DRAFT

November 2001

Department of Family Welfare

Ministry of Health and Family Welfare

Government of India

Table of Contents

Page No.

Boxes

Page No.

Annexures

Page No.

A. Introduction

1. Background

1.1. The National Population Policy 2000 (NPP 2000) recognises the immense potential of Social Marketing in expanding the outreach and coverage of health care products and services, and emphasises the need to formulate and implement social marketing schemes for provisioning products and services, through partnerships between the voluntary sector, non–government organisations, the private corporate sector, Government, Panchayati Raj Institutions and the community. It recognises that all of this will accelerate achievement of the national socio-demographic goals.

1.2 The present paper, "National Strategy for Social Marketing", [NSSM], 2001 in pursuance of the NPP 2000 develops a strategy for the social marketing of products and services for reproductive and child health (RCH) in India

2. What is Social Marketing?

2.1 Social marketing refers to the application of commercial marketing concepts, tools, resources, skills and technologies to encourage socially beneficial behaviour among those segments of the population not served, or not adequately served by existing public and private systems. This technique has been used extensively in international health programs, especially for distribution of contraceptives and oral rehydration therapy (ORT). It is also frequently used for bringing about changes in socially significant attitudes and behaviour in such diverse areas as smoking, the use of seat belts in cars, drug abuse, heart disease, and organ donation.

2.2 Social marketing is globally recognised as a key strategy for improving access to a wide range of products and services that directly and positively impact the outreach and coverage of health care. From conceptualising product development, testing and targeted communication to consumer research and market segmentation, social marketing looks at the provision of health care products and services not as a medical problem, but as a sociological issue, and a marketing challenge. Social marketing in the health sector seeks to bring about changes in health seeking behaviour by creating access to, and improving the demand for products and services, needed for sustaining the sought after change in behaviour.

2.3 Generally speaking, many products and services for reproductive and child health (RCH) care are commercially sold at prices affordable only by the well-off segments of society. The less well off segments currently rely on public health systems for (typically free of charge) access to RCH products and services. Increasingly however, people with some ability to pay are seeking better quality health care facilities, products, and services at affordable prices. However, this segment of the population, though economically active, usually cannot afford the prices charged by commercial marketing firms.

2.4 Accordingly, social marketing for RCH aims to distribute commonly needed products at affordable prices to the less well-off (but not necessarily the poorest who may continue to rely solely on distribution by the public health delivery system), segments of the population, through commercial networks, and community / NGO based distribution systems. These channels are motivated to stock and sell products on the basis of the financial margins received by them. In this manner, social marketing seeks to provision for health care products through multiple channels. Ideally, the socially marketed products should be available in all pharmacies and other retail outlets in cities, small towns, and rural areas, so as to enhance availability and visibility in every possible manner. Additionally, the product be priced low to enhance affordability and increase outreach and coverage. As the consumer’s ability to pay increases, he will graduate from relying upon the public health network to the multiple social marketing outlets for the same products, and eventually to commercially marketed products for meeting their needs. Facilitation of this shift is the rationale of the NSSM.

3. Planning a Social Marketing Programme

3.1 Social marketing applies commercial marketing skills and technologies to the analysis, planning, execution and evaluation of programs designed to influence behaviour change among target audiences in order to bring about socially beneficial health seeking behaviour. Planning a Social Marketing Programme (SMP) requires maintaining a consumer focus by addressing the different elements of the "marketing mix", which are more commomly known as the "six Ps" : (i) a Product, (ii) its Price, (iii) its Place (or distribution), (iv) its Promotion (v), the Partnership involved, and (vi) the Policy environment, detailed in Annexure I.

4. Evolution of Social Marketing in India

4.1 India was one of the first countries globally to adopt the social marketing of contraceptives to extend the coverage and outreach of the then family planning programme. By the end of the sixties, commercial marketing of condoms was two decades old. However, these were stocked in a few hundred drugstores / retail outlets known for selling high priced speciality goods to the upper income groups in large cities. Market prices of condoms were very high, and private manufacturers were unable to generate expansion in consumer sales.

4.2 In the early 1960’s, India had introduced a brand of condom, known as "Nirodh" for free supply through government hospitals and primary health centres. There were at the time, comparatively few doctors and clinics, mostly concentrated in urban areas. Six to seven years into the programme, it became clear that significantly wider coverage was necessary, if the vast numbers in the rural areas are to be motivated to use the condom, which must be reached out to them. Exclusive reliance on government machinery was proving inadequate, and clearly, the family planning administered through doctors and clinics could not accomplish this task alone.

4.3 By 1968, private sector companies with extensive distribution networks for consumer products were invited to promote 'Nirodh' in the market. Union Carbide, a manufacturer and distributor of flashlight batteries, Hindustan Lever and Tata Oil Mills, competing manufacturers for cooking oil and bath soap, India Tobacco Company, the premier distributor of cigarettes, and Brooke Bond Tea, the major distributor of tea, were given responsibility for operations within assigned geographic territories. Collectively they covered the entire country. During the eighties, Government launched an oral contraceptive pill called "Mala-D".

4.4 At the same time, Government initiated massive advertising and awareness campaigns. Up to the late eighties, the campaign spoke of "do ya teen bus", highlighting an average family size of five members. By the nineties, the message was changed to "hum do hamare do", emphasising the two child norm.

4.5 Non-Government Organisations (NGOs) also began to participate in the social marketing programme, with funding from Government as also from other organisations. In 1987,. Parivar Sewa Sanstha. was the first NGO to introduce its own branded condoms in the market.

4.6 By the early nineties however, most of these private firms had withdrawn from the social marketing programme. They were aggrieved that they had not received adequate media support, for which reason they perceived sales as not significantly improving. The cost of distribution was also high. The programme was being implemented more and more by social marketing organisations (SMOs) only. SMOs would rather promote their own products than Government’s branded products. Moreover, distribution in the urban areas was easier and more cost-effective. There was intense competition among the SMOs, who began infiltrating into each others' marketing territories, possibly leading to some unethical practices.

5. Achievements Of The Social Marketing Programme In India

5.1 Achievements of the social marketing programme are to be viewed in the context of a wider market structure, which also includes the free Government supply of contraceptives, and the commercial sector. Free distribution, Social Marketing, and Commercial Marketing share the market. While free supply was intended to address the unmet need of 40% of the Indian population below poverty line (BPL), social marketing focuses at the lower (20%), lower-middle (15%), and middle-middle (12%) income brackets, for a 47% share of the Indian population. Commercial marketing targets an estimated 8% upper middle class and 5% upper class.

MSI

5.2 The social marketing organisations currently participating in the programme are listed at Annexure II. SMOs market brands, owned and promoted by them within India, without geographic limitation. However, SMOs also market public-sector brands in assigned geographical territories, subject to terms and conditions agreed in each case.

5.3 The health care products being socially marketed in India include condoms, oral contraceptive pills, oral rehydration salts, iron-folic acid tablets, sanitary towels, and mosquito nets. These products are either procured at favourable rates in national or international markets, or sometimes, donated by private foundations or multi - lateral international organisations.

5.4 Some trends in condoms and OCP sales are given in the table.

6. Need for a Formal Strategy

6.1 The social marketing programme (SMP) could clearly have done better, in terms of behavioural change, overall use of contraceptives, and rural outreach. After three decades of Government investments and subsidies for social marketing and IEC, the total contraceptive use through modern temporary methods in 1998-99 (NFHS-2) is only 6.8 percent among women of reproductive age.

6.2 In 1999 the Department of Family Welfare, MOHFW set up a Working Group comprising all the stakeholders who are involved in running the programme. The report of this Working Group emphasised the need for clear articulation of a formal national strategy to direct the ongoing SMP is necessary, embodying lessons learnt, in place of ad-hoc approaches.

6.3 Specifically, challenges to be addressed in any formal strategy for social marketing include :

1. The SMP needs to ensure that people in India get the products and services that they need for basic and essential health care, in particular in the areas of maternal and child health, family planning, STD / AIDS, and safe abortion, at reasonable cost to themselves, and to the Government. The SMP needs to provide multiple choices, through multiple products and services, at multiple delivery points, so as to optimise outreach.
2. We need to augment the usage and off take of reproductive and child health products being currently marketed. For instance, the combined sales (free supply, social marketing, and commercial sector ), of condoms does not exceed 1250 million pieces per year, against the installed indigenous manufacturing capacity of about 2500 million pieces a year.
3. In the past, systemic inefficiencies led to frequent stock-outs of contraceptives, and shortfalls in quantities marketed. While these have been substantially addressed since 1999- 2000, there is scope for further expansion and improvement.
4. The potential and segmented market for contraceptives and other relevant products and services, as well as consumer preferences in respect of product attributes need to be properly researched.
5. The programme has remained needlessly over-centralised and government directed, with neither appropriately trained human resources nor administrative capacity to provide appropriate direction and management. Decision-making is based on precedents; opportunities for expansion and diversification are lost.
6. The SMP should not remain confined to the urban and peri - urban areas, but must reach out quickly and massively to rural households. Subsidies should be re-directed accordingly. The following data from the quinquennial National Family Health Surveys (NFHS) 1992-1993 and in 1998-1999 is revealing:

Rural - Urban Disparities in Contraceptive Usage

(% of reproductive age women using method)

Clearly, there is an urban–rural divide in the usage of contraceptives. Furthermore, the low percentage increase in usage over the period even in urban areas, is also a matter of concern.

B. Vision Statement

7.1 Social marketing will evolve as a tool in response to health improvement planning. Planners at the grass-roots should start with the epidemiological and demographic data for the district ( beginning with the block, or village) and determine the unmet need, as manifested by local morbidity information, coupled with the express priorities of the community itself. Any health improvement plan is an attempt to match service priorities with the resources available. For this reason, any programme for social marketing will first respond to locally specific strategies that may have been identified, and then develop partnerships and options for resource mobilization. The actual health problems of the population being served will be reflected in the basket of products and services being provided through social marketing.

7.2 Social marketing will be implemented on the basis of professional market research findings, in a coordinated and cost-effective manner. The Social Marketing Programme will actively promote and distribute a wide range of quality reproductive and child health information, products and services at affordable prices throughout the country, with a major thrust for under – served segments of the population, in particular, the rural population, people in urban slums and vulnerable groups. It is anticipated that by 2010 the commercial sector will address the needs of much of the currently subsidised urban markets, and free distribution would be restricted to specific low - income and vulnerable groups.

C. OBJECTIVES OF THE SOCIAL MARKETING PROGRAMME

8.0

1. To promote the acceptability and adoption of socially beneficial, voluntary health behaviour.
2. To improve access to, and availability of a wide range of quality health information, products and services with a public health benefit, for the rural, under-served, low-income and vulnerable populations.
3. To provide more affordable health care products and services, with more equitable distribution so as to reach the low income groups.
4. To sustain increases in total contraceptive use, especially spacing methods, among all segments of the population.
5. To adequately research the segmented market for contraceptives and other products and services for basic and essential health care, as well as consumer preferences in respect of product attributes.
6. To decentralise the social marketing programme in the field, and to mainstream the coalition envisaged in the National Population Policy, 2000, for private – NGO - public partnership maybe through a Consortium, that has the potential to catapult the social marketing programme into a national movement to improve availability, access and affordability of basic health care products.
7. To simultaneously ensure the strengthening of logistics at state levels to enable an uninterrupted flow of products and services.
8. The national strategy for social marketing seeks to ensure that essential health services reach low income groups and the "economically active" poor people, through an appropriate public - private mix of financing and provisioning so that they do not pay exorbitant sums for quality health care.

D. Strategic Themes

1. Expand Demand among Priority Target Groups

9.1.1 Effective communication is a key ingredient in any social marketing intervention that seeks to encourage the adoption of socially beneficial health seeking behaviour, and to increase the coverage and outreach of products and services. The first step is to promote behaviour change among potential users, more particularly, among priority target groups. Communication approaches based solely on imparting information may not work as well with difficult to reach groups, as for instance, more participatory behaviour change communication that builds skills in identification of the problem, articulation of symptoms and problems, and negotiation. Communication that aspires to increase demand must be combined with simultaneous measures to ensure access and availability of the health care product or service sought.

9.1.2 The absence of a comprehensive advertising and promotional campaign addressing specific concerns about diverse methods of contraception has been a major lacuna in the contraceptive social marketing programme in India. This holds true globally, for other products as well. For this reason, the true potential for expanding the market for contraceptives has remained unexplored. Demand creation as part of social marketing proved extremely effective at increasing the uptake of clearly identifiable products, such as condoms and insecticide treated nets in Tanzania, where increased product supplies were simultaneously ensured.

9.1.3 The strength of social marketing as a behaviour change strategy is that it enhances access to and demand for goods and services. It combines advocacy and communication for health education with the power of commercial brand advertising. It enables people to connect the information they receive with the easy access and availability of the product, and this enables them to act upon the information bombarded at them. While IEC promotes health-seeking behaviour, social marketing facilitates the practice of such behaviour by enhancing the affordability and availability of relevant products and services to low income groups. For example, while IEC may create a demand for temporary contraceptive methods, social marketing would support this demand by promoting the use of specific brands of condoms or oral pills through advertisement, establishing distribution channels and easily identifiable and accessible sales outlets, and marketing these contraceptives to target groups.

9.1.4 In order to ensure comprehensive information sharing in respect of all products included in the social marketing programme, the SMP should include both brand advertising as well as generic educational campaigns.

Generic Campaigns

9.1.5 Despite the vastly increased media options now available in the country, significant segments of the population remain uninformed about contraception options. Rural populations in particular, are somewhat under-exposed to mass-media. Low literacy levels in some states suggest that reliance on local media and inter - personal communication is essential. Additionally, there is sufficient evidence to indicate that groups and segments which have been informed have not changed their behaviour.

9.1.6 The major focus of the communication component of social marketing should now be to bring planned and sustainable changes in health seeking behaviour. For this to happen, the messages need to be adapted for each segment targeted, and personal contact promoted wherever mass-media coverage is insufficient. Generic campaigns will focus on the linkages between the proper spacing of children and reductions in the mortality and morbidity among women and infants. Generic advertising of contraceptives will explain the benefits as well as the limitations of the diverse contraceptive methods, with a view to dispelling myths.

9.1.7 Generic campaigns will simultaneously promote the wider concept of family well-being, which is not limited to contraception. It will include basic and essential hygiene, sanitation, nutrition, and preventive and life-saving practices, along with the use of newly marketed basic health products.

9.1.8 The development of research based communication strategies through multiple channels will further facilitate the process of behavioural change. Consumer preferences should be identified through research and addressed in the IEC component as well as program design, in order to stimulate demand and promote use.

9.1.9 While generic advertising is usually the responsibility of the Government, it does not follow that it must necessarily be carried out by public agencies. The IEC campaigns in different States or nation-wide may be entrusted to qualified professional media agencies, who may be in the private, NGO, or public sectors. Appointments of such media agencies should be based on open competition, involving both technical bids for prescribed performance standards, and financial bids in respect of cost. This will apply to area projects as well.

Brand Advertising

9.1.10 Any budget for social marketing must have a separate budget line for expanding demand through advocacy for behaviour change. The fiscal provision under this head may be apportioned between generic and brand advertising at the beginning of the financial year. There may be a case for seeking external support for brand advertising for RCH products and for franchised services, based on the following facts / norms:

(a) Brand owners have better information and higher motivation to discern the effectiveness of different media in different locations for the different target groups. Accordingly, the choice of media, locations, target groups and campaign details should be left to the brand owners, who must demonstrate that actual awards of advertisement contracts by them are based on open competition to minimise cost.

(b) SMOs must seek funds from partner organisations for brand advertising.

(c) Government assistance for private SMO brands may be sought in the event of proven achievement of specific benchmarks like rural off-take and rural penetration in particularly remote areas.

(d) Any public funds allocated will be rigorously audited on the basis of commercial audit norms.

(e) Any financial provision by government for brand advertising (promotion subsidy currently being given to SMOs) will be premised upon the notion that with time, brand acceptance is expected to grow (as indeed it has in all cases). Accordingly the Government financial provision for brand advertising should be scaled back gradually but completely over 10 years.

9.1.11 Operational Strategies for Expanding Demand

2. Expanding the Basket of Products in the SMP

9.2.1 In India, the SMP was originally started (1968) to promote acceptability and utilisation of the condom and subsequently, the oral contraceptive pill was the second contraceptive to be included (1987) in the programme. For over thirty years the contraceptive SMP has promoted diverse brands of condoms and oral contraceptive pills, increasing availability of and access to contraceptives. In late 1995, the centrochman (saheli) oral contraceptive was added to the basket of contraceptives.

9.2.2 However, the usage of contraceptives remains alarmingly low, and the current basket of contraceptives in the SMP should be expanded to include new contraceptives such as new formulations of low dose oral contraceptives, spermicides, and maybe also provide fertility regulation services. Emergency contraception also has a place, as a means to prevent undesired pregnancies and abortions. Recently, there has emerged a national consensus in respect of introducing the emergency contraceptive pill. After careful consideration, the Indian Council of Medical Research made specific recommendation, on the basis of which, the Drug Controller of India has for the first time (a) granted permission to import the Levonorgesterol component of the combination pill and (b) simultaneously authorised three parties to manufacture the raw material for the emergency pill. These developments augur well for widening the basket of choices in the social marketing programme.

9.2.3 Methods requiring medical intervention, such as the intra-uterine devices, tubal ligations and the no-scalpel vasectomy may be implemented on pilot scale as an operations research project, and the quality closely quality closely monitored. Such pilot research projects could assess client - provider acceptance of the new methods, the quality systems needed for wider usage, and appropriate norms for pricing. The feedback received from the pilot research projects may determine their wider dissemination in a phased manner. Additionally, other socially beneficial health products, including ISM products, should be gradually introduced in the social marketing programme, depending upon their proven efficacy, availability of standardised protocols, and cost-effectiveness.

9.2.4 Operational Strategies for Expanding the Basket of Products:

III A Public – Private / NGO Partnership

9.3.1 The social marketing programme in India was originally conceived as an activity that would strongly engage the private sector. It was expected that major producers of health care products / pharmaceuticals and / or their distributors would, with a little help from Government, market both the idea, and the products (contraceptives) through promotional activities and retail outlets, to extend outreach and coverage into rural areas. This would generate widespread demand for contraceptives; over a period of time, repeatedly and satisfactorily meeting this demand would bring about behavioural change.

9.3.2 The contribution of the private sector has been invaluable in the first two decades of the programme. It was largely through their efforts that the condom (nirodh) became a household name. The social marketing programme in India was unique in that well established corporate sector distribution chains of consumer goods - Union Carbide, Brooke Bond, Hindustan Lever, Tata Oil, Indian Tobacco Company, and Lipton Tea participated for over two decades, in this national endeavour to reach out to remote rural areas with the condom. It is now time to ensure the renewed interest and participation of the private sector, in partnership with NGOs and the Government as envisaged in the NPP 2000.

9.3.3 The main role envisaged for this coalition is to make available, affordable and accessible a wide range of quality health products and services, at diverse delivery points, as close to rural households as feasible.

9.3.4 Partnership between the for - profit commercial sector, the non - profit NGO sector, the panchayati raj institutions and government is essential for the country-wide distribution of social marketing products. Each of these sectors has for the large part, evolved on its own, with scant reference to each other’s networks, exposure and experience. The first step towards building this coalition is to establish and institutionalise channels for effective dialogue between these entities, and at all levels. Each should define the type of networking / partnership they envisage, articulate those objectives which are common, define a commitment of resources, and then proceed with details of project design and mechanisms for delivery. Effective partnership can promote joint planning, a more rational deployment of resources, the use of multiple distribution networks, a diverse array of competencies, and finally, but most significantly, may lead to multiple sources of funding. NGOs will contribute their wide-ranging experience at the grassroots, and will be particularly sought after for their flexibility and acceptability at local levels.

9.3.5 Operational Strategies for Private – NGO - Public Partnership:

IV Expand the market to reach rural areas and urban slums:

Optimise utilisation of the public health infrastructure.

9.4.1 It is clear that the social marketing programme remains largely confined to the urban and peri -urban areas. In the urban milieu, the socially marketed brands of contraceptives, for instance, compete with the commercially marketed labels, resulting in misdirection of subsidies. Social marketing initiatives need to focus on rural areas, which are not targeted by commercial contraceptive marketing companies. Additionally, for the urban slums, specific and targeted initiatives for promotion and delivery of contraceptives becomes necessary, because commercially marketed contraceptives are beyond the ability of this segment to pay.

9.4.2 Government has in position a widely dispersed network of rural health infrastructure, comprising 137,000 health sub-centres, 25,000 primary health centres, 4,000 community health centres, and 23,000 ISM dispensaries.

9.4.3 However, these channels are not currently available to social marketing organisations, or NGOs, for making either the health care product or the clinical service available. The problem is further compounded when we note that it is often the case that reproductive and child health care products meant for free distribution are also not available in the public health infra-structure on account of systemic shortcomings. NGOs and social marketing organisations should seek to develop public – NGO – private partnerships for the delivery of health care products and clinical and non – clinical services through the existing and widespread public health infra-structure. This will be vastly supportive of the effort to reach out to communities. It will help address the unmet need for health care products and services, and expand the market.

9.4.4 Additional channels such as the ICDS program could similarly be utilised for the sale and dissemination of concepts, ideas, products and services to access the large numbers in the under served segments of the population, primarily in the rural areas and the urban slums.

9.4.5 Operational Strategies for Expanding the Market

V Social Franchising of Health Care Services

5.1 It is being noted that as governments review their role in ensuring the provision of health care, there is a shift from provision to purchasing services from private providers, who may include doctors, other health professionals, health centres, hospitals or any combination of these. Where there are target groups who do not have access to basic and essential health care services, the accreditation of specific services by health care providers from the public, private and the NGO sectors is an effective way of increasing coverage and addressing unmet needs. Health care providers may be affiliated into a network, and provided training in the delivery of a product / service in accordance with a stipulated minimum standard. The skills of providers may be evaluated and similarly, the premises where these services are provided may be externally assessed and accredited inasmuch as they comply up front with norms and standards. Accredited providers may qualify for third party payments from prepayment schemes.

5.2 In India, the private sector provides 82 percent of outpatient days of care⁸. However, private sector clinics tend to focus on higher profit curative services over preventive services. Accordingly, a key challenge is to motivate the private sector to contribute to national health goals by providing good quality basic and preventive health care targeted at the low - income and vulnerable segments of the population. Social franchising can help bridge this gap.

9.5.3 In commercial franchising, a "franchiser" normally develops a prototype business that is profitable and creates management and marketing capacity to expand it. The franchiser then sells or licenses this technology, skill, and know-how to local entrepreneurs, i.e. "franchisees". The franchiser typically maintains an ongoing contractual relationship with the franchisee by providing overall management, supplies and marketing support. This in turn, assists the franchisee to maintain quality and standards, thereby enhancing the franchise image and brand name. Simultaneously, it serves to quickly increase sales volumes.

5.3 Social franchising consists of developing networks of private sector and NGO run clinics, contracted to offer health information and counselling, health products, and health care services. The network would use commercial franchising techniques, and focus on the twin objectives of enhancing equity of access to health care and a high level of financial sustainability. The franchised clinics would promote efficiency, coverage, and utilisation of the country's overall primary health care delivery system.

5.4 The social franchisee would be a private-NGO-public partnership, which will operate as a network of franchised clinics involving formal and informal health care providers. The SMP will, apart from distribution of contraceptives through the franchises, consider providing RCH services, such as no-scalpel vasectomy, tubectomy, IUD insertion, first trimester abortions, post abortion care, family planning counselling, STI/RTI, and VCT (voluntary counselling and testing) for HIV, preventive services, i.e. rehydration, immunisation, growth monitoring and counselling on nutrition, pregnancy check-ups, etc, and products such as oral rehydration salts, bed-nets, safe water kits, IFA and other micro-nutrient supplements. Government services may also benefit from these networks.

5.5 Similar programs have successfully been implemented in other countries, including in south-east Asia: Blue Circle and Gold Circle in Indonesia, Blue Star clinics in Bangladesh, Green Star clinics in Pakistan, and the Integrated Maternal Child Care Service Development project in the Philippines.

In India, Janani, a non-profit Indian organisation, is piloting a similar programme. We give details of some of these systems below.

5.6 Operational Strategies for Social Franchising:

VI Align Government Subsidy to Programme Objectives

6.1 Government provides to social marketing the following subsidies:

• a product subsidy i.e. the difference between procurement cost of the product and the issue price to the SMOs.
• a promotional subsidy to pursue promotional activities, pegged upon the sales achieved.

• a packaging subsidy for those SMOs who market their own brands, since they supply the packaging materials to the manufacturer

6.2 The product, packaging and promotional subsidy is different for the different products. Unfortunately, the sales linked promotion subsidy has led to some distortion in the actual implementation, in that the programme is entirely sales oriented and urban biased. Now that the market is expanding, there is a need to reconsider and formulate afresh the basis of these subsidies.

6.3 The social marketing programme must place a premium on more equitable penetration to reach out to all under - served segments of the population i.e. the rural areas, urban slums, hill areas and tribal populations, displaced and migrant persons. Government subsidies will aim to enhance coverage of under–served segments of the population, inclusion of new products, social franchising of RCH services, and generic promotion. GoI will consider planning, implementing, and monitoring the promotion of its own products. Sales - based promotion subsidies could be replaced by individual promotion subsidies, based on annual promotion plans (benchmark-based) submitted by SMOs.

6.4 This will imply that subsidies will be gradually but substantially reduced for urban areas (except for urban slums). At the same time, free distribution will gradually be restricted to specific low-income and vulnerable groups, to sharply curtail the current unacceptable level of wastage.

6.5 Operational strategies for aligning government subsidy to program objectives:

VII Diversify sources of funding

7.1 Effective implementation of the SMP will require sustained funding. While GoI will continue to provide financial support to the SMP, additional resources do need to be mobilised from diverse sources.

7.2 Multilateral development banks, bilateral and other development organisations, and global foundations should be proactively tapped for funding priority areas of the SMP.

7.3 The SMP will also seek to involve the private corporate sector in program funding. Individual corporate houses may sponsor all or some selected components of the program such as advertising and promotion at state, regional and national levels.

7.4 The SMP will also seek funding support from other related programs and organisations such as National AIDS Control Organisation (NACO). The NPP 2000 emphasises promotion of greater integration between the reproductive health and the HIV/AIDS control programs. Funds from NACO would be sourced to support activities such as condom quality assurance, consumer research, brand promotion, market segmentation, and promotion focused at groups vulnerable to HIV/AIDS.

7.5 Special efforts and early financial support will be required for those states, which are currently lagging in the achievement of socio-demographic indices. Funds for these states could be tapped from the National Population Stabilisation Fund, if necessary.

7.6 Program funds will be used for procurement of products, subsidies for products and services, provider training, generic promotion for child spacing by use of contraceptives, promotion of reproductive health products and services, consumer research and tracking studies, action research for new reproductive health products and services, setting up management information systems, and other uses with approval of the government and funding agencies concerned.

VIII Institutional Mechanism for Running the Social Marketing Programme

8.1 The contraceptive social marketing programme is currently managed by a Social Marketing Unit within the MoHFW and financial support is provided from the budget of the Department of Family Welfare. The SMP needs to be redirected into a more sustainable public – private partnership with diverse stakeholders like the NGOs, the private corporate sector, advertising agencies, market research firms, and state governments. A major recommendation of the Working Group of 1999 on Social Marketing set-up by the MoHFW, has been for the creation of an independent national level agency for managing the programme, preferably with substantial autonomy in its day to day functioning. Several workshops on social marketing in India has also recommended autonomous management arrangements. However, for over thirty years, the social marketing programme has been run by government.

8.2 Till such time as an autonomous organization is set up, there is a consensus on the setting up of a Secretariat within the UNFPA whose mandate it is inter alia, to promote the expanded use of contraceptives. This Secretariat will be aided by a Technical Support Group.

8.3 The UNFPA is the most suitable agency for taking a lead role in setting up an institutional echanism which fully comprehends the private sector operational framework where every activity must be implemented through the most optimal and cost efficient way. This could be a Consortium consisting of representatives of donor organisations, the Indian corporate sector, social marketing organizations, and public health managers, and an appropriate representative of the government. Representation on the executive board of the consortium could be a rotational basis, applicable to all stakeholders, except the government and the lead multilateral agency (UNFPA). This mechanism will remain outside the day-to-day control of the MoHFW, but within a framework suggested by it. The Consortium will determine a long-term sustainability plan to bring about cost efficiencies in the social marketing programme, and to build in flexibility that facilitate the addressing of unmet and emergent needs in diverse under-served areas within the country.

8.4 The Secretariat and the Consortium will be operational to coincide with the commencement of the Tenth Five Year Plan. The Social Marketing Unit within the MoHFW will continue, till that time, to be the administrative unit responsible for the implementation of the Social Marketing Programme. It will pursue all relevant functions including, preparation of budget, release of government funds, issue of government sanctions, co-ordination with other Ministries and state governments, regulatory responsibilities, accountability to parliament, judiciary and other institutions.

8.5 The stakeholders in the SMP, for instance the State Governments, social marketing organizations, multilateral and bilateral donors, manufacturers, private corporate sector, NGOs, research agencies, and in the future, RCH services franchisees may become members of a Consortium on Social Marketing. The need for regular feedback and sharing of information has been identified as crucial for the success of the SMP.

8.6 The institutional mechanism for the SMP will comprise of the following:

• Secretariat coordinated by UNFPA within the Consortium.

• Consortium on Social Marketing: A mechanism for stakeholder involvement in decision-making and for transparency.

• A dedicated Social Marketing Unit within MoHFW for performing the role of facilitator.

• Technical Support Group: A TSG contracted by Social Marketing Unit, within the MoHFW, for providing needed technical inputs in programme management, and advising the Secretariat and the Consortium.

8.7 Operational Strategies for the Institutional Mechanism:

IX Improving Programme Management

1. Participation in the Social Marketing Programme

9.1 Participation and exclusion in the SMP will be based on pre-defined criteria, carefully documented, and reviewed each year. There will be a transparent process for selection, and a competitive system for award of contract, award of non-overlapping concession areas for marketing of GOI brands, distribution contracts for pre-specified periods, long enough to enable the concessionaires to organise the logistics of distribution, but not so long that they need not fear the future consequences of poor performance. The award of contract will be defined in terms of specified areas e.g. rural, urban slums of several districts each to allow for an efficient, cost effective scale of operations. There will not be any provision for automatic renewal without fresh tenders. Independent programme monitoring and evaluation mechanisms will be set up.

9.2 There will be complete transparency about the procurement and supply of contraceptives, in particular, in respect of time schedules, reimbursement of subsidy amount, product pricing and costing.

9.3 There is an immediate need to bring about changes in the packaging of the socially marketed brands of GOI, as proposed in the following operational strategies. The existing norms will be revised to coincide with the next financial year.

Operational Strategies for Improving Programme Management:

(2) Product Management :

Branding

9.4 The GOI brands have been driving the overall condom and oral contraceptive pill market in India, and their low pricing is proving detrimental. However, the multiple brand approaches followed in the Social Marketing Programme in India has widened choices for the clients. Branding promotes market segmentation and image building, which enhances demand. The Social Marketing Programme (SMP) in India will keep introducing newer products and brands. The list of brands currently distributed by SMOs is in Annex II.

Quality assurance

9.5 Quality assurance and mechanisms for testing will be strengthened. The SMP will support research on improvement of the SMP product quality and set up mechanism to take cognisance of advances in biomedical technology as well as packaging. For effectively monitoring quality of condoms, an inter-laboratory calibration mechanism will be set up at the Nodal GOI laboratory for testing.

Product pricing

9.6 Social Marketing is designed to take full advantage of the free-market system. Setting consumer prices at the correct level is critical in the success in any social marketing programme. The success of social marketing programmes is to make contraceptives truly available to the large segment of low-income citizens and the right price is therefore critical to successful programming. The social marketing programme will develop for all its products and services an appropriate structure of margins in the MRP, to cover the cost of distribution and some minimal incentive. SMP will undertake market segmentation and pricing studies will be done to help pricing of various reproductive health services and products before inclusion into the programme. Flexibility will be allowed to the social marketing organisations to set their maximum retail price within a stipulated price range. This price range should be lower than the price of the largest selling commercial brand (determined on the basis of the ORG data), and higher than the GOI social marketed brands.

9.7 Operational Strategies for Product Management :

X Allocation of Public Funds towards Area Projects

10.1 In view of the wide disparities that obtain the country with regard to performance in the health and reproductive health sectors, the MoHFW will create special instruments within the programme that will enable implementation of highly focused interventions by the coalition of public – private – NGO partnership. The Ministry has already supported a few such interventions and the lessons from this experience offer a strong basis for scaling up this strategy.

10.2 The secretariat established for the administration of the social marketing programme will be entrusted with the responsibility to identify areas of need in all parts of the country and to invite plans from the stakeholders for addressing the need through the special projects. Funding support for this component will be over and above the funds earmarked for normal social marketing operations.

Operational Strategy for Area Projects

Area projects are targeted projects for social marketing, which are actively promoting and distributing a wider range of health products and new services to rural populations and vulnerable groups, using professional research and innovative IEC, as recommended in this document. A list of such projects is in annex V. Such pilot initiatives need to be further encouraged, and may be supported by public funds.

Allocation of public funds to area projects will be based on rational and transparent procedures. DoFW will issue requests for applications based on GoI priority geographical and strategic areas. Terms of Reference will describe the type of social programme project to be implemented, as well as corresponding goals, objectives, results, indicators, and targets. Applications from SMOs will be evaluated on specific criteria and according to a pre-defined process.

XI Social Marketing Ethics

11.1 Social marketing organisations bear a responsibility to ensure that they do not jeopardise the smooth running of the social marketing programme by plugging for their individual financial interests. In the past, unethical marketing practices i.e. undercutting each other to grab a share of the market, making sales outside of allocated territorial areas have been noted. Undoubtedly, these practices are facilitated in the absence of clear-cut procedures and norms. This lacuna will be remedied.

11.2 Operational Strategies for Social Marketing Ethics

H. Conclusion:

12. The overall thrust of the SMS is to accelerate achievement of the socio-demographic goals of NPP 2000. Social marketing has immense potential for expanding the outreach and coverage of RCH products and services. The programme is currently at a stage where a clear articulation of a comprehensive strategy will improve the policy environment and strengthen the program. The SMP will strive to achieve the following:

• Lead to behavioural change among priority target groups of specific target groups using local, innovative and research-based communication strategies.

• Expand the market in rural areas and urban slums, using Government rural health infrastructure in addition to private distribution networks.

• Involve the private sector and encourage public-private partnership at all levels.

• Expand the current basket of products.

• Apply commercial franchising techniques to the delivery of standard preventive services.

• Encourage these shifts with Government subsidies for the development of new rural markets, better targeting of free distribution towards most vulnerable groups, and funding of specific interventions in specific areas (area-projects).

• Diversify the sources of funding (private corporate sector).

• Set-up a new mechanism for stronger stakeholder involvement in the management of the programme.

• Improve the management of the programme with the development of rational and transparent guidelines for product management, allocation of government funds, monitoring and evaluation.

• Along with its partners, set-up a Code of Ethics for social marketing practices, and corresponding sanction measures.

THE COMMENTS/SUGGESTIONS/QUERIES RELATING TO THIS DOCUMENT ON NATIONAL STRATEGY FOR SOCIAL MARKETING MAY BE SENT TO THE FOLLOWING LATEST BY 25^TH DECEMBER 2001

Shri Rajendra Mishra,

Director(SSM),

Ministry of Health & Family Welfare,

Room No. 259-A,

Nirman Bhavan,

New Delhi.

Telephone No. 3017740

E-mail : mishra_rajendra @hotmail.com

Annexure 1

Different elements of the "market mix"i.e., the concept of 6 Ps’ are elucidated below

Product

People must first perceive that they have a problem, and that a product on offer is an adequate and acceptable solution for that problem. Research and analysis precede development of a viable product. The role of research is to analyse consumer perception and preferences in terms of the problem and prospective solutions. Social marketing for RCH care encompasses a diverse range of products: from tangibles (e.g., condoms and oral contraceptive pills), to services (e.g., administration of the IUD, no-scalpel vasectomy, and medical termination of pregnancy), to practices (e.g., breast-feeding and use of oral rehydration therapy [ORT]). Products included in the SMP must be distinguished (at least) in brand and packaging from products of the same category meant for free (wholly subsidised) distribution, as well as those sold without subsidy on a strictly commercial basis. This is to ensure that on the one hand, SMP products, being priced, are perceived as being of better quality than the products for free distribution, and on the other, to minimise misuse of subsidy for RCH product distribution.

Price"

Price" refers to what the consumer pays in order to obtain the product or service. The "price" may be monetary, or it may (additionally) involve intangible costs in terms of, for example, time and effort required to access the product / service from the nearest outlet. Many issues need consideration while setting the price for socially marketed products and services. If the price is too low, or the product is provided free of charge, the consumer sometimes perceives it as being of indifferent quality. The free supply of untargeted contraceptives does not always translate into actual contraceptive use. Charging a price addresses issues of wastage, poor product image, and enables monitoring of usage . A reasonable price increases perceptions of quality, and confers a sense of dignity on the transaction. On the other hand, too high a price would make the product unaffordable by the majority. Perceptions of costs and benefits by consumers may be determined through research. Social marketing organisations need to balance these considerations

Place

"Place" refers to the mechanism adopted for distribution, to enhance accessibility of the product or service. The quality of service delivery often greatly improves adoption and acceptability. For a tangible product, e.g. contraceptives, this refers to organisation of the logistics of distribution, i.e., the warehouses, trucks, sales force, retail outlets where it is sold (and other places where it is made available, e.g., self help groups and mahila swasthya sanghs). For an intangible product, e.g. counselling for safe abortion, it refers to channels through which consumers are reached with information or training. This may include clinical premises of health care providers, and health sub-centres or encounters with the ANM and / or the aanganwadi worker.

Promotion

Promotion consists of the judicious use of advertisement, public relations, promotions, media advocacy, inter-personal selling, and "infotainment" . The focus is on creating and sustaining demand for the product. Research helps determine the most effective and cost-effective promotion strategies for reaching defined target beneficiaries.

Partnership

A single agency no matter how dedicated and well organised cannot possibly reach out and make a significant impact in a country as large and diverse as India. It has become necessary to evolve partnerships between different agencies on the one hand, and between the agencies and the community on the other. Identifying prospective partners requires evaluation of which organisations have complementary or similar, though perhaps not identical, goals and capabilities. Avenues for optimal synergy need identification. A key challenge is, accordingly, to build partnerships between the private sector, NGOs, appropriate agencies of Government. Defining the appropriate mix between them, how much the private sector should contribute to public health goals, and defining what the role of the State should be, are also key aspects to consider.

Policy

While SMPs may succeed in bringing about behaviour change in health seeking behaviour, this may be sustainable only if the overall societal environment is supportive of the change in the long term. Policy change often becomes necessary. Media advocacy programs effectively complement shifts in the policy environment.