Project Area

Entrepreneurship       Unleashed

The Butterfly (Titli) Centres are Janani’s conduit to rural communities. They sell over-the-counter products and services, and also serve as the channel to create access to good quality clinical services by linking with the doctors’ network called Surya Clinics.

Titli Centres are a direct outcome of the lessons from the early phase of the Janani programme. Janani realised that the major reason why condoms and oral contraceptives did not penetrate into rural areas was not the unavailability of shops. It was an inherent disinterest among shop owners about stocking such low-cost, low-volume and hence low- profit products. (Consider a village whose population is 2,000. If all eligible couples in the village under current levels of protection bought condoms and oral contraceptives from one shop, the profit in a month would not be more than Rs. 16 to 17--about US¢ 40 to 42. (This does not even provide - complete food for a day).

Till December 2002, efforts were primarily focused on creating the rural Titli (Butterfly) Centre network. Janani aimed at creating two Titli Centres per panchayat (village council), each governing about five villages. These centres were located right in the villages, with service providers who formed a network of "informally qualified" Rural Health Practitioners (RHPs).

There are 12,000 panchayats in Bihar and Jharkhand. So, Janani’s target was to set up 24,000 Titli Centres. By September 2002, 21,000 Titli Centres had been set up.

To sustain interest among the service providers in the Titli franchise, Janani’s strategy was to bundle delivery of non-clinical contraceptives with other services, increasing their income. As most of the services focused on women, Janani also added a gender sensitive dimension to the network by making it mandatory for each rural practitioner to partner with a woman member of the family.

The Women Health Practitioners helped reach out to the village women--this value addition of women's involvement and empathy when advising other women on suitable birth control methods or when providing services like pregnancy test or taking blood pressure, was immense. So to complement the 21,000 Titli Centres, an equal number of women were trained as part of the team to manage the centres at the village level.

Simple tests using pregnancy dipsticks have impacted women’s lives. They can now find out whether they are pregnant as soon as they miss their menstrual period. The women health practitioner is trained to be at par with the men, and is an enormous boost to their self-esteem.

For each client that the Titli Centre referred to Surya Clinics (primarily for clinical family planning service), the service providers earned a commission. The pre-determined commission is usually between 10% and 12% of the doctor’s fee. Titli Centres paid an annual membership fee of Rs. 500 (about $12) discountable by half on good performance. The number of fee-paying Titli Centres served as an indicator of their interest and, therefore, of the viability of the programme. During the three years of the programme till 2002, 86% renewed their membership.

Currently, the Titli network is dealing with four broad objectives:

• Expand to every village in the programme area
• Decentralise stocking and management to villages through a peer tier of Super Titli Centres
• Expand services to keep in synch with Surya Clinics
• Create viable profits for Super Titli Centres so norms can be enforced

Janani’s rural networks are expanding to reach every village in the programme area in order to serve the rural communities better and also to create an economy of scale for the supervisory tier called Super Titli Centres. The Super Titli Centres are selected from the earlier batch of 21,000 Titli Centres. Each Super Titli Centre, on an average, covers 20 Titli Centres in an equal number of villages. The practitioner and his woman partner in each Super Titli Centre are selected on the basis of their past performance, and on their access to main feeder markets. They undergo intensive training in programme aspects, and in effective ways to impart skills to the men and women of the Titli Centres under their charge.

The Super Titli Centres collect, on Janani’s behalf, an annual membership fee of Rs. 300 (about US$7). They also supply commodities to earn a margin. They are entitled to earn a commission on every referral to Surya Clinics from their area. The Super Titli Centres pay Janani an annual membership fee of Rs. 1,000 (US$ 22). All Titli Centre personnel trained by the Super Titli Centre are tested by a qualified technical trainer, always a doctor, before being certified.

The membership payment now is 100% because failure to pay disqualifies the Titli Centres immediately, and the Super Titli Centres, which are local entities, quickly find replacements—a flexibility not available to Janani earlier.

In the years ahead, Janani sees the Super Titli Centres emerging not only as village-level stocking points, but also as nodal points that, on the basis of economies of scale, make such services viable as ambulances, storage of vaccines, and trained paramedical personnel .

Reaching out and touching women

An important component of the rural Titli network has been the presence of a woman member working along side the male practitioner. Each woman undergoes the same training as the man. The experience over the last three years of full implementation shows, however, that their participation is very limited.

The reasons are easy to understand: the range of services the Titli center offers is quite limited and there is no economic viability for two persons to be delivering services. To address this deficiency and to improve the viability of Titli centers and Surya clinics, Janani initiated a new strategy in December, 2004. The strategy is in consonance with the current plan to make Surya clinics the center of Janani’s programming, and building the other networks around it.

The new strategy has two prongs:

• Train a select batch of women practitioners at the Titli centers in certain special skills which help them conduct diagnostic tests that the male practitioners cannot do, thereby extending the services into the households (The tests include assessing status of prolapsed uterus, breast examination, vaginal examination to diagnose RTI and STD, screening tests for appendicitis and methods of abdominal examination etc.). Once trained, these women are designated Surya Health Promoters (SHPs).
• Identify a woman in each Surya clinic town to offer the same tests in the clients’ households through a trained woman from the community. These women are designated Women Outreach Workers (WOWs).

For rural women, a fee of Rs 150 ($3.5) is charged. The training takes place at the nearest Surya clinic. The doctor at the Surya clinic is an enthusiastic participant because this is an effective channel to bring more health-related caseloads to the clinics.

A new curriculum for the training has been developed. Initial results are encouraging.

Each rural practitioner partners with a woman family member (standing) to ensure women of the community can be counseled. At present total number of Titli centers are 40,887 in Bihar & Jharkhand.

Each of the 40,887 Titli Centres have a woman provider. The Centres sell subsidized products, counsel clients and refer to Surya Clinics for clinical services.

Titli Centres are gradually emerging as a village assembly point for women to discuss their health and reproductive health issues. Non-clinical
products and services are readily available at the Centre. Clients needing clinical services are referred to the nearest Surya Clinic.

Top