Robert Hecht

Franchising Family Planning: Janani finds success – and challenges – in rural India

In the wake of the Indian government’s high-level commitments at last year’s “FP2020” summit, I traveled to India to see how the country’s family planning program is advancing. I am part of a team studying efforts to improve monitoring and accountability in family planning in a number of countries, including India.

India is an key focus of these efforts, because a large share of global unmet need for contraception is there. We are looking at ways to boost family planning coverage and meet unmet need by supporting stronger monitoring and accountability programs. NGOs are an important part of the answer.

I had a chance to spend a couple of days in the state of Bihar, where fertility is still the highest in the country—an average of 3.7 births per woman—and there is a large unmet need for family planning services: 23 percent of couples say they do not want more children or want to delay pregnancy, but are not using a family planning method.

The government’s health service in Bihar is weak, both in access and quality. At the same time, the traditional private sector is not that strong, and is too expensive for many women.

The famous “Janani” project offers a novel way to address this problem. The project, which started in Bihar in 1995, is a large NGO focused on providing contraceptives and low-cost, high quality reproductive health services. Janani delivers these services through a combination of social marketing and franchising, and it is filling a big gap. Founded by an American social marketing pioneer named Phil Harvey, Janani has been run by Indian directors for most of its history, including the charismatic Gopi Gopalakrishnan, who has presented the Janani story to audiences around the world. (Since last year, Janani is being led by an American living in Bihar – more on that below).

Operating out of 45 of its own clinics and another 98 franchised clinics owned and managed by other private medical personnel, Janani has managed to reach hundreds of thousands of women in the state of Bihar, with its huge population of 83 million. The NGO also supplies condoms and oral contraceptive pills to thousands of small private outlets, including shops and kiosks, which re-sell these contraceptive products for a small mark-up. In 2012 alone, Janani accounted for nearly 15 percent of all female sterilizations performed in Bihar. The organization has trained more than 300 doctors and 600 nurses and lab technicians, and has a network of over 6,000 health promoters who encourage couples to adopt family planning methods.

Family planning, NextBillion Health CareWhen in Patna, Bihar’s capital, I was able to visit Janani and to speak with its top officials. On my second day, I went to one of Janani’s Surya (“sunshine” in Hindi) clinics located in Patna, where I met with Dr. Seema, the physician in charge, and toured her facility. Even though the clinic was located in an old building, I was impressed by the cleanliness and order that reigned. Nurses, nurse aids and cleaners moved quietly about, counseling patients, delivering services, and keeping everything tidy.

It was the hot season, when demand for family planning is lower (women prefer to come in for sterilizations and other procedures during the cooler winter months, when agricultural labor in the rural areas is also lighter). Yet the clinic’s waiting room was already beginning to fill up when I arrived at 10, and was packed with more than 80 people when I left just before noon. Dr. Seema told me that she performs dozens of tubal ligations (female sterilizations) and abortions every day, as well as numerous IUD insertions. Tubal ligations are by far the most popular method of contraception, and Janani also promotes injectable contraceptives and IUDs as part of a campaign for greater contraceptive method choice.

The Indian national family planning program’s heavy reliance on female sterilization, and lack of choice, is one of its main shortcomings. Male sterilization and oral pills are available but only used by a few percent of the population. Contraceptive implants are not available in India. And the Indian government has not yet approved the use of injectables in its own clinics, even though it permits NGOs like Janani and private doctors to offer the injectable form of contraception. The women I spoke with at the Surya clinic said that they prefer Janani to government clinics because they trust the NGO to provide a safe and courteous service, even if they have to pay a small amount to Janani, as opposed to the government services, which are free.

The current director of Janani, an American named Don Douglas, came to Patna last year to help stabilize the organization and address a set of important strategic issues. One is how to maintain quality across Janani’s large number of franchisees. A second is whether Janani should diversify its service offering to include the safe delivery of babies and other reproductive health procedures such as hysterectomies.

“We may well decide to expand our offering of services, in order to increase demand and revenues, and make sure that women come in for family planning,” Douglas told me. “Janani has been in Bihar for nearly 20 years. And we intend to be here for at least another two decades. We need to find ways to keep on evolving our model, as the state moves forward with its own policies and programs to expand family planning.”

Based on what I saw in Bihar, social marketing organization like Janani have an important role to play in boosting India’s family planning efforts. To do so, a new generation of Indian social entrepreneurs will need to step forward, to strengthen and diversify what Janani is already doing. Hopefully, the Indian central and state governments will provide a supportive environment for this to happen.

Robert Hecht is managing director at Results for Development. He is currently managing a growing portfolio of projects analyzing policy barriers and solutions related to AIDS and health financing and improving R&D and access to new health technologies in developing countries.

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