AFRO-NETS> Social Marketing - Pakistan (SMP)

[Muhammad Tariq <jigar@brain.net.pk>]

Social Marketing - Pakistan (SMP)
---------------------------------

"When faced with a mountain we will not quit, we will keep on striv-
ing until we climb over or find a pass through the tunnel underneath 
or will stay and turn the mountain into a Gold mine with God's help 
(Ameen)"

For Comments Please Reply to:

Muhammad Tariq 
Trainer - Social Marketing Pakistan
mailto:Jigar@brain.net.pk
http://home.brain.net.pk/~jigar/smp.html


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Mission Statement

SMP's mission is to improve the quality of Life of poorer people 
throughout Pakistan by increasing access to and use of Social and 
Health related products, Services and Information. SMP will optimise 
the development and utilization of human and financial resources 
through a commitment to excellence. It will implement effective and 
innovative Social Marketing Programmes, and will be the pre-eminent 
organization of its kind in Pakistan.

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An Introduction of Reproductive Health and Family Planning in Paki-
stan

With a population of 130 million people, Pakistan is the world's sev-
enth largest country and third biggest contributor to world popula-
tion growth with an estimated 4.8 million babies born every year. A 
1997 Contraceptive Prevalence Survey found that only 23.9% couples of 
reproductive age were practicing family planning, with modern contra-
ceptive methods making up only 16.9%. Pakistani women have, on aver-
age, 5.3% children. Pakistan's population growth rate is 2.6% and the 
population is projected to grow to 266 million people by the year 
2020. There is a well-documented unmet demand for family planning in 
Pakistan. A national survey carried out in 1994 found that more than 
half of all married women wanted no more children. 

Levels of reproductive health of people in Pakistan are generally 
low. High maternal and infant mortality rates are directly related to 
poor maternal and safe motherhood practices, which are accentuated by 
the limited access to reproductive health services. Although the mean 
age of marriage has risen to 22.7 years, early marriages are still 
frequent. It is estimated that the teenage fertility rate is 15.7%. 
As many as 45% of the pregnant and lactating women are anaemic. 

Due to poor maternal health, around 25% of the babies are born with 
low birth weight. It is estimated that 1 in 38 Pakistani women dies 
from pregnancy related causes and that for every woman who dies from 
pregnancy or childbirth 16 women suffer from reproductive morbidity. 
Only 19% of deliveries are attended by trained professionals, while 
less than one third of the pregnant women receive pre natal care. 
High maternal mortality and morbidity are also a result of non- hygi-
enic birthing practices and a health system, which reaches only 55% 
of the population. 

The Government of Germany and PSI/SMP:

The Government of Germany (via its development bank, Kreditanstalt 
fur Wiederaufbau or KfW) funds Social Marketing Pakistan / Population 
Services International through social market family planning products 
and services targeting the urban poor of Pakistan.

1998 was a banner year of social marketing in Pakistan. SMP/PSI pro-
vided approximately 1.2 million couple - years - of - protection, 
representing over 20% of the entire Pakistan family planning program. 

These Couple year Protection came via the sales of condoms, oral con-
traceptives, injectable contraceptives, and Intrauterine contracep-
tive devices. 

The Green Star Clinic Network:

The heart of SMP/PSI's social marketing efforts in Pakistan is the 
network of Green Star clinics and health care providers. The network 
uses an innovative approach, which markets family planning services, 
along with contraceptive products. The Green Star Network breaks new 
ground in the social marketing universe in two ways. First, it is a 
comprehensive effort, combining marketing, training, contraceptive 
supply, ongoing monitoring/support, and evaluation into a cost-
efficient program. And second, it has achieved concrete result in a 
short period of time, both by increasing contraceptive sales and the 
number of family planning clients in Pakistan and by improving the 
quality of care in private sector family planning clinics.

The Green Star social marketing program targets low-income men and 
women; thus doctors and pharmacists who deliver services and products 
to low-income Pakistanis are trained. The Green Star program also em-
phasizes sustainability: it begins with existing and already viable 
clinics; then through its Green Star marketing activities, it in-
creases the number of clients, thus making those clinics even more 
financially viable.

The Green Star Network delivers family planning services and products 
at four levels:

Female doctors who operate clinics are trained in all reversible con-
traceptive methods, including IUD insertion 

Male doctors are trained to provide counselling and deliver condoms 
and oral and injectable contraceptives (since it is not culturally 
acceptable for male doctors to insert IUDs in such circumstances); 
and 

Pharmacists stock, promote, and sell these products. 

Female paramedics who are trained to provide counselling and deliver 
condoms and oral and injectable contraceptives 

The Green Star network currently comprises over 10,000 providers 
spread throughout urban and peri-urban Pakistan. Each type of pro-
vider receives a different level of training and follow-up. The core 
of the network are the female doctors who receive a 40 hour training 
in reproductive health counselling and contraceptive methods includ-
ing IUD insertion and removal and infection prevention. There are 
currently over 2000 of these Green Star lady doctor clinics, over 
4000 male doctors, 2500 chemists, and 1800 lady health visitors serv-
ing the urban poor. 

Demographics: Population and Fertility Characteristics of Pakistan

Population Characteristics, 1998

Total Population: 130.6 million - 7th largest (May be largest in two 
generations) 
Urban Population 42,600,000- growing faster than rural population 
Rural Population: 88,000,000 - agricultural, poor, illiterate 
More males than females - (males outnumber females in very few coun-
tries) 
Population Growth Rte: 2.61% 
Infant Mortality Rate: 95/1000 live births 
For 100,000 live births, 350-500 women die of pregnancy related 
causes 
43% of population is under 15 years of age 
Total expenditure on education: 2.5% of GNP 

Key Characteristics of Fertility

Women will produce 5,000,000 babies this year 
High fertility due to early marriage, desire for large families, low 
use of contraception 
Legal age for marriage 18 years for males and 16 for females 
Total Fertility Rate has declined by one birth per woman in twenty 
years (1975 at 6.3 and 1998 at 5.3) 

An Overview of the Training Division

In November 1996, Social Marketing Pakistan (SMP) and Population Ser-
vices International (PSI) began the second wave of Green Star Clinic 
Project with funding from the Government of Germany via Kreditanstalt 
fur Wiederaufbau (KfW). This four years Green Star or Sabz Sitara II 
project is designed to enable 4500 mostly male registered medical 
practitioners in existing private clinics to provide high quality 
family planning services and products to low income urban families. 

The project has four components:

Training of private practitioners 
Demand creation for services and products 
Supply of contraceptives to the clinics 
Evaluation 

The project completed its training of 4065 private practitioners till 
31st July 1999. The Training Division of SMP appointed a task Force 
to review the findings of the evaluation reports both external done 
by management International and the Internal conducted by the train-
ers of all three regions. The Task Force terms of reference included 
identifying strategies to maximize health impact through these 
trained doctors all over Pakistan.

Background

Social Marketing Pakistan is a non profit organization (NGO) that was 
established with the assistance of an international NGO, Population 
Service International (PSI) to carry out social marketing of family 
planning products and services in the private sector. PSI started 
work in Pakistan in the 1980s, with USAID funding, to market condoms 
in the private sector. Social Marketing Pakistan came into being as a 
result of this initial activity. When USAID left Pakistan in 1993, 
and PSI were able to locate other financial support through KfW. The 
Green star Project was initiated in December 1995. This was under the 
endorsement and direct auspices of the government of the Pakistan.

Green Star Social Marketing Approaches

Social Marketing Pakistan procures and distributes Green Star prod-
ucts, Touch condom, Nova combined oral contraceptive pills, and Nova-
Ject injection. These methods are also available at pharmacies all 
over Pakistan through subcontracted distributors.

Demand creation is through a centrally designed and executed communi-
cation strategy (mass media, point of sale, leaflets, etc.).

Social Marketing Pakistan Training Division

SMP has formed a training division under the direction of a National 
Medical Coordinator. There are three regional sub divisions, South: 
Karachi (Head office), Central: Lahore and North Islamabad. Each re-
gional sub division has activities in several cities in that region. 
Each region has a training team of three male trainers, one recruit-
ment officer and one logistics officer.

To avoid duplication and waste of resources the country is divided 
between the two social marketing companies (SMP and TFG).

Green Star Training Packages

Green Star project has five different types of training packages, 
which are as follows: 
Female doctors trained in all reversible contraceptive methods in-
cluding Intra Uterine Contraceptive Device (IUCD). 

Male Doctors 

Comprehensive family planning workshop for general private practitio-
ners, mostly males is a 6 hours workshop that updates general practi-
tioners about new Family Planning information and concentrates on 
management of side effects and Family Planning methods but are either 
out of date or have major misconceptions about most methods. So, this 
training is a refresher or update workshop. Through this workshop, a 
Family Planning reference manual and various materials that help pro-
vide quality information and services to the participant's clients 
are provided. Each workshop graduate receives a signboard and Green 
Star products (except IUD.) Routine provision of Green Star supplies 
is also available.

Chemists

Green Star 3 is a 4 hours workshop for the chemists who are inter-
ested in counter sales of modern contraceptive. Till 31st July 1999, 
2529 chemists have been trained nationally.

Female Paramedics

Green Star 4 is a 6 hours workshop aimed at paramedic workers to pro-
vide better quality Family Planning service. Till 31st July 1999, 
1749 LHV's have been trained nationally.

For those Lady health visitors who are trained under Green Star 4 
but, already providing FP service and have a set up for IUCD ser-
vices, a two day workshop is conducted with the aim to train these 
LHV's for Multiload Cu 375, IUCD insertion. Till 31st July 1999, 171 
have been up graded.

Training Process

Need Assessment

The clinical training activities development process began with the 
need assessment in the form of a focus group discussion with the 
course/workshop target group. Following was held with training divi-
sion staff including trainers from all regions to discuss the find-
ings of the focus group discussion and develop the course/workshop 
concept, learning objectives, teaching plan, course/workshop flow 
sheet and learning materials.

Training Preparation

Preparation of the green Star 2 trainers was done through these 
course/workshop development efforts and through several Training of 
Trainers (TOT) workshops. Teaching methods for the course/workshop 
first were discussed and then practiced in simulations and then ap-
plied in actual course/workshop. Initially Mr. Richard Johnson PSI 
training consultant with the two trainers at head office generated 
the work i.e. development of reference manual, teaching plan, method-
ologies, learning contents, task analysis, participants hand book. 
All these were utilized in the course of trainer's development at na-
tional level.

Training Recruitment

A fairly rigorous and effective process was used to recruit the Green 
Star 2 trainers for the Green Star 2 training program. First, medical 
professional to had the basic talent for and interest in training was 
identified. These potential trainers were asked to observe SMP train-
ing activities and then asked to make a presentation at SMP office. 
If they were successful in presentations, the potential trainer was 
hired on probation and apprentices with a training team. Each new 
trainer is to tutor individually as new member of the training team. 
This tutoring is part of a fairly systematic "on the job training". 
All trainers take part in on going need assessments and training ma-
terials, development activities.

Training of the Trainers

The workshop is four days in length with one day dedicated to train-
ing methodologies, two days for reviewing the six hours workshop par-
ticipants will be teaching and a final day for participants to actu-
ally conduct the 6-hour workshop.

While the opportunity to become familiar with the training package 
they will be using is essential for new trainers, together with prac-
tice using the materials, a single day of actual training skills is 
probably not adequate to make them comfortable and confident in in-
teractive and participatory training skills. Adopting an interactive 
and participatory style involves a major change from traditional 
training techniques and requires a great deal of reinforcement and 
repetition to ensure that the behavior is well established.

Family planning Reference Manual

The reference manual was developed from INTRAH materials and JHPIEGO 
pocket guide. Much of the counselling information comes from the 
INTRAH source, while most of the technical information on specific 
methods was taken from packet guide.

Training Methodology

Training methodology is selected very carefully to achieve each ses-
sion's learning objectives. Emphasis is placed on creating a good 
learning climate and strong participation from the participants. The 
Green Star II training program uses adult learning method extremely 
well in its training activities and an attempt is made to practice 
competency based methods.

Several innovations have been designed and piloted in Green Star II 
training program. A trainer manual was also developed to facilitate 
the trainers at workshop.

Recruitment of Participants for Green Star II Workshop

Each region has a recruitment officer for this purpose but besides 
that each trainer also help in identifying the potential partici-
pants. The recruiter selects these participants and trainers also do 
the follow-up. In this way a good number of participants usually 
turns up. The criteria for recruitment is as follows:

Medical professional with MBBS or equal diploma or degree. 
Having own clinic or is working on permanent basis. 
Over all clients are of low socio-economic group. 
Interested in providing quality Family Planning services. 

Starting of Green Star II Training

Initially Mr. Richard Johnson PSI training consultant with the two 
trainers at head office stated the work in late 1996, i.e. develop-
ment of Reference manual, pre-post test, evaluation/membership/forms, 
mid course questionnaire, teaching plan, methodologies, learning con-
tents, task analysis, participants hand book after the needs assess-
ment group meeting. Several changes were made after the first TOT and 
further were made after the first actual workshop in November 1996.

Expansion at National Level

The Karachi Green Star II team was established first, in 1996. Then 
the Lahore and Islamabad Green Star II teams were selected for the 
expansion of training division. The senior trainers supported other 
regional teams of Lahore and Islamabad in the initial phase to de-
velop uniformity. With the time the need for establishing regional 
centers arose to meet the increasing demands of training activities. 
Presently SMP has sub offices for South region at Hyderabad, Sukkur, 
Larkana, for North region at Peshawar and central region at Multan 
and Faisalabad. These sub foci's support training activities and fol-
low-up in the peripheral areas of respective region.


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