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Focus
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US study warns of dramatic rise in the HIV infection rate
People living with HIV as target group counsellors in Argentina
Empowerment of girls in Africa
Russia's underrated epidemic
Big sales, little education
The Global Fund to Fight AIDS, Tuberculosis and Malaria
Work on the development of vaccines
02/2003
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Social marketing of condoms in India
Big sales, little education
By Tillmann Elliesen
Socially appropriate marketing of contraceptives in India is aimed at encouraging the poor to use them. When the programme began at the end of the 1960s its goal was solely to reduce population growth. Since the 1990s its mission has included preventing the spread of AIDS. But the social marketing organisations have focused too much on selling contraceptives. They are not paying enough attention to educating the people.
About 30 women are sitting in the community centre in Park Circus, a slum quarter in the middle of Calcutta. The walls are hung with banners promoting condoms and the contraceptive pill. Boards with words and pictures tell the story of family planning and AIDS prevention. The women are uneasy, and few of them are concentrating on what Dr Madhu S. Banerjee is telling them. A handful of men are hanging around the entrance, and the younger ones among them are grinning in embarrassment. Dr Banerjee, a circumspect man of about 60, is talking about contraception, about the risks of too frequent births, and about sexually transmitted diseases. Some of the women leave the room. A woman staff member of the organisation Parivar Seva Sanstha (PSS), the event organiser, interrupts Dr Banerjee and says that these are not "dirty things". She tells the women that it is important for them to learn about these subjects. When yet more women are about to leave, up jumps Jahangir Molla, a small, stocky man with a moustache, whose Focus organisation has worked in this slum quarter for almost 20 years. Annoyed, he calls out that the women should listen and ask questions. A girl of about 16 puts up her hand and asks Dr Banerjee why she has had no appetite for food recently and is no longer growing.
In India, speaking openly about contraception and preventing AIDS is not easy. But it is most certainly imperative. True, the country's annual population growth rate in recent decades was reduced from 2.28 per cent in 1965 to a current 1.7 per cent. But it is still markedly higher than the average rate of other Asian countries, where population growth during the same period declined from 2.4 per cent to 1.3 per cent. If the trend in India continues, the country will over the next 30 years replace China as the most populous in the world. The number of people living with HIV/AIDS is also growing faster in India than in most other Asian countries. In 1992 almost two million adults on the sub-continent were HIV positive. The total has meanwhile already reached five million, and according to a US National Intelligence Council report it could rise to 25 million by 2010. In 2002 the number of HIV positive people totalled 0.8 per cent of the adult population of India, twice the average for Asia as a whole. What is the cause of that? Are the methods of combating AIDS not effective enough?
Only few use condoms or the pill
A problem is that few couples in India use reversible contraceptive methods such as the pill or condom. The most frequent method is sterilisation of the woman (75 per cent); the pill and condoms each account for only 5 per cent. That means that in India contraceptives are scarcely used to extend breaks between births, which would be desirable for the sake of the health of the mother and child. And for combating AIDS it would be important that more men used condoms; all other contraceptive methods are irrelevant in this sense.
In particular, the poor people in urban slums and rural areas are neither sufficiently informed on family planning and AIDS prevention nor have they adequate access to contraceptives. True, the central government in Delhi and the federal states have distributed condoms free of charge since the early 1960s, but these are often not accepted. Many people believe that if they cost nothing they are also worth nothing. But the poor cannot afford commercial products. A third sales channel is aimed at closing the ensuing supply gap. State-subsidised contraceptives, especially pills and condoms, are marketed commercially but offered at more favourable prices. This so-called social marketing has been in place in India since the end of the 1960s. In those days the programme was aimed solely at slowing the country's population growth. The combating of AIDS was added in the 1990s a purpose which since then has become more and more important. At the beginning of the programme the sale of contraceptives was handled by companies operating nationwide, but in the 1980s there arose a number of state-promoted NGOs that specialised in this sector.
One of these NGOs is Parivar Seva Sanstha (PSS), or Reproductive Health Services. With financial support from the Kreditanstalt für Wiederaufbau (KfW), the German Development Bank, PSS seeks to distribute contraceptive pills and condoms among women and men in the slums of Calcutta and the poor villages in the surrounding area. PSS is organised tightly like a private sector company and presents itself so. Explaining its sales curve on a computer screen at the PSS head office in New Delhi, sales manager Sunil Kumar Lall says: "In West Bengal, our sales figures for condoms have doubled from more than four million units in 1998 to more than eight million today." Before he switched to the social marketing branch at the beginning of 2000 he did the same job for a company trading in office machinery. At PSS he has under him two regional sales managers responsible for the East and the North of the country respectively, where PSS is mainly active. These in turn are reported to by area sales managers that are responsible for the individual federal states. About 34 per cent of the PSS budget is funded by bilateral and multilateral development assistance, only 6 per cent comes from the Indian government. The remaining 60 per cent the organisation earns itself.
However, the PSS mission does not give priority to selling as many contraceptives as possible to whom whatever. Rather, the products as well as the educational work of the social marketing organisations are intended for certain target groups: the poor, as well as AIDS risk groups such as women sex workers and their regular customers. However, when one observes the practice of PSS one has to doubt whether the educational part of the mission is taken seriously enough.
Education or marketing?
On the one hand, there are meetings such as that in Park Circus in Calcutta, a mix of an educational seminar and a sales action. For events like this PSS works with smaller NGOs such as Focus, which have close contacts with the people PSS wants to reach and act as it were as door openers. On the other hand, PSS develops together with an advertising agency in Delhi marketing strategies in which the educational components are limited to short slogans targeted at certain groups. For instance, the Milan condom brand is addressed to men who go to prostitutes regularly, such as long-distance truck drivers or day labourers. The condom is very cheap and is sold only at cigarette kiosks, not in chemist's shops like the other PSS condoms. The advertising slogan on the packaging and on the countless metal signs that advertise Milan in Calcutta's red-light districts and along the busy truck routes promise protection from disease. A picture of a scantily-clad young woman in an erotic pose supplements the message: Milan ensures fun without worries.
Social marketing in the past placed too much weight on sales figures. We have to do more about education and information, our second major mission, Krishna Jafa, of Population Services International (PSI), another leading social marketing organisation, concedes self-critically. Sunil Lall of PSS begs to differ. "Education has always been important for us. We couldn't sell our products if we didn't go to the people and tell them, for instance, how they can protect themselves from AIDS." How tough that can be is made clear in Sonagachi, Calcutta's biggest red-light district, where 15,000 prostitutes work. Vikram Kothari, regarded by all in the district as a doctor, but who is actually the local chemist, speaks quite openly at first. But when the talk comes around to AIDS he suddenly becomes taciturn and makes it clear that he would like us to leave. Later, Indranil Bose, PSS sales manager for West Bengal, says that AIDS is of course widespread among prostitutes. "But in districts such as Sonagachi gangs of pimps have the say, and they make sure that nothing is said about that openly. When it becomes known that a prostitute is infected with HIV a pimp can no longer earn money with her."
The men are the problem
One of the biggest challenges for the social marketing organisations' educational work is to reach the men. "It is not as if the men are uninformed, says Ms Malavika Bakshi Rao, of the UN Population Fund (UNFPA), in Delhi. "But they are simply not interested in the subject of family planning." Usually, men do not attend PSS events.
Critics say the social marketing organisations in India lack imagination; it is simply not enough to display a semi-naked woman on a condom packet. They say the Indian organisations should follow the example of Mechai Viravaidya, of Thailand, the charismatic head of the Population and Community Development Association, whose folksy actions have made a decisive contribution to family planning and AIDS prevention now being a matter-of-course in the country, including among men. "It's true, we actually should have achieved more, says Krishna Jafa, of PSI, noting the condom's still-low share of the various methods of contraception. Since the mid-1990s the total number of condoms sold and distributed for free each year has remained practically unchanged. The growth in the annual sales figures for social marketing condoms since 1995 from almost 163 million pieces to more than 465 million in 2000 is offset by a corresponding decline in the number of condoms distributed gratis, from more than 891 million units to only 587 million. The number of commercially sold condoms during this period remained largely constant.
Ms Rao, of UNFPA, has another explanation for the rising PSS sales figures in West Bengal. "Many people have probably simply switched from another social marketing product to a PSS condom, she says, pointing out an open secret. That is, that there is great competition between the Indian social marketing organisations. The government in Delhi remarked in its draft for a National Strategy for Social Marketing that in the scramble for market share "unethical practices" had occurred. At both PSI and PSS that is a subject which people do not like to talk about. Yes, there is now and again certain "duplication, admits Ms Jafa, of PSI, cautiously. At PSS they see no problems: competition is good for the consumer because he has the choice of several products. But in fact what is sold is always the same type of condom that is produced to government order and merely packaged differently by the social marketing organisations.
The enormous growth of the sales figures since the beginning of social marketing in India at the end of the 1960s gives the impression that the programme is a complete success. But the fact that the total number of condoms sold and distributed free is stagnating indicates that Ms Jafa's assessment is right. The Indian social marketing organisations have in the past focused too much on selling their products and too little on educating the people. Social marketing, however, defeats its purpose when the organisations involved merely poach customers from each other. Their task must above all be to create an awareness of family planning and AIDS prevention and gain new customers. But that has been achieved to only certain degrees. It might be helpful if the organisations were to cooperate more with each other, if they would exchange ideas more on strategies and problems. Not least for this purpose, some donor countries two years ago proposed the setting up of a social marketing consortium, which the Indian government rejected. Delhi fears that via such a consortium too many actors could gain influence on population policy decisions.
"There are still many taboos that make our work difficult, says Krishna Jafa. "On the other hand, much has also happened since the mid-1990s. For instance, ten years ago it would have been inconceivable to speak openly about the spread of AIDS due to prostitution." Indranil Bose, of PSS, confirms that. "Only a few years ago we were glad if we had brought five women together at our information events. Now, they want us to visit the villages every month. Come and visit us again in ten years' time, he says optimistically. "Men will then account for half the participants."
The draft for a National Strategy for Social Marketing can be seen on the Government of India Ministry of Health and Family Welfare website: health.nic.in/PPP.htm
Information on PSS via:
www.mariestopes.org.uk/ww/india.htm
Net resources:
Population Services International: www.psi.org
UNFPA India: www.unfpa.org.in
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