PROJECT REPORT ON

MARKETING STRATEGY OF HEALTH AND FAMILY WELFARE PRODUCTS

Submitted In Partial Fulfillment of the Requirement of Bachelor of Business Administration (BBA)

Jamia Hamdard University, New Delhi

Project Supervisor: MR. INTSAR ALI Senior Faculty

Submitted By: NEHA Enrollment No. ODL/08/403/4986

Session: 2008-2011

JAMIA HAMDARD UNIVERSITY, NEW DELHI Through SOFTDOT HI-TECH EDUCATIONAL AND TRAINING INSTITUTE

CERTIFICATE
This is to certify that Neha is the student of BBA final year course affiliated to Jamia Hamdard University, New Delhi. He has prepared a project report titled Marketing Strategy of Health and Family Welfare Products as a partial fulfillment of Bachelor degree in Business Administration (BBA) from Jamia Hamdard University for the academic year 2008-2011.

Inter Guide Mr. INTSAR ALI

Center Co-ordinator Manoj Aggarwal

ACKNOWLEDGEMENT
I have prepared this study paper for the Marketing Strategy of Health and Family Welfare Products. Quite frankly, I have derived the contents and approach of this study paper through discussions with colleagues who are also the students of this course as well as with the help of various Books, Magazines and Newspapers etc.

I would like to give my sincere thanks to a host of friends and the teachers who, through their guidance, enthusiasm and counseling helped me enormously. As I think there will be always need of improvement. Apart from this, I hope this study paper would stimulate the need of thinking and discussion on the topics like this one.

NEHA Roll No. - ODL/08/403/4986

TABLE OF CONTENTS
Chapter-1- Introduction Chapter-2- Objectives of the Study Chapter-3- Research Methodology
Research Design Primary Data Secondary Data Data collection Primary Data Sample Size Sample Area Sample Unit Secondary Data

1-11 12 13-16

Chapter-4- Literature Review

The dynamics of public health in India The scenario of malnutrition in India: Project Mandi: Role of MNCS Family planning and reproductive health indicators Marketing of contraceptives

17-62

Chapter-5- Data Analysis Chapter-6- Conclusion BIBLIOGRAPHY APPENDIX

63-74 75-76 77 78-79

INTRODUCTION
Delivering quality public health services in India is a major challenge. At the heart of this lies the cause unplanned pregnancies, lack of birth spacing and risky sexual behaviour, all of which not only endanger the mother and child's health, but also place a severe financial burden on the family. With over 70% of Indians living in villages, the challenges are daunting. Population concerns have a long history in India. Until 1920, Indias population had been growing very slowly owing to the heavy toll from famines, epidemics, and wars. According to census reports, the population of the country within its present geographical boundaries actually declined between l911 and 1921, from 252.1 to 251.3 million because of the high mortality inflicted by the influenza pandemic of l918-19. It is estimated that about 5 percent of the countrys population - some 13 million persons - died in that epidemic. The population has increased steadily since l921, largely because of epidemic and famine control measures undertaken simultaneously with sanitation programmes by the provincial governments. India, with a current population of 967 million, will most likely surpass China in population size by about the middle of the next century. Indias population is currently growing at a rate about 70 percent higher than that of China and will continue growing faster than China for many years in the future.

MORTALITY AND HIV/AIDS

India, like other developing countries, has achieved substantial improvements in mortality. Since independence (1947), life expectancy has roughly doubled from about 32-33 years to 62 years in 1997. The infant mortality rate (IMR) has been reduced from 200-225 infant deaths per 1,000 births to 66. India has a lower IMR than its immediate neighbors Pakistan and Bangladeshbut a much higher rate than China, Sri Lanka, and various other South East Asian countries. Among Indias major States, IMRs (1992-94) range from 15 to 109 per 1,000 births. Uttar Pradesh, the largest State, has one of the highest rates (93). Inadequate antenatal care and delivery services, low levels of immunization among children, and a substantial proportion of high risk births are some of the reasons for the relatively high mortality of infants and children in India.

Future improvements in mortality may be slowed or even stalled by the HIV/AIDS epidemic in India. While HIV was introduced into India at a later date than much of the rest of the world, the epidemic is extensive, with rapid growth in some geographic areas. Studies of high-risk populations (commercial sex workers, intravenous drug users, and sexually transmitted disease patients) show high and rapidly rising rates of HIV infection, exceeding 50 percent in some areas of the country. Recent studies show that the virus also is spreading in the general population. For example, the level of HIV seroprevalence among pregnant women in the State of Tamil Nadu quadrupled between 1989 and 1991 from a rate of 0.2 to 0.8 percent; in Manipur it was 2 percent in 1994 (U.S. Bureau of the Census, 1995). A recent report (AIDSCAP, et al., 1996) estimates that between 2 and 5 million people in India are currently infected with HIV. An earlier report (WHO, 1995) had estimated that at the end of 1994, 1.75 million adults were infected. The level of HIV seroprevalence varies by regions. It is higher in south and west India compared with the rest of the country (AIDSCAP, et al., 1996).

The population policies formulated, and the national programmes of family planning implemented after independence went through a number of changes both in the intensity and modus operandi; can conveniently be classified into six phases as follows: 1. Clinic Approach (1951-61); -------- As an important component of its developmental strategy it sought to reduce the birth rates to the extent necessary to stabilize the population at a level consistent with the requirements of the national economy. A modest sum of Rs 6.5 million (or US $ 1.44 million at the exchange rate of 1 US $ = Rs 4.5 at that time) was allocated by the Central Government for the family planning programme which included a plethora of activities such as motivation, education, research and clinical services. The initial approach adopted by the Government was a clinic approach; a number of family planning clinics were opened throughout the country and it was assumed that there was already a strong desire to space and limit family size among the couples and if contraceptive services such as condoms, diaphragm and jelly, and vasectomy for men were offered in a clinic setting, it would be sufficient to reduce the birth rate. The clinic approach was extended during the second plan period, 1956-61, increasing the number of clinics from 147 to 4165.

2. Extension Education Approach low intensity HITTS model (1962-69); ------Incentives were offered to vasectomy acceptors and to women who were accepting IUD insertions, and the clinic approach was replaced by extension approach in which the family planning workers were asked to make house to house visits to motivate couples to accept family planning methods; targets on the number of contraceptive acceptors to be recruited were fixed to the workers. The concept of improvident maternity to indicate all births of order 4 and above as accidental and not really wanted by the parents themselves was proposed. 3. High intensity HITTS Approach (1969-75); ---- vasectomy camps were organized, first as mini camps (where not more than 30 vasectomies were done in one day) and then as large camps such as the Ernakulam camp in Kerala in 1970 where over 60,000 vasectomies were done over a week. Government officials from many other departments, other than health, were involved in the organization of these camps and incentives both in cash and kind, were offered in addition to those officially sanctioned by the Government of India. The involvement of officials from revenue and police departments added a touch of coercion and even compulsion in the programme. 4. Coercive approach (1976-77) ------- For the first time, a National Population Policy was formulated and adopted by the Parliament (April 76) which called for a frontal attack on the problems of population and which inspired the state governments to pass suitable legislation to make family planning compulsory for citizens and to stop child bearing after three children, if the state so desires. Many other measures were introduced such as stipulations to government officials in the health and revenue departments to recruit given numbers of vasectomies from their

areas of operation, failing which punishments were to be meted out to them. Various coercive tactics were used to control the fertility levels, mainly though increased number of vasectomies. 5. Recoil and recovery Phase (1977-94);------- The health-based, time-bound targetoriented family planning programme was revived with reduced emphasis on sterilization and greater emphasis on spacing methods and on child survival programmes. These were to be implemented through all the sub-centers and Primary Health Centers in the rural areas, without any aggressive campaigns or mass camps for sterilization as were adopted in earlier years. 6. Reproductive and Child Health Approach (since 1995)-------- At present three policies seem to be in operation in the country that have direct impact on population issues and availability of family planning services. These are the National Population Policy 2000 (NPP 2000), the National Health Policy (NHP 2002) and the recently launched National Rural Health Mission (NRHM 2005).

Contraceptive Prevalence
The national family planning program, which was established in 1952, has played an important role in Indias fertility decline. When the program began, there was little awareness or use of modern birth control methods. Four decades later, the 1992-93 National Family Health Survey (NFHS) found nearly universal knowledge of family planning, with 96 percent of married women ages 13 to 49 years having heard of at least one modern method, and almost 41 percent, or almost 70 million women, using contraception.

Eighty-nine percent of married women who practiced family planning in India relied upon modern contraceptive methods. Female sterilization, the method which is strongly promoted by Indias family planning program, was by far the most widely used method. Nearly 67 percent of married women who were using contraception, or 47 million women, had been sterilized compared with an average of only 30 percent for the entire world. Spacing methods, primarily available through the private sector, were used by a small proportion of users: the pill by 3 percent, IUD by 5 percent, and condom by 6 percent. Education, religion, place and State of residence are among the factors that strongly correlate with contraceptive use in India. Nearly half of the married women with some primary schooling use contraception compared with one third of illiterate women. Differentials by religion are also strong. Higher prevalence rates (48 to 63 percent) are found among small minority religions (Jains, Sikhs, Buddhists, and Christians) than among Hindus (42 percent), and the lowest use (28 percent) is found among Muslims. A higher proportion of urban married women (51 percent) than rural married women (37 percent) use contraceptives. Among the major States, contraceptive use ranges from more than 63 percent of married women using contraceptives in Kerala to less than 20 percent in Uttar Pradesh

FERTILITY PREFERENCE AND UNMET NEED FOR FAMILY PLANNING According to the NFHS, a large majority of married women in India (77 percent) prefer to regulate their fertility: 26 percent do not want another child, 31 percent (or their husbands) were sterilized, and 20 percent want to postpone their next birth.

However, the survey found incongruence between womens desire and actual practice to regulate their fertility. Nearly 23 percent of births during the 4-year period before the survey were not wanted by women: 14 percent of all births were mistimed and 9 percent were not wanted at all. If there were no unwanted births in India, its TFR would be lower by nearly three quarters of a child. For Uttar Pradesh, avoidance of unwanted births could reduce the TFR by at least one child. A substantial portion of the total demand for family planning services remains unsatisfied. According to the NFHS, nearly 20 percent of married women in India have an unmet need for family planning: 8.5 percent want to stop having children and 11.0 percent want to postpone their next birth. Unmet need for spacing is a substantial portion of the total unmet need for family planningmost of the unmet need among younger women is for spacing. This suggests that more attention should be given to methods other than sterilization, such as condom, the pill, and IUD.3 Further, fully meeting todays unmet need for family planning, that is, providing services to an additional 35 million women, will require substantial additional resources. If this were accomplished, India could meet its goal for 2016 of having 60 percent of married women practicing family planning. To meet this goal in 2016, will require that 159 million women practice family planning (about double the current number). Poverty assumes different dimensions across the world and has a global impact. The International Community came together to develop and implement an agreement the Millennium Development Goals- that focused on development of the global community through strategies focused on poverty alleviation. It was hoped that the MDG will be achieved by 2015.

THE EIGHT MILLENNIUM DEVELOPMENT GOALS

Eradicate extreme poverty and hunger- Halve the proportion of people living on less than one dollar per day suffer from hunger Achieve Universal Primary Education-- Ensure that boys and girls alike complete primary schooling Promote gender equality and empower women-- Eliminate gender disparity at all levels of education Reduce child mortality-- Reduce by two-thirds the under-five mortality rate Improve maternal health--- Reduce by three-quarters the maternal mortality rate Combat HIV/AIDS, Malaria and other diseases-- Reverse the spread of HIV/AIDS Ensure environmental sustainability-- Integrate sustainable development into country policies and reverse loss of environmental resources. Halve the proportion of people without access to potable water. Significantly improve the lives of at least 100 million slum dwellers Develop a global partnership for development-- Raise official development assistance. Expand market access There are several interesting aspects to the eight MDGs. Five of the eight goals and one of the two prongs of the strategy for development concern health and education. Success in reaching these goals had to be based on system wide reforms to support progress. The focus on health and education outcomes did not imply- either implicitly or explicitly- that other factors were not important. Health and education are interlinked

with social dynamics, accessibility, availability and affordability of infrastructure and trained human resources, and the availability and utilization of technology to produce favourable outcomes The spirit of the MDG- time bound, outcome based targets- does not die by achieving these goals. Worldwide, Governments are committed to the principle and targets of the MDG. Whether countries can scale up health interventions by 2015 to meet the MDGs and the increasing pressure of life style diseases, depend only in part on sound governmental policies and expanded funding. Halfway through the interval for achieving MDGs, the score is mixed; for example, the poorest 20 percent of the population within countries have seen improvements in nutrition, but child mortality has been falling more slowly among the poor than among the betteroff. In addition to this challenge, developing countries also face the rapidly increasing burden of life style related diseases across populations. Clearly, there is a need for improvised or innovative solutions. In the context of the above mentioned discussions, the present study assumes wider significance which deals with the following objectives:

OBJECTIVES OF THE STUDY

To understand the concept of public health and the basic issues involved in it, including the barriers in this direction, To delineate the basic and innovative methods and products which are utilized for improvement of public health in India, The marketing strategy of the public health products in India, in the context of analysis of Family Planning, HIV/ AIDS and malnutrition.

RESEARCH METHODOLOGY:The present study is purely an exploratory study, dependent on both the primary and the Secondary sources of data. The primary sources of data constitutes the interaction, both formal and informal, of the researcher with the top managers and other company officials and the responses gathered through the method of questionnaire. The Annual Reports of the concerned Ministries and the study papers of various NGOs and that of Seminars and Conferences, the relevant literature and facts and figures available on the problem of the study in various books, journals and magazines constitute the Secondary sources of data.

RESEARCH METHODOLOGY
A Research Methodology defines the purpose of the research, how it proceeds, how to measure progress and what constitute success with respect to the objectives determined for carrying out the research study. The appropriate research design formulated is detailed below. EXPLORATORY RESEARCH: This kind of research has the primary objective of development of insights into the problem. It studies the main area where the problem lies and also tries to evaluate some appropriate courses of action. The research methodology for the present study has been adopted to reflect these realties and help reach the logical conclusion in an objective and scientific manner. The present study contemplated an exploratory research

RESEARCH DESIGN
The research design is the basic framework, which provides guidelines for the rest of the research process. The present research can be said to be exploratory. The research design determines the direction of the study throughout and the procedures to be followed. It determines the data collection method, sampling method, the fieldwork and so on.

NATURE OF DATA
PRIMARY DATA: Primary data is basically fresh data collected directly from the target respondents; it could be collected through Questionnaire Surveys, Interviews, Focus Group Discussions Etc. SECONDARY DATA: Secondary data that is already available and published

.it could be internal and external source of data. Internal source: which originates from the specific field or area where research is carried out e.g. publish broachers, official reports etc. External source: This originates outside the field of study like books, periodicals, journals, newspapers and the Internet.

DATA COLLECTION PRIMARY DATA: Primary data was selected from the sample by a selfadministrated questionnaire and interviews among many NGOs, Government Officials (Health Ministry), and the unemployed, poor and downtrodden people in regard to my research study.

SAMPLE SIZE: The survey is conducted among 100 respondents SAMPLE AREA: SAMPLE UNIT: NCR Delhi Officials and Employees of many NGOs, Government

Officials (Health Ministry), and the unemployed, poor and downtrodden people in regard to the current research study

SECONDARY DATA:
through Articles, Reports, Journals, Magazines, Newspapers and Internet

Secondary data has been used which is collected

SAMPLING TECHNIQUE
Random sampling technique has been employed to extract the fruitful results. This includes the overall design, the sampling procedure, the data collection methods, the field methods and the analysis procedures SAMPLING PROCEDURE ACTUALLY EMPLOYED: The process employed to select the sample was simple random sampling. Simple random sampling refers to that sampling technique in which each and every unit of the population has an equal and same opportunity of being on the sample. In simple random sampling, which item gets selected is just a matter of chance.

ANALYTICAL TOOLS:
Simple statistical tools have been used in the present study to analyze and interpret the data collected from the field. The study has used percentiles method and the data are presented in the form of tables and diagrams.

LITERATURE REVIEW
THE DYNAMICS OF PUBLIC HEALTH IN INDIA
Poor people usually have the worst health outcomes and people are pushed further into poverty due to ill health. Health services fail poor people because health systems are often caught in a web of failed accountability. At the current pace, most countries will not reach the Millennium Development Goals for Health by 2015. Halfway through the interval for achieving MDGs, the score is mixed; for example, the poorest 20 percent of the population within countries have seen improvements in nutrition, but child mortality has been falling more slowly among the poor than among the better-off. In addition to this challenge, developing countries also face the rapidly increasing burden of lifestyle-related diseases across populations. Interestingly poor groups have high rates of malnourishment, obesity and diabetes and are no longer excluded from the epidemiological transition. Several factors besides the availability and quality of care affect health outcomes among poor. The availability of services often varies inversely with need. Health financing solutions for the poor often range from a difficult-to-sustain completely free package to health insurance schemes that are not necessarily sensitive or flexible enough for the rural psyche. The reality of easily accessible quality health care in rural India remains a myth for many parts even after 59 years of independence. Responsiveness to patient needs is better in the private sector but the technical quality of services may vary from the excellent to the very poor and is compounded by a lack of regulatory mechanisms. Gaps exist in several areas of health care. Some of the most important gaps include an understanding of the burden of disease and what leads or causes ill health, the availability and use of appropriate technology in the

management of diseases and ill health, and health systems that impact upon service delivery. Relatively little attention has been paid, by either the private or the public sector, to technology applications that could improve the capacity of communities to carry out non-clinical or population-based functions of public health. On the public heath front, thus far, the efforts of central or state governments have been mostly related to computerization of hospitals for the delivery of medical care to individuals. Health is a key driver of development. The National Rural Health Mission of the Government of India is an example of an initiative aimed at achieving the MDGs. The National Rural Health Mission of India seeks to provide effective health care to the rural population, especially the disadvantaged groups including women and children, by improving access, enabling community ownership and demand for services, strengthening public health systems for efficient service delivery, enhancing equity and accountability and promoting decentralization. Innovation in public health needs a constant flow of information. There is potential to improve upon technology for information generation, for analysis of collected information and to use it appropriately. Information in public health is to a large extent present in the health care, surveillance and research domains. The information present in different domains needs to be collected and synthesized appropriately for optimal benefits. Progress in public health is essentially achieved through new knowledge or new means to use existing knowledge. A commitment of resources to research and national and appropriate international and intersectoral collaborations is essential along with mechanisms to strike a balance between exploration of new ideas and the possibility of failure to demonstrate anything new. There has to be demonstrable outcomes from research (even if it is a negative outcome) like new drugs, vaccines, diagnostics, devices, and strategies for their effective use. Ultimately, political will, stewardship, public accountability and outcomes driven policies are necessary to drive the process forwards.

Public health has to shift focus from disease prevention to health promotion. There are, of course, several challenges including social and economic inequalities to access, stratification of society by different criteria including race, ethnicity, gender, religion, the possibility that political power is not always exercised focusing on public health and the differing environments and biological ecology among member states of the world. There are several other challenges as member states strive to improve public health equitably. Diseases are now assuming complex multi factorial patterns There is an epidemiological transition of diseases from the unfinished agenda of communicable diseases to the more complex non -communicable diseases The epidemiological transition is increasingly prevalent even among resource poor populations Achieving equity is not as easy as it sounds - A reality too often overlooked in the search for equity is that problems only of the poorare no longer the only problems of the poor (Julio Frenk: Bridging the divide: global lessons from evidence-based health policy in Mexico. Lancet 368: 954, 2006) Several innovations for information collection and dissemination are possible:Electronic reporting track disease patterns, risk factors, access to care, pharmacy, outcome Rapid, sensitive, reliable diagnostic tools Remote sensing integration with ground level data Personal data storage secure, private, portable accessible, usable, personal medical records Telemedicine to less accessible areas Mobile phones to communicate among providers, assist adherence, transfer lab data with feedback, manage drugs, and provide patient support Celli medicine. However, innovations require commitment at different levels- a commitment to act, to equity, of resources, to innovation and accountability. Traditionally, governments are the major players in health care delivery especially related to public health. Governments across the world demonstrate their intent of

concern for the health and education of populations by financing, providing or regulating the provision of services that influence health and education outcomes. These services are replete with market failures- with externalities- that traditional schools of thought have questioned the ability of a profit driven private sector to provide necessary services that will help communities achieve the desired levels of health or education. However, changing demographics and changing complexities of disease including epidemiological transition are placing greater strain on the public sector. Responsiveness to changes needs rapid solutions and heavy investment in people and infrastructure, something that governments are increasingly finding difficult to address as other priorities compete for its attention. Services are failing poor people. Health budget allocations that actually are spent on poor people are abysmally low. The money does not always reach the frontline service provider. Incentives for service delivery are weak, wages are often not paid on time, corruption is rife and political patronage is accepted as a way of life. There is also an increasing lack of demand for services from the public sector. People increasingly prefer the private sector for services equating higher charges with accountability and better quality. Worldwide, governments are aware of the need to develop alternative service delivery arrangements and are engaging the private and not-for-profit sectors. Some governments contract services out to private or not-for-profit agencies. Governments also sell concessions to the private sector. Some societies have transferred responsibility to lower tiers of government as part of a decentralization process. Responsibility is sometimes transferred to communities, or to the clients themselves. Sometimes, resources and responsibilities are transferred to the household as a unit. India has not been an exception to the global trend of non-government players becoming more active in the delivery of healthcare. There are several models in the not-for-profit and profit sectors that have changed the way health care has been delivered in India.

A balance has to be struck between what the public really want and what policy makers want the public to have. Lack of accessibility to health centres, lack of information and erroneous treatment from health staff remain major issues. The relatively lower rates of literacy and enrolment into technical streams and technology diffusion are areas of concern. Issues like lower priority for health care, lack of information and family support, lack of transportation, lack of money and social taboos or beliefs still influence the uptake of health care. There are several technological innovations developed by research institutes in India like detection kits for filariasis, leishmaniasis, dengue fever, west nile virus, typhoid, HIV, and kits for the detection of pregnancy. Many of the diagnostic tests that are marketed & available in primary healthcare settings in developing countries are sold and used with little or no evidence of their effectiveness. This is because unlike drugs, diagnostics are not subject to strict regulatory approval standards. During 2006-07 diagnostic tests for malaria, TB, dengue, schistosomiasis and sexually transmitted diseases will be evaluated in their intended settings & the evidence communicated to policy makers (WHO TDR news 2006). Possible roles for Health Technology Assessments (HTA) in India like responsible incorporation of technologies, development of framework of cost-effective / benefit analysis based on rural conditions and needs (Dye et al, 2005, Sculpher et al, 2004), publicly reported data on quality of health care (Broder et al, 2004), identify factors for high volume, high quality work (Thulsidas et al, 2006) and HTA (PD and T) of major conditions (Kirkwood et al, 1995), facilitate and guide indigenous health technology products e.g. blood bags, titanium implants, heart disc valves (Chitra Tirunal Institute), provide health information advising consumers and policy makers and planning integrated curative and investigative services. The politics of diseases and their implications on research and development was discussed. Technologies maybe high priced and patented or disproportionate to the global burden of disease or through sheer serendipity. Public health demands cost-benefit ratio, reduction in mortality and morbidity and reduced side effects, while market demands need demand, technological feasibility and returns on investment. The politics of multi-country agreements that favour developed countries at the expense of premier research

institutes in developing countries is a concern. Double or triple standards for a single indicator exist - potable water and pesticide residue analysis in India is an example. There is a lack of support services for a society that is willing to invest in health care, is increasingly demanding high quality at affordable prices, and in societies with a rapid disappearance of the urban rural divide.

The crucial need for new health tools is plainly apparent for the worlds three leading infectious killers, which together account for more than five million deaths annually: HIV: While a range of prevention tools currently existsuch as male and female condoms, harm reduction for injecting drug users, and antiretroviral prophylaxis for mother-to-child transmission none is 100% effective or reaches more than a small fraction of those needing protection. Women lack a prevention method designed for their use and control. Tuberculosis (TB): The screening technology used to diagnose TB remains unchanged since its development more than a century ago, no new class of TB drugs has emerged since the 1960s, and the existing vaccine for TB has limited efficacy. Malaria: No vaccine exists for malaria, which kills a child every three minutes. Throughout much of Africa, resistance to the least expensive malaria medications has become widespread, while bed nets are insufficiently used and pose the challenge of requiring periodic re-treatment with insecticide to remain effective. The present study basically deals with three broad issues relating to the dynamics of Public Health in India:(i) (ii) (iii) Family Planning HIV/ AIDS Malnutrition

POPULATION PROBLEM AND THE CHANGING FAMILY PLANNING SCENARIO IN INDIA

While the average life expectancy in high-income countries is nearly 80 years, a child born in one of the world's least-developed countries can barely expect to reach age 50. A handful of communicable diseases, most of which are either non-existent or minimally present in the developed world, are responsible for much of the health gap between rich and poor. Each year India adds more people to the worlds population than any other country. In 1997, there were almost as many babies born in India (about 25 million) as in all of Sub-Saharan Africa and more than in China (21 million). The total fertility rate is declining by 42 percent since the mid-1960but the continued increase in the number of women of reproductive age suggests continued high numbers of births. Currently, India has a young population which will grow somewhat older largely as a result of the fertility decline which is already underway. Between now and 2020, both the working age population and the number of women in childbearing ages will grow more rapidly and will become larger proportions of the total population than now. Among Indias major States, IMRs (1992-94) range from 15 to 109 per 1,000 births. Uttar Pradesh, the largest State, has one of the highest rates (93). Inadequate antenatal care and delivery services, low levels of immunization among children, and a substantial proportion of high-risk births are some of the reasons for the relatively high mortality of infants and children in India. Fertility varies widely among States; it is significantly below the national average in the southern and western States and higher in the others. With a TFR of 5.2 in 1993, Uttar Pradesh clearly stands out as having especially high fertility, nearly 50 percent above the national level. Population as an important factor in determining the means of subsistence originated with the great work of Thomas Malthus published in 1796 in Principles of Population. His view that high fertility leading to high population growth is a great impediment to development and even meeting the basic needs of the people, because of population size has a potential to grow at geometric progression while food production can at best grow only at arithmetic progression, prevailed as a leading thought in the western world for over 100 years. If human beings do not control fertility, Malthus argued, nature would bring back the balance between food supply

and population size by famines, wars, and epidemics or positive checks. India was shown as the typical case where Malthusian checks are likely to occur because population growth was overrunning the means of production and unless population growth rates are controlled the checks on it by hunger; famines and epidemics could not be avoided. Being a devout religious Christian priest, Malthus considered the use of contraceptives morally wrong and advocated late marriage and abstinence within marriage as the means of controlling fertility and population growth. In this aspect Gandhiji, a century later, shared the views of Malthus. The British as colonizers attributed all the famines, epidemics and deaths that happened in the Indian sub continent to its overpopulation, rather conveniently, without assuming any responsibility on their side. A critical study of the population policies and programmes adopted in India since l951, briefly outlined above, and an analysis of the current situation reveals that the deficiencies and mistakes that we have made so far in this front have been many and serious, though with good intentions and are to be corrected forthwith. And with a strong will for taking the country to the league of the developed nations of the world by 2020 (Planning Commissions Vision 2020) the following conclusions can be drawn: The program placed almost a total emphasis on sterilization as the major method of family planning from the very beginning; vasectomy until 1977 and tubectomy thereafter, and the quality of services offered in this regard was far from satisfactory and has not improved over time. With emphasis on sterilization, only high parity older women accepted the method, and the young high fertile lower parity women were not covered by the programme. While other developing countries such as, China, South Korea, Malaysia, Indonesia started their family planning programmes with spacing methods and then introduced sterilizations after the spacing concept was ingrained in the psyche of the population, India went the opposite way with limitation as the ultimate goal of family planning. Spacing methods, such as IUD, oral pills, injectables and condoms are being used by a small proportion of the eligible couples, even 50 years after the initiation of the programme. Though there are wide inter-state differentials in fertility levels, there are no large differentials in the pattern of use of various methods. Sterilization is as dominant a method of family

planning in Andhra Pradesh, Kerala and TamilNadu with below replacement fertility levels as in Uttar Pradesh and Bihar with TFR above. This trend has to be reversed by specific policy and programme measures. In most of the high fertility states there exists a very high level of unmet need for family planning, expressed by the women themselves, for limitation methods but there is also high unmet need for spacing methods and this is bound to increase in the coming years. Contraception has come to mean sterilization for most of the couples in the country. Spacing as a concept is yet to take root and the need of the hour is the offer of choice and quality of service. While spacing and limiting their family size it is desirable to retain, as long as possible and feasible, the potential fertility of women, their god-given power and their right. I think to keep her power of reproduction is a woman s fundamental right and has to be respected. Sterilizations should be the last resort than the first one in the contraceptive choice. Thus there is an urgent need to expand the range of choice of contraceptives and the quality of services to the couples. Over the last decade, India has shown overall improvement in social and health indicators. This improvement is particularly observable in the Southern states than in the Northern belt. In the Northern belt the predominant needs still relate to access, availability and delivery of comprehensive and quality reproductive health services, support for womens empowerment, addressing adolescents needs and prompting and enhancing male participation in all issues related to reproductive and sexual health. The National Family Health Survey (NFHS 1998-1999) indicates a Total Fertility Rate (TFR) of 2.85 births per woman with a contraceptive prevalence of 42 per cent among currently married women (modern methods). Less than 7 per cent of currently married women use any of the three major spacing methods, (oral contraceptives, condoms, and IUD) and sterilization accounts for three-fourth of the contraceptive prevalence. HLFPPT has conducted numerous social marketing projects to market the various brands of condoms and oral contraceptive pills.

Changing Methods/ Products Family Planning Scenario In India:The Family Welfare Programme in India has experienced significant growth and adaptation over the past half century since its inception in 1951. During this period, financial investments in the programme have substantially increased and service delivery points have significantly expanded. Services administered through the programme have been broadened to include immunisation, pregnancy, delivery and postpartum care, and preventive and curative health care. The range of contraceptive products delivered through the programme has widened. Multiple stakeholders, including the private sector and non-governmental sector, have been engaged in providing contraceptive services. Of late, the programme has been integrated with the broader Reproductive and Child Health Programme. The couple protection rate has quadrupled from 10 per cent in 1971 to 44 per cent in 1999 (MOHFW 2000). Notwithstanding these achievements, several issues continue to daunt the programme and many goals remain under-achieved: a significant proportion of pregnancies continue to be unplanned; the contraceptive needs of millions of women remain unmet; several sub-population groups including adolescents and men continue to be neglected and under-served; and contraceptive choice remains conspicuous by its absence, as is quality of care within the programme. The Family Welfare Programme in India was launched with the objective of reducing birth rates to the extent necessary to stabilise population at a level consistent with the requirements of the national economy. The programme has since evolved through a number of stages, and has changed direction, emphasis and strategies. During the first decade of its existence, family planning was considered more a mechanism to improve the health of mothers and children than a method of population control (Visaria 2000; Visaria and Chari 1998). Clinic-centred family planning service delivery, along with health education activities, were promoted during this period. Over time however, the primary focus of the programme became the achievement of demographic goals. The Reproductive and Child Health Programme, which was launched in 1997, espouses the principles of client satisfaction and high quality comprehensive and integrated health services. It seeks to integrate services for the prevention and

management of unwanted pregnancy, the promotion of safe motherhood and child survival, and the prevention and management of reproductive tract infections and sexually transmitted infections. The programme aims to expand services to meet the needs of hitherto under-served and neglected population groups, including adolescents, and economically and socially disadvantaged groups, such as urban slum and tribal populations. It envisages utilising and upgrading the existing health infrastructure to deliver these services. To make the programme a peoples programme, the new approach champions local needs-based, decentralised, participatory planning and monitoring, and seeks to involve several stakeholders, including non-governmental organisations (NGOs), the private sector, panchayati raj institutions and civil society in more meaningful ways to move the new agenda forward (MOHFW 1997).

THE CONTRACEPTIVE SCENARIO

Over the decades, contraceptive use has been increasing in India. At the same time, there is a substantial unmet need for contraception. The contraceptive scenario is also characterised by the predominance of non-reversible methods, limited use of male/couple-dependent methods, substantial levels of discontinuation, and negligible use of contraceptives among both married and unmarried adolescents. Official statistics report that 87 million eligible couples, out of an estimated total of 171 million eligible couples, were effectively protected against conception by various contraceptive methods in the year 2000 (MOHFW 2003a). Data from National Family Health Survey (NFHS)2 indicate that nearly one-half of currently married women were using some method of contraception in 199899. Contraceptive prevalence increased with age except at the older ages (8 per cent among adolescent girls vs. 67 per cent among women aged 3539 years), with education (43 per cent among illiterate women vs. 57 per cent among women with a high school education), with standard of living (40 per cent among women from households with a low standard of living index vs. 61 per cent among women from households with a high standard of living index), and with number of living children (5 per cent among women with no living children vs. 68 per cent among women with three living children) (IIPS and ORC Macro 2000). Similarly, at each parity, current use was

lower among women with no sons than among women with one or more sons, with a maximum differential at parity three, indicating that strong son preference prevails in India (at parity three, 38 per cent of women with no sons vs. 62 per cent with one son and 75 per cent with two sons). Most of these differentials have persisted over time (Visaria 2000). Contraceptive prevalence varied widely among the states, from less than 30 per cent in Meghalaya, Bihar and Uttar Pradesh to more than 60 per cent in Delhi, Haryana, Himachal Pradesh, Punjab, West Bengal, Maharashtra and Kerala. Despite improved availability and access to contraceptive services, a substantial proportion of pregnancies in India are unplanned (mistimed or unwanted). It is estimated that if all unwanted births could be eliminated, the total fertility rate would drop to the replacement level of fertility. Data from NFHS2, for example, show that 21 per cent of all pregnancies that resulted in live births in the three years preceding the survey (including current pregnancies) were unplanned12 per cent mistimed and 9 per cent definitely unwanted (IIPS and ORC Macro 2000). In all likelihood, this is an underestimate of unintended pregnancies because longitudinal survey data reveal womens tendency for ex post revision of their preferences in favour of the wantedness of existing children (Bankole and Westoff 1998). Moreover, a substantial proportion of unintended pregnancies may be terminated through induced abortion. Estimates show that about 6.7 million induced abortions take place annually in India (National Commission on Population 2002). Several studies report that the desire to limit family size and to space the next birth are the main reasons for abortion mentioned by the majority of abortion seekers (Ganatra 2000). These findings provide clear evidence of the substantial unmet need for contraception among women in India.

BARRIERS TO MEETING CONTRACEPTIVE NEEDS

The Family Welfare Programme has been successful in spreading the message of the small family norm, improving contraceptive acceptance and reducing fertility rates but its achievements have been modest. While contextual and structural factors (high levels of illiteracy, poor access to sources of knowledge, poverty, and gender- and non-gender-based disparities) are partly responsible, the direction, emphasis and

strategies followed hitherto in the Family Welfare Programme have largely contributed to the limited success of the programme. There is an increasing recognition of various barriers to promoting contraceptive choice and meeting contraceptive needs in the country. Several measures to address these have been launched in recent years. The following sections discuss some of these barriers, measures proposed or currently under way, and emerging evidence on the extent to which these measures have succeeded in promoting contraceptive choice and addressing unmet need. LIMITED KNOWLEDGE--- Awareness of reversible (modern or natural) methods is relatively limited among both women and men. Nationally, for example, only 71 per cent of currently married women were aware of condoms (IIPS and ORC Macro 2000). In some major states including Andhra Pradesh, Karnataka, Madhya Pradesh and Orissa, fewer than three in five currently married women were aware of condoms. What is more disturbing is the finding that awareness of specific reversible methods, which are more suitable for young women, is even more limited among younger women compared to older women GENDER INEQUALITIES AND LIMITED MALE INVOLVEMENT--- Given that men dominate in reproductive health matters, promoting shared responsibility and the active involvement of men in safe and responsible sexual relationships, family planning, safe motherhood and responsible parenthood is critical. The National Population Policy and the Reproductive and Child Health Programme recognise this synergy, but mens roles have not been properly defined in government programmes. There have been some efforts to promote the use of male methods such as vasectomy and condoms, and initiatives to re-popularise vasectomy, including IEC campaigns and training of surgeons in no-scalpel vasectomy, have been launched in several states (MOHFW 1999). Though these efforts have proved successful in some districts in Andhra Pradesh, a similar change has not occurred in most other states (Planning Commission 2002). LIMITED INFORMED CHOICE--- Not only is access to a wider choice of methods limited, but providers also often do not assist women and men to exercise

their right to contraceptive choice by offering them complete and accurate information about the variety of methods available. LIMITED ACCESS TO AND AVAILABILITY OF SERVICES --- Gaps in infrastructure, manpower, equipment and supplies at the primary health centre level remain.

THE SCENARIO OF HIV/ AIDS IN INDIA:HIV/AIDS is a human tragedy unparalleled in the sheer scope of the physical and emotional pain it inflicts on sufferers and on those who take care of them. The disease is also a global crisis that weighs heavily on corporations and governments worldwide and it is getting worse. While HIV/AIDS epidemics in poor countries (many of them in Africa) are well known, the danger of HIV/AIDS spreading at the same speed through poverty-stricken and health-carechallenged places such as China, Russia, or India is looming. Fearing the effects this would have on sales, labor resources, and suppliers in these emerging economies, more multinationals are engaging in local efforts to fight HIV/AIDS in countries where they operate, not just because it is socially responsible, but because their businesses are at risk. Eighteen years ago, the first HIV infection case was diagnosed in India. Today, the worlds largest democracy has entered a critical period in its fight against the HIV/AIDS pandemic. In late 2002, Indias HIV-positive population reached 4.6 million; if present trends continue, that number could reach a staggering 2025 million by decades end, meaning that a single country could have a greater number of people with the HIV virus than the population of the state of New York. The disease still does not have the high prevalence rate of infection in India that has devastated some African countries, yet India already has the second-largest number of people living with HIV/AIDS after South Africa; and with a population of more than one billion, even a small shift in the prevalence rate could result in a staggering number of infections. The United Nations Program on HIV/AIDS warned in 2003 that India and her neighbors stand at what epidemiologists call the tipping point in the trajectory of the disease. The HIV virus has spread to all of Indias states and territories since it was first discovered in the country, but six out of 28 states in particular Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu, Manipur, and

Nagalandare considered high-prevalence states, where more than 1 percent of prenatal mothers test positive for HIV. In effect, the epidemic has spread beyond high-risk groups to the general population in these localities. Three additional states Gujarat, Goa, and Pondicherryhave concentrated epidemics, with a prevalence rate of 5 percent or higher among high-risk groups. Most of Indias states have populations the size of relatively large countries; 10 states have a population of more than 50 million. If even one of these states reaches South Africas nationwide 20 percent prevalence rate among adults, 10 million people will have contracted the disease in that state alone. The national adult prevalence of HIV is 0.91%, but prevalence varies by state, with Andhra Pradesh (2%) and Nagaland (1.63%) leading the country, and states such as Punjab (0.13%) and Kerala (0.25%) representing the lower end of the spectrum (AVERT n.d.). Sentinel surveillance data suggest that the epidemic is moving from urban to rural districts, with villages accounting for 57% of the national disease burden (UNAIDS n.d.)

In response to the growing HIV epidemic, the Indian government created the National AIDS Control Programme (NACP) in 1987 and the National AIDS Control Organisation (NACO) in 1992. NACP initially focused on prevention efforts, raising public awareness, improving blood safety measures, and promoting condom use. The

programme recently expanded to incorporate antiretroviral therapy (ART) in its agenda. Along with other public and nongovernmental programmes, NACO has helped curb the momentum of the epidemic. However, the nation needs to remain aggressive in addressing the future course of the epidemic.

SCIENCES SIGNIFICANT ROLE

Unlike the majority of countries hit hard by the AIDS pandemic, India is fortunate to have a vibrant domestic pharmaceutical industry that can play a crucial role in the fight against the pandemic by providing ARV drugs at low cost to the government. Several Indian pharmaceutical companies manufacture generic drugs at competitive prices. Cipla, Ranbaxy Laboratories, Matrix Laboratories, and Hetero Drugs recently announced an agreement with the Clinton Foundation to provide drugs to four African and nine Caribbean countries at a per capita cost of about $0.37 per day. Indias Ministry of Health, which is still negotiating a final price with the generic drug manufacturers, hopes to obtain the drugs for India at a price even lower than that. In addition to a thriving pharmaceutical industry, India also has first-rate scientists and biomedical researchers who can be tapped to improve the epidemiological studies. Adopting a new health technology logically requires that there be a public health need for the product or service not already being met, and that there is general agreement on the magnitude of the problem and the need for a solution. However, defining public health need is not always a simple matter; in some cases, adequate incidence and prevalence data may not exist, or might be subject to debate or denial.

GOVERNMENT ADOPTION OF TECHNOLOGIES

Public health need: How is need defined and how has agreement on the magnitude of the problem and the appropriate solution been reached? Appropriateness: Is the technology appropriate to local needs and conditions? Other regulatory approvals: Because national regulatory agencies often follow the lead of other countries and agencies, what are the opinions of such agencies as the U.S. Food and Drug Administration (FDA), the European Agency for the Evaluation of Medicinal Products (EMEA), or the World Health Organization (WHO)?

Cost and cost-effectiveness: Are cost and cost-effectiveness analyses available to inform governments' evaluation of health products? Funding and donor attitudes: What levels of resources are available from either Internal or external sources? Political leadership: What level of political will is there to support a decision to adopt new technologies, and are there key champions, including political, technical, and medical leaders, to move products forward?

IMPLEMENTATION OF NEW TECHNOLOGIES

Roles of different levels of government: Are the roles of central, state, and local governments clearly defined, and how will these roles be coordinated? Role of the private sector: What role does the government envision for the private sector? Role of civil society and nongovernmental organisations (NGOs): How can civil society and NGOs contribute to the introduction of new health technologies, and will their involvement, especially in physically remote areas or with marginalised populations, have an important influence on effective roll-out of services or products? Infrastructure: How can the necessary infrastructure be anticipated and managed, and will it build upon existing structures or necessitate the creation of new ones? Procurement and distribution: What type of supply system is required, and what is the capacity of the health care system to distribute the product to where it is needed? Human resources: Are there sufficient numbers of adequately trained personnel to successfully introduce these health technologies? Accessibility: Will the target population have access to the product or services? Are there physical or other limitations to access? Acceptability: What are individuals perceptions of a technologys acceptability and usefulness, and how do these perceptions influence its utilisation? As the HIV/AIDS epidemic and sexually transmitted diseases continue to advance at a rapid pace in India, the strategies to promote condom usage and other quality reproductive health care products is imperative. Conventional product delivery mechanisms have their own advantages but lack personal interaction and end user knowledge levels remain unmeasured. Description: An alternative to the conventional social marketing methodology was tested at Chennai, south India, between July '97

and Dec '99 with the following objective. "Test if remunerating individuals for their effectiveness in selling products through "word of mouth" networks can significantly increase the demand for supply of the reproductive and sexual health products". Conclusions: 8000 people from the community registered to become active change agents and 40% were women. 75% of all the people who attended the initial training sessions, enrolled as change agents and close of 50% of the condoms and sanitary pads sold were on repeat purchase indicating a strong demand creation. If this project is further fine-tuned to enroll change agents on predetermined economic incentive pattern, a strong community movement is envisaged. Community outreach meetings and network creation is a positive indicator in a conservative environment such as this city in South India, with strong traditional values and beliefs.

Transmission Categories Number of cases % Sexual 106,669 85% Mother-to-child 4,755 4% Blood and blood products 2,563 2% Injecting drug users 2,930 2% Others (not specified) 8,078 6% Total 124,995 100% Age group Male Female Total 0-14 3,313 2,283 5,596 15-29 23,905 15,876 39,781 30-49 54,204 16,701 70,905 50 6,823 1,890 8,713 Total 88,245 36,750 124,995

In 2006 UNAIDS estimated that there were 5.6 million people living with HIV in India, which indicated that there were more people with HIV in India than in any other country in the world. However, NACO disputed this estimate, and claimed that the actual figure was lower. In 2007, using a more effective surveillance system, UNAIDS and NACO agreed on a new estimate between 2 million and 3.6 million people living with HIV. This puts India behind South Africa and Nigeria in numbers living with HIV. In terms of AIDS cases, the most recent estimate comes from July 2005, at which stage the total number of AIDS cases reported to NACO was 111,608. Of this number, 32,567 were women, and 37% were under the age of 30. These figures are not completely accurate reflections of the actual situation though, as large numbers of AIDS cases go unreported. Overall, around 0.36% of Indias population is living with HIV. While this may seem a low rate, Indias population is vast, so the actual number of people living with HIV is remarkably high. There are so many

people living in India that a mere 0.1% increase in the HIV prevalence would increase the estimated number of people living with HIV by over half a million. The national HIV prevalence has risen dramatically since the start of the epidemic, but a study released at the beginning of 2006 suggests that the HIV infection rate has fallen in southern India, the region that has been hit hardest by AIDS. In addition, NACO has released figures suggesting that the overall rate of new HIV infections in the country is slowing. Researchers claim that this decline is the result of successful prevention campaigns, which have led to an increase in condom use.

WHY PREVENTION
It has been estimated that comprehensive prevention could avert 29 million of 45m new infections projected to occur in this decade, yet prevention programmes currently reach only one in five people at risk of HIV infection. In 2003, only one in ten pregnant woman was offered services for preventing mother-to-child HIV transmission in low and middle-income countries (UNAIDS, 2004). Cost effectiveness studies have clearly shown that prevention through behaviour change is the cheapest alternative among various options. For example based on year 2000 prices, a case of HIV/AIDS can be prevented for US$ 11, and a DALY gained at less than US$ 1 by condom use and Treatment of STIs. PMTCT and VCT cost under US$75 per DALY gained. On the other hand the treatment approaches like home care programmes and ART therapy cost several hundreds of dollars per DALY gained (Creese et al., 2002, Walker, 2003). It has been suggested that any intervention that achieves a DALY gained for less than US$62 was highly cost effective in poorest countries. It has been shown that even high cost prevention strategies like PMTCT are much more cost effective for the governments than not intervening at all as Governments end up spending much more on ART and home care later on (Skordis and Nattrass, 2002). These findings have serious policy implications for resource allocation between prevention and care. WHO has estimated that in Africa a 10% spending reallocation from treatment towards more prevention would increase the DALY gained by over 15%. The state of Tamil Nadu in India is an excellent example of focus on Prevention (Ramasundaram et al., 2001). The need therefore is to direct the attention and resources towards preventive strategies.

THE SCENARIO OF MALNUTRITION IN INDIA:According to the World Health Organization, reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this are the rights of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth (WHO 1998). Public health issues are strongly intertwined with those of poverty, as reflected in India's health profile. Diseases such as malaria and diarrhoea continue to cause significant mortality and morbidity in India. In 2005, it was estimated that 30% of newborns were of low birth weight and over 50% of children under five years of age were malnourished (UNICEF 2007). The infant mortality rate was 74 per 1,000 in 2005, and 18% of children under five were classified as severely underweight. These figures mask differentials across states and between urban and rural areas, with the latter facing much worse health outcomes (WHO 2000). For example, while 45% of the overall population has access to adequate sanitation facilities, only 26% of the rural population has access to sanitary facilities compared with 83% of the urban population (International Institute for Population Sciences 2007). While life expectancy, infant mortality rates, and infectious disease morbidity have improved in recent years, further advances in health require increased efforts to strengthen health care infrastructure, scale up resources, adopt more advanced health technologies, and support programmes that effectively address pressing public health problems. The high rate of child mortality (80 per 1000 live births in the course of the first eleven months) points to the low coverage of antenatal, delivery, and postnatal care. Great efforts are being undertaken by the Indian Government to supply pregnant women with iron and folic acid tablets and vaccinations. Women are encouraged to deliver in health facilities. Indicators show that prenatal care is higher than delivery assistance and postnatal care, but in principle, all three components are low. Based on the weight-for-height index, 36 percent of all women are undernourished. 49 percent of

all women suffer from anemia in different degrees. 43 percent of all married women report some type of reproductive health problem, of these, 78 percent have not sought professional medical advice. One-third of Indias nearly one billion people lack adequate food. More than half of Indias young children (73 million) are underweight and chronic maternal malnutrition is high one of every nine children dies before the age of five. Infant and child mortality rates are very high. Poor access to health care, high illiteracy rates and poor nutrition and health practices contribute to the high mortality and malnutrition. Because poor women and children, particularly in remote rural and tribal areas, have the greatest mortality risks, the purpose of this SO was to reduce the high levels of child mortality and malnutrition. The Program for Advancement of Commercial Technology/Child and Reproductive Health (PACT/CRH) provided support for technologies aimed at improving child survival while increasing commercial marketing and distribution of quality child survival products and services, such as Oral Rehydration Salts (ORS). Nearly one-fifth of the child deaths are due to diarrhea, a substantial proportion of which can be prevented by the use of ORS.

MARKETING STRATEGY OF PUBLIC HEALTH PRODUCTS IN INDIA

The American Marketing Association defines marketing as "the process of planning and executing the conception, pricing, promotion, and distribution of ideas, goods, and services to create exchanges that satisfy individual and organizational objectives." Marketers use an assortment of strategies to guide how, when, and where product information is presented to consumers. Their goal is to persuade consumers to buy a particular brand or product. Successful marketing strategies create a desire for a product. A marketer, therefore, needs to understand consumer likes and dislikes. In addition, marketers must know what information will convince consumers to buy their product, and whom consumers perceive as a credible source of information. Some marketing strategies use fictional characters, celebrities, or experts (such as doctors) to sell products, while other strategies use specific statements or "health claims" that state the benefits of using a particular product or eating a particular food.

IMPACT AND INFLUENCE

Marketing strategies directly impact food purchasing and eating habits. For example, in the late 1970s scientists announced a possible link between eating a high-fiber diet and a reduced risk of cancer. However, consumers did not immediately increase their consumption of high-fiber cereals. But in 1984 advertisements claiming a relationship between high-fiber diets and protection against cancer appeared, and by 1987 approximately 2 million households had begun eating high-fiber cereal. Since then, other health claims, supported by scientific studies, have influenced consumers to decrease consumption of foods high in saturated fat and to increase consumption of fruits, vegetables, skim milk, poultry, and fish. The tremendous spending power and influence of children on parental purchases has attracted marketers, and, as a result, marketing strategies aimed at children and adolescents have increased. Currently, about one-fourth of all television commercials are related to food, and approximately one-half of these are selling snacks and other foods low in nutritional value. Many of the commercials aimed at children and adolescents use catchy music, jingles, humor, and well-known characters to promote products. The impact of these strategies is illustrated by studies showing that when a majority of television commercials that

children view are for high-sugar foods, they are more likely to choose unhealthful foods over nutritious alternatives, and vice versa.

SOCIAL MARKETING:The term social marketing was first introduced in 1971 and describes the application of proven concepts and techniques drawn from the commercial sector to promote changes in diverse socially important behaviors such as drug use, smoking, sexual behavior, family planning and child care (ANDREASEN 1995). Social marketing also health products accessible to underprivileged population groups in a costeffective way. In India, social marketing of contraceptives dates back to 1968. In the 1980s and early 1990s new organizations specialized in social marketing and NGOs began to participate in the government-led program. Social marketing products in India aim at catering for the lower and lower middle-income strata of society. People living below the poverty line are intended to be supplied with free contraceptives distributed by the government. By 2001, condoms and oral contraceptives distributed under the social marketing program accounted for one third of all condoms and pills distributed in India (MHFW 2001: 9). Social marketing is the application of marketing principles to the design and management of social programmes. It is a systematic approach to solving problems, in this case public health nutrition problems related to the adoption of healthpromoting behaviours such as the enhanced use of services, the trial and continued use of a product, and the improvement of household or community practices. In 1971 Kotler and Gerald Zaltman further defined social marketing as the design, implementation, and control of programs calculated to influence the acceptability of social ideas, and involving considerations of product, planning, pricing, communication, distribution and marketing research. The draft National Strategy for Social Marketing prepared bt the Ministry of Health and Family Welfare, Government of India defines Social Marketing as 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. 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. 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. 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 consumers 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.

Social marketing provides a voice for consumers the programme beneficiaries and is concerned with their perspectives and practices and with making it easier for them to follow better practices. Social-marketing techniques can lead to modifications and innovations in the design of all programme components, not just the communication component, where they are usually applied. Social-marketing specialists can inform planners about changes needed in clinic procedures to enhance the use of services, or about alternative systems to distribute iron pills to women, or about the need to manufacture a feeding bowl to help mothers measure their children's food, in addition to showing them how to craft messages to motivate people to try out and adopt new practices. Thus, while communications is an element of social-marketing programmes, it is not their sole area of concentration. Social marketing opened new areas for marketers expertise and intrigued public health advocates. Not only did it provide powerful new tools, but it had a kind of poetic justice in borrowing from marketers the very discipline that was aggressively promoting such harmful products as cigarettes, alcohol, fast cars, fast food, and infant formula, against which public health educators felt they were fighting a rear-guard action. Social marketing stretches public health in at least two important directions. First, it calls attention to the need to learn how to identify fruitful areas for using social marketing strategies. Second, social marketing experience to date challenges health specialists to think in new ways about consumers and product design. 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.

ACHIEVEMENTS OF THE SOCIAL MARKETING PROGRAMME IN INDIA 1. Since the introduction of the social marketing programme in 1968, awareness regarding condoms and oral contraceptive pills has substantially increased. Current awareness among women of reproductive age is 80% for OCPs and 71% for condoms. 2. Social marketing products have registered large increases in sales since they were launched. Condoms increased from 16 million pieces sold in 1968-69 to 478 million pieces in 1999-2000, and the sales of OCPs increased from 7.24 lakh cycles in 1987-88 to 349 lakh cycles in 1999-2000. The share of Social Marketing now accounts for one third of all condoms and all oral contraceptives distributed annually in India. 3. This is in part reflected in the quadrupling in the Contraceptive Prevalence Rate (CPR) from 10 % of eligible couples in 1971 to 48% of eligible couples in 19981999 (NFHS-2), and in the consequent decline of the Total Fertility Rate (TFR) from an average of 5 children per woman of reproductive age in 1971 to 3.3 in 1997. However, condoms and OCPs only account for 10.8% of the current Contraceptive Prevalence Rate. 4. The SMP has helped provide a wider basket of choices and options within each product (condom and the OCP) for the consumer. 5. Number of new products, e.g. oral rehydration salts, iron-folic acid tablets, have recently been introduced, and are further widening the basket of health care products. 6. Several Area Projects in social marketing, commenced as pilot projects in Madhya Pradesh (by a trust of Hindustan Latex Limited) and in Uttar Pradesh (by the State Innovations in Family Planning Services Agency) have clearly demonstrated that there is an unmet need for these products in rural areas, that can be successfully addressed and even gain immense popularity. 7. Over the years, the Government-owned brand name "Nirodh" (GoI-owned brand) also distributed through Social Marketing, has become a generic name for condoms in India.

Achievements of the social marketing programmes 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. The role of social marketing for behavioural change in nutrition programming The importance of informing families about improved practices has been recognized in nutrition programming for decades, albeit often as an afterthought. This entire area of operations has been marginalized because of doubts about its efficacy. However, now the application of social marketing to nutrition education has been shown to be effective in several studies and evaluations of operational programmes. Examples were cited at the beginning of the article. The next doubt that is raised concerns its cost and cost-effectiveness. That the application of social-marketing techniques can make nutrition education a cost-efficient intervention is illustrated by figures from the Indonesian Nutrition Communication and Behavior Change Project: The annual cost per participant of that programme was US$3.94 during the pilot phase, including formative research and design and testing of messages, and is estimated at US$2 for subsequent expansion. This can be compared with US$12 per participant for a programme to weigh children and screen them for malnutrition, and to US$56 for an integrated programme that includes feeding. If the coverage of the behaviour-change project were extended nationwide in Indonesia, it would cost about 0.15% of the national budget, or less than one-tenth the cost of an average institutional feeding programme or one-twentieth that of consumer food subsidies. When the costs and effectiveness are considered together, the results of the Indonesia behaviour-change programme remain impressive. The cost per child of improving nutrition status was US$9.80 a year during the pilot phase and is estimated to be US$3.90 a year for an expanded programme, which is considerably lower than figures for nutrition improvement from studies on other interventions, including feeding programmes. Clearly, social marketing, which makes behavioural change the

fundamental goal, has made a difference in nutrition education. Yet, inherent in the approach is its relevance to other programme decisions. Why has it not been used more as a decision-making and management tool for nutrition programming generally? In part, it is because there are also strong links between malnutrition and poverty, so that economics has driven much of the analysis and solution of problems. In part, it is because of the strong links between malnutrition and infection, so that epidemiology and clinical analyses have been the underpinning of project plans. While both of these points of view clearly must be included in the analysis and solution of problems, there is now a clearer articulation [9] and a growing appreciation of the importance of behaviour and the influences on practices that relate to child and family well-being. To date, in only a few programmes has a behavioural analysis been the framework for planning. It makes sense to shift our thinking more in this direction obviously not abandoning the economic, epidemiological, and clinical analyses but bringing behaviour onto a more even footing. The following are some supporting arguments for this point of view. The majority of families can do more within their social and economic constraints to improve significantly the nutrition status of their most vulnerable memberswomen and young children. They should be given the tools to make these changes. Malnutrition often persists when the incomes of poor families rise, and when more food enters the household and the available food exceeds the household energy requirements [10]. Commercial market influences require countering when they lead to detrimental practices. These influences have been most profound in the areas of breast-feeding and weaning. Working to help families become more self-sufficient within existing resources cuts down on psychological dependence. Beginning a programme by trying first to achieve improvements in practices, measuring their impact on nutrition, and later introducing economic and health assistance means that the more expensive activities can be better targeted to those truly in need.

Behaviour change programmes should be more sustainable at lower cost and have more persistent benefits (those that last once the programme activities cease) than other kinds of activities. As the HIV/AIDS epidemic and sexually transmitted diseases continue to advance at a rapid pace in India, the strategies to promote condom usage and other quality reproductive health care products is imperative. Conventional product delivery mechanisms have their own advantages but lack personal interaction and end user knowledge levels remain unmeasured. Description: An alternative to the conventional social marketing methodology was tested at Chennai, south India, between July '97 and Dec '99 with the following objective. "Test if remunerating individuals for their effectiveness in selling products through "word of mouth" networks can significantly increase the demand for supply of the reproductive and sexual health products". Conclusions: 8000 people from the community registered to become active change agents and 40% were women. 75% of all the people who attended the initial training sessions, enrolled as change agents and close of 50% of the condoms and sanitary pads sold were on repeat purchase indicating a strong demand creation. If this project is further fine-tuned to enroll change agents on predetermined economic incentive pattern, a strong community movement is envisaged. Community outreach meetings and network creation is a positive indicator in a conservative environment such as this city in South India, with strong traditional values and beliefs. Efforts should be to provide contraceptives that are affordable and accessible, disseminating information to encourage correct and consistent use, increasing awareness and sustaining interest levels. The Sales Representatives are the lifeline of the company. They not only drive sales and track stock movement but also maintain a close vigil by supplying invaluable feedback for prompt responsive action. We should strive to invent new and better promotional schemes to influence its target segments. T h i s can be r e f l e c t e d b y s e v e r a l c u t t i n g - e d g e innovations and promotions. Schemes for the stockists, exciting display materials and schemes for r e t a i l e r s , d i s c o u n t s a n diners ngontestsforconsumers are just a few of the promotions DKT conducts. DKT uses a wide mix of communication and promotional aids to endorse its products to doctors and private clinics. The DKT newsletter, INFOMED, is designed for the

medical fraternity. Regular doctor meetings and informative leaflets for patients are also part of the mix.

PROJECT MANDI:
WHAT IS ENJOYED IS WHAT IS REMEMBERED DKT, an NGO uses a highly relevant platform of 'the weekly market' or Mandi, an integral part of rural India, through a blitz of popular infotainment activities. This is done at a stall, strategically located at the main market (Mandi) area of the town. This is sustained through educational activities conducted in villages by focused interactive sessions with specific groups like married men and women for family p l a n n i n g , w h i l e barbers & adolescents are educated on HIV/AIDS awareness. Within a year of its launch, Project Mandi has yielded some encouraging results Sales of contraceptives have increased and so have the number of outlets stocking contraceptives. Based on this initial performance, the donor has extended its funding for an additional 3 years.

ROLE OF MNCS
For manufacturers with operations or large work forces in regions affected by HIV/AIDS, the disease is directly linked to reduced productivity, high absenteeism, and increased demand for workers to replace stricken colleagues. In a 2003 study of the economic impact of HIV/AIDS in South Africa, conducted by the South Africa Bureau for Economic Research and the South African Business Coalition on HIV/AIDS, more than half of the manufacturers surveyed said the disease had led to

lower labor productivity or increased absenteeism. Forty percent of manufacturers reported that HIV/AIDS had reduced their profits. Manufacturers are highly integrated into the economic and social fabric of the communities where their plants are located. As a result, we found that they are well positioned to piggyback on existing in-country relationships and networks to provide health-care services and comprehensive prevention, testing, and treatment programs. In India, Tata Steel is utilizing its existing infrastructure of medical programs to mobilize resources to fight the pandemic. Tata Steel also developed a Safe Highway project to establish HIV/AIDS clinics targeted at truck drivers. It is equally critical that companies not view financial investments as the sole means of contributing to the battle against this disease. Leveraging their products, services, and assets to combat HIV/AIDS through co-investment strategies, in kind donations, or other approaches that promote of publicprivate partnerships is just as important. MNCs should pursue the eradication of HIV/AIDS and Malnutrition and maintenance of public health as one of their most committed Corporate Social Responsibility.

GOVERNMENT ADOPTION OF NEW TECHNOLOGIES

The first step in the introduction of a new health technology into a national health system is adoption by the national government, that is, a formal decision to approve a product or service, as well as to pay for and deliver it. Some of the factors influencing adoption are the need for the technology; the appropriateness and/or adaptability of the technology to the specific economic and socio-cultural needs of the country; available funding, from either internal or external sources; availability of technical data on safety, efficacy, and cost-effectiveness of the technology; regulatory benchmarks from other regional or international sources (e.g., WHO guidelines); and political will. PUBLIC HEALTH NEED: Adopting a new health technology logically requires that there be a public health need for the product or service not already being met, and that there is general agreement on the magnitude of the problem and the need for a solution. However, defining public health need is not always a simple matter; in some cases, adequate incidence and prevalence data may not exist, or might be subject to debate or denial. APPROPRIATENESS: Another factor influencing adoption is whether the technology is deemed appropriate for local needs and conditions, including whether it can be modified or adapted for local use. This has both technical and socio-cultural implications. On the technical side, a technology must address the specifics of local need; for example, with an AIDS vaccine, it must protect against strains of the virus prevalent in India. On the socio-cultural side, a technology must be consistent with local mores and norms and work within the context of traditional beliefs, habits, and accepted practices. COST AND COST-EFFECTIVENESS: The likely cost of a technology will be an important factor in government decisions on whether to adopt it. Many governments will evaluate a new product or service in relation to both its cost-effectiveness and its affordability. For health technologies, this generally implies measuring the disease burden (both morbidity and mortality) that can be avoided per dollar spent. Ideally, decision-makers would be able to compare a new health technology with other health interventions (programmes and products), or even with other public sector

investments contributing to overall national priorities and goals. Health sector decision-makers might want to know the estimated cost effectiveness of AIDS vaccines compared to other prevention efforts (e.g., counselling and education programmes, or microbicides) or to treatment programmes. At the highest macrolevel, ministries of finance might want to compare investments in AIDS vaccines with investments in other sectors, such as agriculture or industry. ROLE OF THE PRIVATE COMMERCIAL SECTOR: Of course, the public sector need not be alone in introducing a new health technology. In some instances, the private sector may take a leading role and provide these services and products before the public health system is willing or able to do so. In other cases, there may be joint roles for both public and private sectors, with different target populations or geographic areas to be covered. However, one of the critical factors is whether or not the government envisions a role for the private sector, either at the time adoption of a technology is being considered, or when implementation is planned or under way. Having the government consider potential roles for the private sector in advance and institute regulations that enable private sector delivery can lead to more appropriate design of a roll-out programme for new technologies. PROCUREMENT AND DISTRIBUTION: Successful introduction of a new health technology requires well-functioning procurement and distribution systems. Especially in the case of products, having access to a reliable and adequate supply of the technology is critical. In the case of vaccines, competitiveness among suppliers helps to ensure availability, lowers prices, and contributes to success in technology introduction. UNICEF's competitive bidding processes have yielded very low prices for developing world immunisation programmes, but these may not be sustained in the future with new and more expensive vaccines. To ensure continued adequate supplies of low-cost vaccines requires (1) encouraging competition in the market, (2) developing strategies, such as tiered pricing, to make vaccines available to the poorest countries at low prices, and (3) strengthening public sector vaccine producers in the developing world (Mahoney et al. 2000). However, local manufacturing does not always translate into affordable technologies or adequate supply. Despite local manufacturing of low-cost drugs, the ART programme has faced procurement problems and issues as it tries to scale up. Health policy experts caution that

additional expansion will likely strain the system even more, and that perhaps stricter monitoring, tighter linkages with prevention activities, and expansion beyond firstline drugs are critical next steps. Appropriate distribution systems require several of the factors mentioned in this section (infrastructure, human resources, etc.) but need clear identification of the target populations and specific measures to reach them. An important part of successful distribution is overcoming geographic boundaries to ensure that different states, municipalities, and localities are all served, and that ruralurban differences are adequately addressed. THE CHALLENGE OF INTRODUCING NEW TECHNOLOGIES IN INDIA Indias health care system faces several obstacles to the successful introduction of new health technologies. The size of the country is an obvious challenge, combined with limited financial resources to address significant health problems. There are substantial inter- and intra-state differences in health and demographic indices, combined with variation in performance of health programmes across geographic and economic lines. Inadequate surveillance systems make it difficult to assess the true burden of disease and to monitor the impact of specific interventions. Within the public health system, there are persistent gaps in manpower and infrastructure, especially at the primary care level, and weak referral services. Shortages of personnel, equipment, and commodities are found in voluntary and private sectors as well.

THE PARTICULAR CHALLENGE OF AIDS VACCINES

Some challenges specific to AIDS vaccines are likely to exacerbate the difficulties in Indias health care system. First, although substantial progress has been made since the beginning of the epidemic, the stigma and discrimination associated with the disease remain significant and are likely to affect not only decisions about adopting vaccines but how vaccination programmes are implemented. Continued strengthening of awareness and education programmes will be required to support government commitment to AIDS vaccines and to minimise the reluctance of individuals to be vaccinated due to fear of others perceptions. Second, it is likely that first-generation AIDS vaccines will have efficacy levels below 100%. While such vaccines can have an important impact on the epidemic, this might complicate adoption and implementation decisions for governments because of perceived potential behavioural disinhibition effects. Policymakers and program managers worry that individuals receiving an AIDS vaccine will believe themselves to be completely protected and may increase risky behaviour. In worst-case scenarios, this could lead to increased incidence and a worsening of the epidemic. However, there is no clear evidence that this will happen. It is thus important to conduct social science research now to assess the likelihood of such behaviour change; current vaccine trials provide an important opportunity to learn more about this. Research results could allay fears about potential behavioural changes, or if disinhibition appears to be likely, future implementation programmes can be designed to incorporate educational messages about the need for continued and complementary prevention measures. Third, countries that do not face a generalised epidemic, including India, will most likely target the vaccines to specific populations. The target groups, including possibly sex workers, migrant workers, injecting drug users, and men who have sex with men, are difficult to reach, often due to legal issues and social mores. While there are health and social services that reach such target groups, especially those provided by NGOs, difficulties in identifying and reaching those individuals will undoubtedly affect potential coverage levels for AIDS vaccines. There may also be additional challenges in securing political support and financial commitments for programs targeted only to certain groups.

Finally, and related to the point above, delivery of AIDS vaccines to adolescents and adults will likely take place outside the traditional childhood immunisation programme. Despite any shortcomings childhood immunisation programmes may have, they do have an established infrastructure and a ready means of reaching their target population. AIDS vaccines, however, will likely be targeted (at least initially) to adults and adolescents, and will therefore require new delivery and informational systems. A baseline study has revealed that one major barrier to an increased usage of family planning and reproductive health products is a lack of information, both on the side of consumers as well as on the side of health providers. Therefore, the purpose of EIC is to improve the quality of information available to the population. As part of this approach, EIC Training aims at improving the attitudes and practices of the health providers so that they provide better information to their clients. There is a gap between the real and the perfect health provider in the sense of offering choice and information. PSI should proceed with its innovative approaches of training/informing health providers because of their importance in future social marketing activities, and because the assessment has shown that the interventions can lead to an improved provider-client interaction. Continuous impact and process monitoring is necessary in order to take full advantage of experiences gained, and in order to adjust the interventions accordingly. In order to have a lasting impact on attitude and practice, interventions need to be focused in terms of health providers addressed, topics raised and the follow-ups conducted. This is all the more important if the interventions are to be extended to state level or beyond.

Role of Social Marketing as a strategy for the Promotion of Public Health in India:The products that are attractively packaged and heavily promoted are better sold. Selling the product might seem in contradiction with the aims of a programme aimed at improving the health of low-income populations. Market research has shown, however, that this is not the case. Products which are purchased are valued more highly by the consumer and are more likely to be used than those received for free. In social marketing programmes, the price of the product is kept low enough to be affordable to low-income consumers but high enough to attach a value to the product. By selling the product, social marketing programmes can also defray some of the costs associated with distribution and promotion. First, the product must be made widely available. This effort is complemented by a communications campaign which incorporates commercial marketing techniques to raise brand awareness, promote the product and encourage healthier behaviour as a result of purchase and correct use. Using this two-pronged approach, social marketing programmes have successfully addressed many of the issues of demand and supply. In the case of condoms in particular, social marketing acts as a .normalizer. of the product. Until recently in many societies, condomswere a product used rarely, available only in pharmacies behind the counter and regarded as appropriate for use only with commercial sex workers. Now, thanks to social marketing programmes, in many countries condoms are sold in other types of shops, their brand name is known and accompanied by a recognizable logotype, and medical providers and others talk about them in the media and educate people about their benefits. The result is the destigmatization or .normalization. of condoms and their use in populations in general and especially amongst those at high risk of HIV infection. In this sense, social marketing programmes can help populations to overcome social and cultural resistance to practising effective HIV/AIDS prevention. Social marketing programmes do not compete with the public health system. On the contrary, such programmes complement and support existing services. By making products available and affordable outside the health system, CSM programmes alleviate the pressure on existing services, allowing the health system to use scarce resources more effectively. Social marketing programmes also serve those consumers

who are unable or unwilling to access condoms in a clinic setting. This is particularly true for adolescents and those who prefer the anonymity of a commercial transaction. In addition, CSM programmes are developed in close collaboration with host country governments and reflect current priorities and needs. Communications campaigns are designed to support existing interventions, and many of the materials developed by social marketing programmes can be used in clinics, schools, and throughout the public health system. Social marketing programmes do not operate in a vacuum; government support is a key component of a successful programme. Many governments have recognised the valuable role social marketing programmes can play in preventing the spread of HIV/AIDS, and have extended financial and political support to the activity. The Indian government subsidises both the socially marketed condom and its associated promotion costs. In South Africa, the government recently awarded the tender for a national AIDS prevention communications campaign to the Society for Family Health, which has operated a social marketing programme since 1992. Other governments, for example that of Romania, have asked that social marketing pro grammes be made a priority for interventions aimed at preventing HIV/AIDS. While there are numerous examples of cooperation and support between CSM programmes and host governments, it should be noted that social marketing programmes also play an important role in countries where governments are dysfunctional or undergoing a period of economic and political transition. Social marketing projects in Haiti, Cambodia, Russia, and Rwanda have made condoms available and conducted effective communications campaigns when there has been an overwhelming need and a limited or non-existent public health infrastructure. The key to a successful family planning program lies in the wide range of contraceptive choices available to couples. Oral contraceptives (OCs) are a highly effective and safe method of contraception that should be made available as a choice to couples in need of family planning. Combined oral contraceptives have been on the market for 40 years now and have been used by more than 200 million women around the world. Current use of OCs worldwide is estimated to be approximately 80 million women per year. In 1998 alone, social marketing programs worldwide generated fivemillion couple years of protection (CYPs) from OCs. Because social marketing distributes products through commercial channels as well as clinics, the products are

made readily available to consumers. Products are priced at a level that is affordable to low-income consumers with competitive margins built in to motivate the trade to stock the product. To supplement marketing activities, PSI trains service providers in family planning counseling and method administration. Service providers include doctors, paramedics, and pharmacists, as they are often the first points of contact for clients interested in learning about these methods. Notable examples of PSI's work in training service providers include the Green Star project in Pakistan and the ProFam project in Zimbabwe. 1Introducing any new technology to potential users is challenging. There are enormous obstacles in changing peoples behaviours; overcoming deeply rooted biases, especially among providers; breaking down gender disparities; addressing existing dynamics between sexual partners and between providers and patients; and addressing the stigma of using any condom, male or female, for potential users. The introduction of the female condom in India involved a unique public private partnership between the Female Health Company (UK based private manufacturer of Female condoms), its Indian partner Hindustan Latex Limited (a Public Sector Undertaking) and 28 Non Governmental Organizations working in 3 states of the country. While FHC and HLL provided the product and the technical and research base, the NGO partners played the key role in product placement, counseling, motivating target groups for usage, support during recruitment of the respondents for the qualitative exercises, arranging the venue for the discussion/interview, and coordinating overall logistical organization of the qualitative exercises. The acceptability research clearly shows that most issues related to female condom introduction are not specific to the product; rather they are fundamental issues that must be addressed when introducing new technology. These include- obstacles in changing peoples behavior, overcoming deeply rooted biases [especially among providers]; breaking down gender disparities, addressing existing dynamics between sexual partner and between providers and clients; addressing the stigma of sexuality and allocating resources between different technologies. Other barriers to empowerment include need for education about basic reproductive anatomy and perhaps also a lack of female pelvic models to teach correct use. 1

Promotion and distribution channels: Involvement of key stakeholders Female condom could reach consumers through the same channels as the male condoms- pharmacies, kiosks, market stalls, clinics, community based distribution, peer educators and many other places. It is also clear that despite willingness to adopt dual protection strategies, women are constrained by various social, cultural and other factors beyond their control. Since husbands and even elderly women in the family are strong determinants of FP and dual protection decision making, more sensitization and education for these influencers would be useful for strengthening HIV/STI prevention. The female condom may be provided through public sector health facilities, social marketing outlets and other innovative methods like hairdressers, and beauty parlours. In case of commercial sex workers, pimps and brothels-owners need to be involved with the FC programme, as they are the key channels through whom the target respondents may be reached. Other community leaders also need to be sensitized to the new method. A similar approach needs to be adopted for MSM as they are a highly sensitive and stigmatized category and the need to maintain anonymity is supreme. A social marketing approach to behaviour change is guided by three key assumptions about human behaviour: (i) The theory of exchange, (ii) low and high involvement behaviour, and (iii) stages of behaviour change.

The Contraceptive Market in India and its Marketing Strategy:India has long had a program to promote responsible and planned parenthood through voluntary and free choice of family planning best suited to individual acceptors. Sterilization has gained widespread acceptance as a permanent contraceptive. Before 1996 (Holmes 2005) Indias national sterilization program relied on aggressive techniques, such as quota systems and rewards, to encourage sterilization. While this conduct is no longer the case, Indian society has become comfortable with limiting family size through permanent means. However, India has long had a program to promote responsible and planned parenthood through voluntary and free choice of family planning best suited to individual acceptors. Sterilization has gained widespread acceptance as a permanent contraceptive. Before 1996 (Holmes 2005) Indias national sterilization program relied on aggressive techniques, such as quota systems and rewards, to encourage sterilization. While this conduct is no longer the case, Indian society has become comfortable with limiting family size through permanent means.

FAMILY PLANNING AND REPRODUCTIVE HEALTH INDICATORS

The total market for commercial OCP brands is estimated at 10 to 15 million cycles per year. According to the DOFW, the public sector supplied 57.4 million cycles of OCPs for free distribution in fiscal year 20022003 and SMOs sold 47.8 million cycles during that period. According to the DOFW, 7.52 million IUDs were inserted in fiscal year 20022003.

MARKETING OF CONTRACEPTIVES
By the time a product goes off patent, it has established a position in the market. Manufacturing a bioequivalent product and selling it to professional audiences, including ministries of health and SMOs, allows generics companies to capitalize on a products established position. In turn, the buyer may brand the product for resale, as SMOs do. In other cases, such as in the public sector, the product may be supplied in bulk with its generic name. From a public-health perspective, it is desirable to offer the end user a choice of methods. While many of the issues involved in expanding the availability and affordability of generic contraceptives cut across the four contraceptive-product groups, logistical and marketing considerations differ among them. In some cases a company may manufacture a range of products that does not constitute a basket of complementary products to the target audience. In other cases the different products may not reach the target audience through the same channel. Therefore it is essential to analyze contraceptive methods in terms of distribution and marketing rather than in terms of manufacturing. THE CONTRACEPTIVE SOCIAL-MARKETING SCHEME

SUGGESTED INNOVATIVE MARKETING STRATEGY OF PUBLIC HEALTH PRODUCTS IN INDIA: An expanded reproductive health programme must address men both in terms of their own health needs and in terms of their shared responsibility as partners, husbands and fathers, and should not be limited to promoting the use of male contraceptive methods. The role of male health workers who could play an active role in promoting male involvement also needs to be clearly defined. The contraceptive needs of sexually active young people remain largely unmet. Young people, married as well as unmarried, need accurate, user-friendly information and services, and multiple entry points (education, work, sports or other social activities) and settings (home, community, workplace, school or clinic) must be used to enhance access to information and services. The review indicates that the vast majority of unmarried, sexually active adolescents are engaging in unprotected sex, and whenever they use a method, pregnancy prevention seems to be the overriding concern rather than preventing both pregnancy and sexually transmitted infections. This indicates the need for educational and counselling efforts emphasising the dual protection properties of condoms. Provider bias continues to restrict the rights of women and men in exercising contraceptive choice. Providers need to be oriented about the clients right to exercise choice. Additionally, a variety of providers, including traditional medical practitioners, should be trained and engaged to promote detailed information on various contraceptive methods. There is evidence that trained traditional medical practitioners could be effectively engaged to increase contraceptive knowledge about reversible and non-reversible methods among rural women (Kambo et al. 1994). Given that women, especially young women, are powerless and voiceless in sexual and reproductive matters, multi-sectoral activities to enhance womens status are urgently needed. Since reproductive decision-making is often beyond the control of young women and their husbands, engaging other gate-keepers, including senior men and women in the family and influential people in the community, is crucial.

 IEC efforts to enable clients to exercise informed contraceptive choice have been increased, but inadequate collaboration between the health sector, IEC units and other stakeholders is reportedly rendering these efforts ineffective. Hence, intersectoral coordination needs to be vigorously promoted. The involvement of the community in planning and monitoring remains minimal, and concerted efforts to promote community participation are needed. As reflected throughout in this review, there are substantial state-level variations in contraceptive prevalence, the method-mix used, the extent of unmet need, the level of awareness of reversible methods and the quality of services. This clearly highlights the importance of state-specific interventions to improve family planning services. Decrease time to market. A good product available soon is better than the best product not available until later. Introduce a product that is free of the stigma associated with prevention or treatment of HIV and other sexually transmitted infections (STIs). Research indicates that a woman seeks her husbands approval before using a vaginal product and that male partners will not permit their wives to use a microbicide with an STI/HIV indication.1 Another way is to Collaborate with a commercial partner. A commercial partner is essential for efficient formulation and clinical development, regulatory approval, manufacturing, distribution, and marketing of the product. Start with products already marketed in India----These products are already formulated, manufactured, and distributed, and commercialization mechanisms are in place to facilitate access. Introduce a microbicide using an escalating claim strategy. Use benchmarking criteria to select leads for advancement.

DATA ANALYSIS
1. WHICH AGE-GROUP DO YOU BELONG? 10-15 years 15-20 years 20-25 years 25-30 years 30+ years

30% 25% 20% 15% 10-15 years 10% 5% 0% 10-15 years 15-20 years 20-25 years 25-30 years 30+ years 15% 25% 30% 25% 5% 15-20 years 20-25 years 25-30 years 30+ years

2. HOW EDUCATED ARE YOU? Matriculate XIIth Pass Graduate Post Graduate

60% 50% 40% 30% matriculate 20% 10% 0% matriculate XIIth pass graduate post-graduate 60% 35% 4% 1% XIIth pass graduate post-graduate

3. WHAT IS YOUR OCCUPATION? Student Skilled Professional Office goers unemployed

70% 60% 50% 40% 30% 20% 10% 0% student skilled professionals office goers unemployed 5% 65% 20% 10% student skilled professionals office goers unemployed

4. ARE YOU AWARE ABOUT THE PUBLIC HEALTH AWARENESS PROGRAMMES BEING RUN/ORGANIZED BY VARIOUS NGOS & GOVERNMENT ORGANIZATIONS? Yes No Cant say

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% yes no cant say 30% 50% 20% yes no cant say

5. HYGEINICALLY HOW SAFE IS THE AREA WHERE YOU LIVE IN?

40% 35% 30% 25% 20% 15% 10% 5% 0% very safe quite safe not at all safe highly unsafe 10% 15% 40% 35% very safe quite safe not at all safe highly unsafe

6. THERE IS A CLEAR LACK OF PROPER INFORMATION ABOUT VARIOUS CONTRACEPTIVES, DO YOY AGREE? Strongly agree Moderately agree Neutral Moderately disagree Strongly disagree

40% 35% 30% 25% 20% 15% 10% 5% 0% strongly agree moderately agree neutral moderately disagree strongly disagree 40% 30% 5% 20% 5% strongly agree moderately agree neutral moderately disagree strongly disagree

That is not only due to a lack of proper information about contraceptives but also to a gap between knowledge and use. 40 percent of all married women currently use contraceptives, with female sterilization accounting for 80 percent, condoms for three percent, pills for two and intrauterine devices for one percent of methods used. The use of contraception for spacing the time between births is low. Instead, once the desired number of children has been reached, women use contraception for limiting the number of births. In-laws and neighbors play a major role in family size issues, because they are highly respected. Social pressure and the fact that a married woman

does not have her own social network in the home of her husband are major factors influencing the life situation and decision making power of newly wed women.

7. MEDICAL CENTRES AND AGENCIES ARE LOCATED MORE IN URBAN AREAS THAN IN RURAL AREAS, DO YOU AGREE? Strongly agree Moderately agree Neutral Moderately disagree Strongly disagree

40% 35% 30% 25% 20% 15% 10% 5% 0% strongly agree moderately agree neutral moderately disagree strongly disagree 40% 30% 5% 20% 5% strongly agree moderately agree neutral moderately disagree strongly disagree

According to our findings, private health providers, such as private doctors, registered medical practitioners and chemists are concentrated in urban regions, where the client volume is higher. The rural areas are mainly covered by the public sector, i.e. public doctors, auxiliary nurses and midwives at health center level. At village level, there are Aangan Wadi workers responsible for child health and nutrition and the Jan Mangal model couples for family planning. The private sector in rural areas is represented by a few chemists, a few registered medical practitioners, and traditional birth attendants. The health service providers, such as private and public doctors as well as registered medical practitioners, and health product providers, such as chemists, are mostly men. In comparison, auxiliary nurses and midwives, traditional birth attendants and Aangan Wadi workers are exclusively female; Jan Mangal couples are, of course, mixed. Doctors and registered medical practitioners attend a high number of patients, yet it is quite clear, that for social reasons delicate female health issues cannot always be counseled in a proper way. In contrast, auxiliary nurses and midwives, traditional birth attendants, and Aangan Wadi workers seem to be in a better position to empower women in reproductive health issues.

8. GENERALLY DOCTORS IN GOVERNMENT HOSPITALS DONT EVEN LISTEN TO THE PATIENTS PROBLEMS & START THE MEDICATION, DO YOU AGREE? Strongly agree Moderately agree Neutral Moderately disagree Strongly disagree

35% 30% 25% 20% 15% 10% 5% 0% strongly agree moderately agree neutral modeartely disagree strongly disagree 25% 35% 10% 20% 10% strongly agree moderately agree neutral modeartely disagree strongly disagree

In terms of attitude, we have discovered that most health providers whether from the private or from the public sector, urban or rural, female or male have a paternalistic attitude. Quite often they believe that they know exactly what is right for their patients, without even asking them. Many health providers in the public sector, most notably the auxiliary nurses and midwifes, are very strict with the targets for family planning and even tend to exceed them, which must be regarded as a strong barrier for behavior change. According to government politics, changed only recently, targets for family planning, especially female sterilization were set to be met by all the different categories of health workers. The approaches of working directly with

health providers represent important innovations to social marketing of reproductive health methods and products. Given their design and desired output they can be merged into one single approach, thus taking advantage of their synergy effects. The potential benefit of a public health surveillance system was discussed using emerging infectious diseases as an illustrative example. Over the last thirty years at least 30 new infectious diseases have emerged. These encompass infections of plants, animals, and human beings. Bioterrorism is a concern but so is the need for rapid detection and characterization. For some of these emerging infections, it was months before an agent was isolated and thus timely and sensitive public health surveillance and response was to a great degree syndromic. The questions asked of a surveillance system differ based on the agent and the scenario to be detected. Tracking infrequent and not highly unique human syndromes across a large general human population (as in the West Nile Virus outbreak) may not be most effective to achieve the rapid recognition envisioned in the new International Health Regulations. A system of systems that includes animals that manifest aberrations earlier in time would be preferable to waiting until larger numbers of people develop encephalitis and land in intensive care units. The need for national and international coordination was emphasized. It was reiterated that national solutions are needed to solve national problems and that nations or organizations could act alone sometimes but not always. Global solutions are needed for global problems and it is almost impossible to act alone to solve global problems. The most important consideration for innovation is a clear understanding of what the system is trying to accomplish. The Internet voluntary reporting and the Global Public Health Intelligence Network are examples of innovations. Syndromic surveillance systems and the data sources including automated and voluntary data sources, and software technologies including software integrated with cell phones are other examples of innovations. Different epidemiologic scenarios will affect populations in different ways. Key though is that if one wants to detect any epidemiologic scenario, the population under surveillance should include the one likely exposed. If demographic misclassification affects the description with respect to person, place, and time, associations may be

missed. Sometimes surveillance populations are chosen as a matter of convenience. At risk populations need precise definition. The big challenge for public health is to bring together all appropriate information and to apply it appropriately. The exact roles of several stakeholders (including overlapping of roles) needs to be better defined to pull together in the same direction.

CONCLUSION
A balance has to be struck between what the public really want and what policy makers want the public to have. Lack of accessibility to health centers, lack of information and erroneous treatment from health staff remain major issues. The relatively lower rates of literacy and enrolment into technical streams and technology diffusion are areas of concern. Issues like lower priority for health care, lack of information and family support, lack of transportation, lack of money and social taboos or beliefs still influence the uptake of health care. Several innovative solutions developed to help community health workers with the diagnosis of urinary tract infections, vaginitis or cervicitis, and anaemia was discussed. The one time cost of the capifage (for anaemia) was rupees 1500 with each test costing less than one rupee. A breath counter is available for rupees 300 that will help even a neo-literate health worker to assess lower respiratory tract infections. Technology solutions to detect a rise of body temperature (easier than the conventional thermometers), to assess if the water is potable and to disinfect water, modular delivery kits have been developed. Need in rural areas has led to a lot of improvised solutions that do not necessarily get into the public domain or are not accepted. Solutions for rural health do not necessarily have to be cost intensive. There are several technological innovations developed by research institutes in India like detection kits for filariasis, leishmaniasis, dengue fever, west nile virus, typhoid, HIV, and kits for the detection of pregnancy. Many of the diagnostic tests that are marketed & available in primary healthcare settings in developing countries are sold and used with little or no evidence of their effectiveness. This is because unlike drugs, diagnostics are not subject to strict regulatory approval standards. The panel discussion explored the process of engagement of different stakeholders. Optimization, including scaling up of technologies is important. Restricting spheres of activities to islands of excellence is not sufficient in the long run. An agenda of actual and sustained delivery has to be nurtured. Money in public health is not to be scoffed at and should be allowed to play its legitimate role. Money is not the only incentive for people to perform, other incentives including accountability is necessary for optimal performance. The choice of community workers is thus important.

7. The demand for public health products is already there in urban as well as rural India. However, the most important thing is to market these products so as they reach the target group. Although economics is important here, the most important is attitudinal change to these products by overcoming the inhibition and the stigma attached to it. Therefore, the marketing strategy of the public health product providers should direct their market strategy accordingly and they can use commercials through media for this purpose.

BIBLIOGRAPHY
1. Paxman JM, Zuckerman RJ. Laws and policies affecting adolescent health. Geneva: World Health Organization; 1987. p. 4-5. 2. World Health Organization. Adolescent friendly health services an agenda for change. Geneva: The World Health Organization; 2002. p. 5. 3. Park K. Parks textbook of preventive and social medicine. 18th ed. Jabalpur: Banarsidas Bhanot Publishers; 2005. p. 352. 4. World Health Organization. Action for adolescent health-towards a common agenda, recommendations from a joint study group. Geneva: The World Health Organization; 1997. 5. Eating and physical activity during adolescence: Does it make a difference in adult health status? [editorial]. J Adolesc Health 2004;34:459-60. 6. Paxman JM, Zuckerman RJ. Laws and policies affecting adolescent health. Geneva: World Health Organization; 1987. p. 1. 7. World Health Organization. What About Boys? a literature review on the health and development of adolescent boys. Geneva: The World Health Organization; 2000. p. 11. 8. Jessor R. Risk behavior in adolescence: a psychological framework for understanding and action. J Adolesc Health 1991;12:597-605.

APPENDIX
1. WHICH AGE-GROUP DO YOU BELONG? 10-15 years 15-20 years 20-25 years 25-30 years 30+ years 2. HOW EDUCATED ARE YOU? Matriculate XIIth Pass Graduate Post Graduate 3. WHAT IS YOUR OCCUPATION? Student Skilled Professional Office goers unemployed 4. ARE YOU AWARE ABOUT THE PUBLIC HEALTH AWARENESS PROGRAMMES BEING RUN/ORGANIZED BY VARIOUS NGOS & GOVERNMENT ORGANIZATIONS? Yes No Cant say

5. HYGEINICALLY HOW SAFE IS THE AREA WHERE YOU LIVE IN? 6. THERE IS A CLEAR LACK OF PROPER INFORMATION ABOUT VARIOUS CONTRACEPTIVES, DO YOY AGREE? Strongly agree Moderately agree Neutral Moderately disagree Strongly disagree 7. MEDICAL CENTRES AND AGENCIES ARE LOCATED MORE IN URBAN AREAS THAN IN RURAL AREAS, DO YOU AGREE? Strongly agree Moderately agree Neutral Moderately disagree Strongly disagree 8. GENERALLY DOCTORS IN GOVERNMENT HOSPITALS DONT EVEN LISTEN TO THE PATIENTS PROBLEMS & START THE MEDICATION, DO YOU AGREE? Strongly agree Moderately agree Neutral Moderately disagree Strongly disagree