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March 21, 2000

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Washington-backed Butterfly welcomed
in many homes in India

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Shanthi Shankarkumar

An elaborate new medicine-man marketing network known as Butterfly is attempting to revolutionize the way India curbs its soaring population. The Butterfly is now a ubiquitous symbol in the remotest villages of Bihar where the program is currently in full swing. You can see it plastered across village walls and on billboards, on the prescription pads and stationery used by the local Rural Medical Practitioners.

"We have gone in for total branding. This is not only about serving humanity. It is also about making money," said K Gopalakrishnan, director of the network from Delhi, via e-mail.

This social marketing of family planning is a significant shift in India's family planning philosophy. For decades, India's planners attempted to stabilize population levels by sterilization. Policy makers set sterilization targets, which were achieved at times by threatening, bribing and forcing women to undergo sterilization. The government has now removed the targets given to its health workers and other functionaries. This was a fall-out of the decisions arrived at the International Conference on Population and Development held in Cairo in 1994.

"The decision is to focus on larger-scale delivery of good-quality reproductive health to people. Experience shows once such services are available, they will automatically limit their family sizes," said Gopalakrishnan.

India's census bureau estimates that on May 11, 2000, the nation's population will top one billion. India is expected to surpass China in four decades. That grim scenario has spawned Butterfly and some other programs -- many funded by the US government and private money.

Butterfly was born two years ago when DKT International, a Washington DC, non-profit group created an Indian affiliate, Janani.

DKT also has a branch in Mumbai called DKT-India which has been working in Maharashtra and Gujarat since 1993.

DKT invested $ 1 million and raised another $ 4 million from private Indian and US groups. It uses social marketing -- commercial marketing techniques and shop-level access to contraceptive commodities. DKT currently works in eight countries implementing nine programs.

The Janani program is different from other population programs in that its main objective is to focus on rural areas and deliver non-clinical methods (condoms and oral pills). This is the first social marketing program that attempts to deliver family planing services (IUDs, abortions, sterilization, and injectables).

"Almost all the social marketing programs in the world focus on condoms and oral pills, confined to urban pockets because that is where the markets are the strongest," said Gopalakrishnan.

Janani is currently working in Bihar, Madhya Pradesh and Uttar Pradesh. A full-scale operation is underway in Bihar, India's second most populous state with a population of 86 million

"We thought if we could make it work in Bihar, we could make it work anywhere in India," said Gopalakrishnan.

While India's southern states have made great strides in population control, the northern states particularly Uttar Pradesh and Bihar are threatening to eat into India's economic advances with their population time bombs.

Population experts have warned that if the two states did not curb their population, India as a nation would no longer be viable.

Janani's program strategy is to leverage resources that already exist in the community rather than create something afresh. In the rural areas, health care is essentially through a vast network -- estimated to be around 200,000 in Bihar alone -- of rural medical practitioners. The RMPs are almost always male, typically in the 30 to 40 age group, and they practice an eclectic array of medicinal systems.

Over 80 per cent of them prescribe modern allopathic drugs. The state and central governments have ignored the RMP sector for 50 years. Instead attempts were made to relocate qualified doctors and paramedical practitioners -- a move, which failed miserably, since most doctors, did not want to work in the rural areas.

So far, Janani has trained 7,000 RMPs, each with a woman partner. They sell condoms and oral pills for making a profit and refer clients needing clinical family planning services to the franchised network of doctors for earning a commission.

"Earlier, most did not have any involvement in family planning products and services and focused mainly on treating minor ailments like fever, cough and cold," said Gopalakrishnan.

An RMP has to pay an annual fee of $ 12 (Rs 500) to be affiliated with Janani. But he makes a tidy profit from selling Janani's condoms, oral pills and other services. He makes the same commission that a shopkeeper makes from selling condoms and pills (which is about 60 paise for a cycle of pills and 80 paise for a pack of 6 condoms.)

He also gets paid for every patient he refers to Janani-endorsed doctors for intra-uterine devices or abortions. On an average an RMP could make about $ 70 to $ 90 a month. To preserve the brand's cachet Janani affiliates with no more than one RMP per village.

"The reason the RMPs are delivering these products and services is not because they have a bleeding heart but because they make money. There is an incentive available for performance, and better the performance, more the incentives as more clients will seek advice," said Gopalakrishnan.

Sustaining the interest of the RMPs over a period of time will be the challenge before the program.

"The interest on behalf of the RMPs is there but we've got a long way to go in figuring out how to hold this interest and keep them all actively involved," said Philip D Harvey, president of DKT-Washington.

Harvey feels waning of interest is to be only expected since family planning and preventive health generally does not make up a significant part of their livelihood and therefore maintaining their interest will be a challenge.

He was in India in January and he has come back impressed by the enthusiasm, knowledge and determination of the staff to make Butterfly a success.

The target population is couples in prime reproductive age (20 to 30 years) with a monthly household income of between Rs 1000 and 1,500.

"Of course, social marketing programs target population segments which can pay something for the services. The poorest of the poor, who cannot afford to pay for anything is basically left to the government sector to focus on," said Gopalakrishnan.

Contrary to popular belief, the challenge to the family planning program in India is the inability of the private and public sectors to meet existing demand. The National Family Health survey in 1993 (a countrywide survey conducted by the International Institute of Population Studies with technical and financial support from USAID) has pointed out that 20 per cent of couples do not want a child either now or ever but are not using family planning methods.

For states like Bihar this unmet need is a whopping 25%.

"Our program tries to ensure that the contraceptive needs of this population is met in the first phase of our operation. The next level of our program will be tougher when we have to target populations that have an inherent dislike to family planning. We are however nowhere near that," said Gopalakrishnan.

According to Gopalakrishnan, the main obstacle in Janani's path is surprisingly not resistance from illiterate villagers but bureaucratic hurdles and lack of a cohesive policy both at the central and state levels.

"The irony is that there is genuine desire among policy makers to move quickly on these issues but the red tape stifles every effort," he added.

Meanwhile, in neighboring Uttar Pradesh, another approach is underway at one of the world's biggest US-funded population projects. The US Agency for International Development is devoting $ 325 million over ten years to an array of grassroots programs to educate people about birth control.

But it will take single-pointed dynamism, commitment and entrepreneurship if India is to stem its growing population and settle for being No 2 -- instead of the more likely dubious distinction of being No 1 in population.

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