Gulbibi was married at the age of 16. By the time she was 26, she had been pregnant five times, suffered one miscarriage and given birth to four children. Gulbibi is illiterate, and so are her husband and all their relatives and ancestors, as far back as anyone can recall. They migrated to the city two years ago in search of opportunity and better living conditions, yet could only afford to live in a slum. Gulbibi’s husband is a daily wage earner. Gulbibi has a fine hand for embroidery and has recently begun to use this skill to supplement their income. This also gives her some outside contact in the community. She heard that the Greenstar Network provides quality family planning services. She managed to convince her husband that they could not afford to have any more children for a while. He agreed to let her visit the clinic, as it was nearby. Gulbibi returned home with an effective method of birthspacing. She is now a satisfied user and tells others about the quality service available at the neighborhood Greenstar clinic.

Greenstar
The Greenstar Network is one of the largest developing-country, private reproductive health networks in the world. Greenstar clinics and pharmacies deliver comprehensive, affordable, quality reproductive health products and services to millions of low-income people throughout Pakistan.

Fertility rates have fallen markedly in most developing countries, but Pakistan’s rate has averaged over 5 births per woman. This is not a deliberate choice on the part of Pakistanis—it has its roots in the many barriers they face in seeking reproductive health care.

Men and women in Pakistan—women especially—are poorly informed about family planning. Contraceptive choices and access to information are limited. Seventy-six percent of women are illiterate. Not surprisingly, knowledge about contraception is minimal, and misconceptions abound. Contraceptive use is low, with fewer than 17 percent of couples using any modern method.

Government reproductive health services have not been able to meet the public’s needs, and nearly 75 percent of Pakistanis seek health care from private-sector clinics and pharmacies. Medical school curricula in Pakistan include little practical exposure to reproductive health, with family planning coursework so rudimentary that physicians often share the public’s misconceptions about contraception.

The Greenstar Network: Gateway to Low-income Couples
The Greenstar Network provides comprehensive, accessible and affordable reproductive health products and services to low-income Pakistanis, and does so with care and respect. The Network is sustainable over the long term—it begins with existing clinics and pharmacies, making them even more viable by expanding the number of services they offer and increasing their clientele. The Greenstar social marketing program has five components: (1) medical training, (2) reliable supply, (3) public education, (4) technical support and quality control, and (5) program evaluation.

(1) Medical Training
There are four types of providers in the Greenstar Network, each receiving distinctive training.

Greenstar #1 is comprised of 2,000 female doctors. Participating physicians undertake an intensive 40-hour course on all contraceptive methods, including IUCD insertion, hormonal contraceptive prescription, side effect management and counseling techniques. Because in general practice in Pakistan only female physicians conduct such gynecological procedures as IUCD insertion, Greenstar #1 providers are exclusively female physicians.

Greenstar #2 is comprised of 4,250 doctors—primarily male—who receive a one-day training in reproductive health, counseling, and all contraceptive methods except IUCDs. In Pakistan’s conservative cultural environment, men often discuss family planning only with other men. By working with male doctors, Greenstar seeks to motivate men to use contraceptives themselves, to talk with their wives about contraception, to take responsibility for family planning, and to support their wives when they choose a method.

Greenstar #3 involves pharmacists, who receive a half-day training in reproductive health, counseling and all contraceptive methods. Low-income people in Pakistan often seek the advice of a pharmacist before consulting a physician. The 2,580 Greenstar pharmacists can speak knowledgeably about the contraceptive methods they carry.

Greenstar #4 is made up of approximately 2,200 female health visitors—women who make home calls or run small clinics. They receive a day’s training in reproductive health, counseling and non-clinical contraceptive methods. Female health visitors often work in the poorest neighborhoods and are important conduits to the most underserved communities.

(2) Reliable Supply
International-quality contraceptive pills, injectable contraceptives, IUCDs and condoms are subsidized by program donors and sold at prices that are affordable for low-income clients.

(3) Public Education
Demand creation for Greenstar reproductive health services and products is conducted through mass media promotion of family planning and reproductive health services featuring the Greenstar logo. The logo, promoted as the symbol of high quality, affordable family planning products and services, is placed on signboards of certified clinics and pharmacies, and also appears on the packaging of its four contraceptive products. Program staff members also reach directly into communities, organizing neighborhood meetings in which broad ranges of reproductive health issues are addressed.

(4) Technical Support and Quality Control
Green Star instructors make regular visits to Greenstar clinics to follow up on quality of services and product availability. A medical detailing force also visits Greenstar doctors and pharmacists.

(5) Program Evaluation
The program has conducted a series of evaluations that assess improvements in quality of care, increases in service delivery and program impact.

PSI introduced contraceptive social marketing to Pakistan in 1986 with funding from the United States Agency for International Development (USAID), and worked with commercial firms and the Government of Pakistan to make quality condoms broadly available. In 1991, PSI founded a nonprofit NGO, Social Marketing Pakistan (SMP), to build local capacity. In 1993, when Pakistan’s government declined to sign the nuclear non-proliferation treaty, USAID withdrew from Pakistan. Rather than abandon the program, PSI used its own reserves to continue operations. In 1995, the Government of Germany, through Kreditanstalt fur Wiederaufbau (KfW), provided substantial funding to SMP and PSI to continue marketing condoms and to design and launch the Greenstar Network. Since then, SMP and PSI have received support from a number of generous donors—including the Government of the United Kingdom, the Packard Foundation, the Government of the Netherlands, UNICEF, and the Levi Strauss Foundation—to implement family planning, reproductive health, and nutrition social marketing projects in Pakistan.

Why it Works
The Greenstar Network markets family planning services along with contraceptive products, and breaks new ground in social marketing in two ways. First, it is a comprehensive effort, combining marketing, training, contraceptive supply, ongoing support and evaluation into a cost-efficient and sustainable program. Second, it has achieved concrete results in a short period of time by increasing contraceptive sales and the number of people receiving family planning services in Pakistan, and by improving the quality of care in private-sector family planning outlets.

Making a Difference
This work has substantial impact. In 1998 and 1999, SMP provided approximately 20 percent of all modern family planning products and services in Pakistan. Approximately nine million clinic visits are made each year to Greenstar’s female health providers, and, of these visits, two million are related to family planning.

The success of the Greenstar Network demonstrates that social marketing through the private sector can provide high-quality reproductive health products and services. An evaluation early in Greenstar’s development indicated that Greenstar female doctors provided:

• A choice of contraceptive methods. Over 90% of clinics had oral contraceptives, injectables and IUCDs available.

• Quality client-provider information exchange.

• Doctors discussed three or more birth spacing methods with more than 85% of PSI researchers posing as patients and over 75% of doctors discussed how to use the contraceptive method chosen.

• Friendly client-provider relations. In almost all cases, doctors greeted patients respectfully and interacted with them in a cordial way.

• A follow-up mechanism. A majority of doctors informed clients where to return for follow-up and re-supply options.

• An appropriate constellation of services. The clinics already provided health care principally to women and children, allowing the project to "nest" contraception within pre-existing women’s health provision.

• Medical competence. Each doctor joined the Greenstar Network only after demonstrating technical competence in each area of the training curriculum.

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