta 2. Mr. Ram Narayan Shrestha, Section Officer, District Health Office, Dhankuta Sunsari 1. Mr. Prakash Adhikari, Data Officer, District Health Office, Sunsari 2. Mr. Badri Roy, Center for Social Economic Development, Sunsari APPENDIX IV LIST OF KEY INFORMANTS 74 Morang 1. Mr. Tek Raj Koirala, Public Health Inspector, District Public Health Office, Morang 2. Mr. Sudarshan Shrestha, Regional Manager, Eastern Region, Nepal CRS Company 3. Mr. Santosh Pradhan, Eastern Region, Nepal CRS Company Chitwan 1. Mr. Chudamani Bhandari, Senior Public Health Administrator, Public Health Office, Chitwan 2. Mr. Saroj Adhikary, Area manager, Nepal CRS Company, Chitwan 3. Mr. Sunil Tiwari, Senior Administration and Finance Officer, Nepal CRS Company, Chitwan 4. Mr. Sita Ram Pandit, Field Officer, Nepal CRS Company, Chitwan Tanahun 1. Mr. Muktinath Pandit, District Public Health Office, Tanahun Kaski 1. Mahendra Dhoj Adhikari , Public Health Administrator, Kaski 2. Mr. Niraj Khanal, Area Manager, Nepal CRS Company, Kaski 3. Mr. Bal Krishna Rana Bhat, Area Administrator and Finance Officer , Nepal CRS Company, Kaski Banke 1. Mr. Dhirjung Shaha: Senior Public Health Officer, District Public Health Office, Banke 2. Mr. Angad Shahi, DPHO, Banke 3. Mr. Saroj Kumar Saha, DPHO, Banke 4. Ms. Shova Adhikari, DPHO, Banke 5. Mr. Anil Poudel, Senior Sales Officer, Nepal CRS Company, Banke 6. Ms. Basanti Nepali, Nepal CRS Company, Banke 7. Mr. Prem Khatiwada, Center for Social and Economic Development, Banke Bardiya 1. Mr. Govinda Regmi, Section Officer, District Public Health Office, Bardiya 2. Mr. Suraj Sharma, Area Manager, Mid-Western Region, Nepal CRS Company 3. Mr. Ramesh Bahadur Malla, Nepal CRS Company 4. Ms. Ganga Gurung, Nepal CRS Company 5. Ms. Lauti Kumari Tharu, Nepal CRS Company 6. Ms. Dev Kumari, FGD Participant 7. Ms. Naya Kumari, FGD Participant 8. Ms. Rita Chaudhari, FGD Participant 9. Ms. Lahani Chaudhari, FGD Participant 10. Ms. Jyoti Chaudhari, FGD Participant 11. Ms. Nirmala Chaudhari, FGD Participant 12. Ms. Shyamdulari Chaudhari, FGD Participant 13. Ms. Rampatti Chaudhari, FGD Participant 14. Ms. Renu Chaudhari, FGD Participant Kailali 1. Mr. Govinda Bikram Thapa, Area Manager, Far-Western Region, Nepal CRS Company 2. Mr. Dharma Raj Awasthi, Nepal CRS Company 3. Ms. Shanti Chaudhari, FGD Participant 4. Ms. Laxmi Chaudhary, FGD Participant 5. Ms. Manju Manandhar, FGD Participant 6. Ms. Kalawati Chaudhari, FGD Participant 7. Ms. Bishna Nepali (Panther Didi), FGD Participant U.S. Agency for International Development USAID/Nepal Bramha Cottage, Maharajgunj Kathmandu, Nepal Tel: +977-1-4007200 Fax: +977-1-4007285 nepal.usaid.gov Fax: (202) 216-3524 www.usaid.gov