Mobilizing Private Sector Resources

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Mobilizing Private Sector Resources

India
Project Summary
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The Janani program addresses the reproductive health needs of low-income people primarily in the Indian states of Bihar and Jharkhand. Our primary program beneficiaries are people who can pay something for reproductive healthcare but not full commercial rates and live in areas where the government system is not functioning. We try to reach the poorest of the poor through coupon/voucher schemes and free service camps. Our program provides affordable and high quality contraceptives and clinical reproductive health services through three linked distribution networks. We sell Government of India subsidized Mithun and Style condoms and Apsara oral contraceptives in addition to commercially sourced Plan X condoms through a network of 40,000 shops in urban and rural markets. We have also trained a male and female couple, branded as a Titli (Butterfly) Center, in 38,500 villages to sell products, counsel clients on reproductive health issues, do rapid diagnostic tests (e.g. pregnancy dipstick), and make referrals to our franchise Surya (Sun) Clinics for services. We have trained 505 M.B.B.S. qualified doctors to perform a range of reproductive health procedures including tubal ligations, no scalpel vasectomies, and abortions using medical vacuum aspiration technology. We are currently operating 59 franchise Surya Clinics staffed by doctors whom we have trained, to whom we provide advertising support and a clinic administrator, and for whom we generate patient referrals from our Titli Centers. The doctors pay us an annual membership fee, and we expect them to adhere to our prices, which are 40-50% of commercial sector prices, and our quality of care norms. The reasonably priced and quality products and services that we offer through our extensive networks of shops, Titli Centers, and Surya Clinics make reproductive healthcare accessible to the people of Bihar and Jharkhand who cannot afford commercial rates and who are not served by the public sector.

About You
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Your idea
Focus of activity

Reproductive Health

Start Year

1995

Positioning in the mosaic of solutions
Main barrier addressed

Limited reach of healthcare infrastructure

Main principle addressed

Adopt market-based models as a scaling-up strategy

Innovation
Description of health product/service offering:

The Janani program addresses the reproductive health needs of low-income people primarily in the Indian states of Bihar and Jharkhand. Our primary program beneficiaries are people who can pay something for reproductive healthcare but not full commercial rates and live in areas where the government system is not functioning. We try to reach the poorest of the poor through coupon/voucher schemes and free service camps. Our program provides affordable and high quality contraceptives and clinical reproductive health services through three linked distribution networks. We sell Government of India subsidized Mithun and Style condoms and Apsara oral contraceptives in addition to commercially sourced Plan X condoms through a network of 40,000 shops in urban and rural markets. We have also trained a male and female couple, branded as a Titli (Butterfly) Center, in 38,500 villages to sell products, counsel clients on reproductive health issues, do rapid diagnostic tests (e.g. pregnancy dipstick), and make referrals to our franchise Surya (Sun) Clinics for services. We have trained 505 M.B.B.S. qualified doctors to perform a range of reproductive health procedures including tubal ligations, no scalpel vasectomies, and abortions using medical vacuum aspiration technology. We are currently operating 59 franchise Surya Clinics staffed by doctors whom we have trained, to whom we provide advertising support and a clinic administrator, and for whom we generate patient referrals from our Titli Centers. The doctors pay us an annual membership fee, and we expect them to adhere to our prices, which are 40-50% of commercial sector prices, and our quality of care norms. The reasonably priced and quality products and services that we offer through our extensive networks of shops, Titli Centers, and Surya Clinics make reproductive healthcare accessible to the people of Bihar and Jharkhand who cannot afford commercial rates and who are not served by the public sector.

Description of innovation:

Our program is an innovative reproductive health social marketing and social franchising model that differs from a traditional social marketing approach in several ways. Conventional family planning social marketing involves selling low cost contraceptives in urban markets. The Janani program goes beyond this approach to reach shops in rural markets, and it also integrates a village level network of Titli Centers that not only serve as sales points but also function as referral generators for our franchise Surya Clinics. The Surya Clinics broaden the social marketing of products to include the provision of clinical services through social franchising. Another distinguishing feature of our program is that all three of our networks are linked.

Operational model:

Our organization focuses on providing affordable and high quality reproductive health services to the neediest members of the population in the Indian states of Bihar and Jharkhand. We also have a smaller operation in the state of Madhya Pradesh. We implement our program through three linked networks of retail shops, Titli Centers, and Surya Clinics. Shops, mostly pharmacies, are located in urban and rural markets, and they sell our condoms and oral contraceptive products. At the village level, we train a male and female Titli Center team to sell contraceptives, provide counseling on reproductive health issues, do rapid diagnostic tests (e.g. pregnancy dipstick), and refer clients to our Surya Clinic doctors for reproductive health and related general health services. Our Surya Clinics are franchises that are run by M.B.B.S qualified doctors who we have trained on reproductive health procedures, to whom we give substantial IEC promotion support, for whom we place a clinic coordinator in the clinic to provide administrative assistance, and from whom we expect them to adhere our price and quality of care norms. We reach low-income or marginalized populations through selling subsidized contraceptive products, offering clinical services at 40-50% of commercial sector prices, and providing free services through seasonal sterilization camps. The partnerships that help us to effectively deliver services to the poorer, underserved segments of the population will be elaborated in question 9.

Human resources:

We have a dynamic and hard working team of 106 people with a variety of backgrounds who implement our program. Everyone except the Country Director and Deputy Program Director is from India, and the majority of our team is from Bihar and Jharkhand. Many of our team members are highly motivated university graduates committed to development whom we have recruited and trained and who we rapidly move into management positions if they perform well. Following are brief profiles of our senior management team: Larry Holzman, Country Director, MPA - has over 35 years of overseas development experience in Asia, Africa, and Latin America. Noah Sprafkin, Deputy Programme Director, MPH - has extensive business experience and has also worked in the development sector in India and Bangladesh. Dr. Nita Jha, Surya Clinics Deputy General Manager, MD (OB&GYN) - is a fellow of the Indian College of Maternal and Child Health has 8 years of work experience. Sandeep Srivastava, Finance Deputy General Manager, Commerce graduate accounting and office management - has 10 years of work experience, particularly in the reproductive health sector.

Key operational partnerships:

We have several important government and business partnerships that are essential to us for implementing our program. Our government partnerships help us procure products and deliver services to the poorest of the poor. We are part of the Government of India?s Contraceptive Social Marketing program, and we purchase subsidized condoms and oral contraceptives from the government that we then sell at affordable rates to consumers through our shop and Titli Center networks. We have also started receiving reimbursements from the government for providing reproductive health procedures, like sterilizations, for free to clients. Our business partnerships allow us to sell our products and provide services through our three different distribution networks. In our shops network, we partner with stockists who store our contraceptives. We also work closely with entrepreneurs who provide salespeople. In our Titli Center network, we partner with the existing rural medical practitioners in villages and train them to sell our contraceptives, counsel clients on reproductive health issues, and make referrals to our Surya Clinics. In our Surya Clinic network, we partner with private doctors who become franchise Surya Clinics. Some of our Surya Clinic franchisees are financial partnerships with the doctors or entrepreneurs sharing costs, profits, and losses. We also have two corporate partners, the India Tobacco Company and Tata Steel, who partially fund two Surya Clinics.

Impact
Financial Sustainability:

<ul><li class="entry-label">Fees charged to clients?: <span class="entry-text">Yes</span></li><li class="entry-label">How do you assure affordability?: <span class="entry-text">? We have several systems in place to determine on an ongoing basis whether our program beneficiaries can continue to afford our products and services. We do regular willingess-to-pay studies for both the contraceptives that we sell and the clinical services that we provide. We also track inflation and its immediate impact on our clients through a quarterly price index that is derived from monitoring the prices of a range of products commonly used by the people whom we target. Additionally, we monitor price and sales trends among our competitors as another reference point to assess what clients can pay for products and services. We use the findings from the studies, the price index, and the competitor monitoring to adjust our prices accordingly.</span></li><li class="entry-label">Earned incomes as a percentage of operating costs: <span class="entry-text">42%</span></li><li class="entry-label">Other funding sources: <span class="entry-text">? Our program is currently not self-sustainable. We generate revenues from the sales of contraceptives and membership fees from Surya Clinics and Titli Centers which cover approximately one third of our costs. However, we do incur substantial expenses, particularly for operating our Surya Clinics and servicing our Titli Centers and rural markets. Our other sources of funding are a grant from the Packard Foundation, a loan from the Population of India for setting up Surya Clinics, funding from the India Tobacco Company and Tata Steel for helping run two Surya Clinics, a grant from the Government of India?s Department of Science and Technology to train traditional birth attendants, and reimbursements from the Government of India for contraceptive packaging and marketing costs.</span></li><li class="entry-label">Strategy for long-term sustainability: <span class="entry-text">? We have a five part strategy for long-term sustainability. First, we are continually streamlining our work processes to increase efficiency and reduce costs. Second, we are negotiating with India?s central and relevant state governments to outsource the provision of reproductive health services to our clinics. Third, we are developing corporate, NGO, and academic partnerships to fund the costs of certain activities. Fourth, we are searching for additional revenue generating opportunities to cross-subsidize other expenses and to decrease dependence on donor funding. Five, since the Surya Clinics that we own involve large set up and operating expenses, we are entering into partnerships in which we will eventually recover our investment and transfer the running of a clinic to the partner.</span></li></ul>

Current and Future Impact:

<ul><li class="entry-label">Total number of clients: <span class="entry-text">? 6900000</span></li><li class="entry-label">Clients in the past year: <span class="entry-text">1730000</span></li><li class="entry-label">Percentage of low-income clients: <span class="entry-text">50%</span></li><li class="entry-label">Impact: <span class="entry-text">Our program has had a significant impact locally, nationally, and internationally. Locally, we have empowered people in our program area to talk openly and make informed decisions about their reproductive health. Nationally, we have played an important role in convincing the Government of India to change the composition of the oral contraceptives it procures in order to reduce side effects, to include manual vacuum aspiration technology into its first trimester abortion protocols, and to make emergency contraceptives available over-the-counter. Internationally, we have demonstrated through our initiative that private resources can be successfully leveraged to supplement the public sector infrastructure to improve the lives of people in severely resource constrained areas.</span></li><li class="entry-label">Overall "market": <span class="entry-text">? There is a large potential demand for the reproductive health products and services that we provide not only in Bihar and Jharkhand but also in India. Per the 1998-99 National Family Health Survey for India (NFHS-2), there is a 49.1% in Bihar and 64% in India need among currently married women for family planning. The total fertility rate is 3.59 in Bihar and 3.07 in India. Although 51.2% of currently married women in India are using any modern contraceptive method, only 35.4% are in Bihar.</span></li></ul>

Scaling up strategy:
Stage of the initiative:

<i>Scaling Up</i> stage.

Expansion plan:

We currently have 59 Surya clinics in Bihar and Jharkhand. 19 of these clinics are Janani owned and serve as models for the 40 other franchise clinics. During the next three years, we would like to open 41 more Janani owned and 260 franchise Surya clinics for a total of 360. This expansion will enable us to have a strong clinical presence throughout all 60 districts in Bihar and Jharkhand. We have trained 38,500 Titli Centers, but only about 31,000 of these locations are presently active with regard to selling our products and making referrals to our Surya Clinics. Over the next three years, we would like to set up 26,000 additional functional Titli Centers, so that there is one in each of Bihar and Jharkhand?s 57,000 villages and that there are at least 150 Titli Centers in every Surya Clinic?s catchment area for making referrals. We presently market our condoms and oral contraceptives in approximately 40,000 shops. Most of our outlets are chemists, but in the next three years, we would like not only to increase the number of chemists that stock our products but also to place our contraceptives in a wider variety of retail shops. We would also like to expand our presence in

Origin of the initiative:

Gopi Gopalakrishnan began working for Population Services International in 1987. During his time there, he realized that the traditional social marketing approach did not reach people in rural areas, particularly villages, and did not address the need for family planning clinical services. He also knew that there were large resources already available in the private sector which could be mobilized to deliver affordable and quality family planning products and services in both urban and rural areas. Gopi created the plan for Janani?s innovative model and started the program in 1995 in Bihar. Gopi is one of the most experienced social marketing and social franchising program managers in the world. He has a Master?s degree from the Birla Institute of Technology and Science, Pilani (India) and has over 25 years of experience in journalism, advertising, IEC, and program management.

Sustainability
Policy change:

The key policy change required to speed up social change in reproductive health in India is to promote gender equity. Although India is undergoing rapid changes, particularly in its major cities, the rural areas in which the majority of its people live are still lagging significantly behind especially with regard to reproductive healthcare. In rural areas, men continue to be the primary decision makers in terms of choosing and financing the reproductive health product or service that a couple uses. Until women have equal standing in their families and financial independence, their ability to influence their reproductive health choices will be severely limited. With greater autonomy in regard to their reproductive health options, women will be able to demand and avail better products and services which will lead to better lives for them and their families.

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