Case study on ngo_management by dr.shaikh tanveer ahmed

Case

‘Where there’s a will, there’s
a way’: The Supply Chain of
MARVI Project, HANDS
Mustaghis-ur-Rahman
Sheikh Tanveer Ahmed

South Asian Journal of
Business and Management Cases
1(2) 129–144
© 2012 Birla Institute of Management Technology
SAGE Publications
Los Angeles, London,
New Delhi, Singapore,
Washington DC
DOI: 10.1177/2277977912459437
http://bmc.sagepub.com

Abstract
This case study concerns supply chain of a project ‘MARVI’. The acronym MARVI stands for ‘The
Marginalized Areas RH (Reproductive Health) and FP (Family Planning) Viable Initiatives’. This project,
funded by the David and Lucile Packard Foundation, was started by Health and Nutrition Development
Society (HANDS), a Karachi based integrated development NGO. This project was designed to pilot
an integration of RH and FP with rural support programmes in Umerkot district, which is one of the
most remote and poorest districts of Sindh, Pakistan. The modus operandi of this project is to operate
in collaboration with other NGOs in the district through developing a community based model of social
marketing of RH and FP products. The macro objectives of this project are to increase awareness and
positive RH and FP behaviours to improve the life of people in the district. For this project, HANDS
team came up with a non-conventional method to reach out the community to supply the RH and FP
products in the difficult economic, cultural and physical environment of the district Umerkot.
This case can be taught in Supply Chain, NGO Management, Reproductive Health and Family Planning
disciplines.
Keywords
Supply chain, innovations, non-profit, NGOs, reproductive health, MARVI project

Introduction
At the start of the MARVI project Phase II, Dr Tanveer, Chief Executive, Health and Nutrition
Development Society (HANDS) was having reflections on the conceptualization process of the project
after receiving an offer from David and Lucile Packard Foundation to HANDS for promoting reproductive health and family planning practices in one district of Sindh province.1 During the brainstorming
session for seeing possibilities of accepting a new project on reproductive health (RH) and family planning (FP), Dr Tanveer and HANDS’s team was wondering how this project would be a different project
This case has been developed solely as a basis for class discussion and for education purposes. It is not intended to
illustrate either effective or ineffective handling of an administrative situation or decision-making, or represent or
endorse the views of management about the topic of the case.

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Mustaghis-ur-Rahman and Sheikh Tanveer Ahmed

from HANDS’s other family planning projects it had done in past. The team reached the decision that
they would like to reach out to the new but most deserving area in the province. The team found Umerkot
one of the fittest districts to start this project, as this was one of the remotest areas in Sindh—difficult
in outreach and the population was marginalized in the sense of their socio-economic well-being.
There were debates within the organization for the prospective modus operandi of the project in the
given features of district Umerkot. At the end of debates and deliberations, a baseline survey was conducted in the district, which revealed: ‘The current situation in Umerkot district regarding the health
seeking behaviors, access to health care facilities and availability of services and family planning products requires some innovative and cost-effective solutions that take the local context into account.’ The
survey also highlighted that the reproductive health issues cannot be addressed in isolation without considering the existing socio-cultural norms, educational and economic status of the community. (HANDS,
2008, p. 35)
Hence, on the basis of the base line’s result, it was decided that Umerkot district was the right place
to launch this project with the integration of rural support interventions to improve the reproductive and
family planning status in the district through viable initiatives under the title ‘The Marginalized Areas
RH (Reproductive Health) and FP (Family Planning) Viable Initiatives (MARVI)’. The acronym is after
the name of a brave girl character from a folk story2 associated with the district Umerkot.
The case deals with the issues of supply chain in a difficult geographical area in non-profit setting.
At the same time, this case highlights the difficult but innovative decision making to meet and succeed
the challenges of supply chain by the organizations encountering with limited resources and physical
obstacles.

HANDS, an Integrated Development NGO
HANDS started getting shape in 1979 envisioned by Dr Ghaffar Billoo, a paediatric professor, with
several colleagues to make Pakistan healthy, educated and prosperous. Now after 33 years, HANDS has
developed into a multispectral intermediary NGO, engaged in the delivery of primary and secondary
health care, water and sanitation, microcredit, education, income-generation support, and gender empowerment and training services. It is reaching more than 13 million people, with a geographic spread across
more than 19,182 villages in 24 districts across three provinces of Pakistan. It collaborates with 1,485
community-based organizations (CBOs), 31 women CBOs, 252 savings groups and 5 community water
committees (HANDS, 2011).
Like many other grassroot NGOs, HANDS was formed informally by a team in response to the inadequate health infrastructure in rural parts of Sindh province and started by focusing on the delivery of
primary health care to disadvantaged communities. HANDS by passing through the three key stages in
its development—philanthropic, formalization and growth—reached the present status of multi-sectoral
NGO with a focus on building communities at the grassroots levels (Khan, 3 2012).
Due to HANDS’s track record of services for humanity and development work, it has received recognitions from the Government of Pakistan and other international bodies. HANDS has been certified
as a tax-exempted organization by the Government of Pakistan. The international donor agencies like
USAID and European Union accredited HANDS as a not for profit organization for their projects
(HANDS, 2011).
South Asian Journal of Business and Management Cases, 1, 2 (2012): 129–144

The Supply Chain of MARVI Project

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HANDS’s Strengths
HANDS is presently running 72 development projects in collaboration with individual philanthropists,
philanthropic foundations, international donor agencies, corporate sectors and government agencies of
various nature from simple projects like ‘Health Equipment Supplies for Communities’ to the complex
services as ‘City District Government—HANDS Hospital & Emergency Obstetric Care Services (EOC)’
in 22 districts of Pakistan.
The important feature of HANDS projects is that all have been planned for and being operated in the
rural areas of the country, and most of the projects are in far-flung areas of Sindh. It would not be wrong
if HANDS is placed in the category of rural development organizations for its rural based projects.
HANDS’s 33 years working experience in the rural settings has empowered it to work innovatively to
cope up with the challenges like physical and economic toughness of the project areas. Capabilities of
HANDS were tested at several occasions like the massive earthquake in the northern areas of Pakistan
in 2005 and the devastating effects of floods in 2011. MARVI project’s supply chain management is
one of the positive proofs of its capabilities. The high commitment of HANDS’s 1,796 paid staffs and
100,000 volunteers under the leadership of Dr Ghaffar Billo to the cause of socio-economic development
in the country is the real strength of this organization (HANDS, 2011).

MARVI Project
The driving force behind MARVI project was the HANDS’s commitment to reach the most disadvantaged people in the country with dismal health services in the field of primary health care and family
planning in the rural areas of Pakistan. The initiative stands justified as the national programme of
primary health care and family planning covers only 54 per cent of the country’s population, thus making
46 per cent of highly marginalized population more vulnerable to ill health and deaths all over the
country (HANDS, 2008).
MARVI project has been designed to improve the life of the people in the remote and the poorest
district of Umerkot in Sindh province through an integrated development approach with a focus at the
RH and FP. MARVI project is a three-year project in Phase I from 2007 to 2010 and later extended for
three more years, that is, till October 2013 by the donor David and Lucile Packard Foundation. The purpose of this project is to pilot an integration of RH and FP with rural support programmes to increase
awareness and positive RH and FP behaviours among the community by developing 350 community
health workers (CHWs) and lady health workers (LHWs) in the areas uncovered by the national health
programmes. The specific objectives of this project is to improve RH and FP behaviour in marginalized
communities of Umerkot, Sindh through the development of a community-based model linking microfinance, social marketing and facilities improvement. The specific targets of the project by the end of 2010
(Project Phase I) were the following:
• 350 CHWs trained in social mobilization, referral strategy, FP and RH, social marketing of FP
products
• 350 traditional birth attendants (TBAs) trained in RH, FP and safe motherhood
• 10 per cent increase from baseline in new acceptors of FP in four years in the district

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• 60 per cent of trained CHWs running successful microcredit programmes in their community by
the end of the project
Another aspect of this intervention includes social marketing of RH and FP products through
CHWs. The CHWs of rural support programmes are being trained to work as social marketing agents for
selected RH and FP products for their sustained income generation. The project intervention also includes
initiation of women-friendly health facilities and health care providers’ certification programme by district government. The district government is facilitated by the project to establish a women-friendly
certification programme to monitor RH and FP service facilities.

Challenges for HANDS
The real challenge for HANDS in operating MARVI project was to reach the people with services in
Umerkot district while keeping the operation cost and subsidy on the product as low as possible to make
it viable and sustainable intervention. Umerkot district lies in the extreme south-east of Sindh with
sparse human settlement, and there is widespread poverty. Due to the district’s remoteness, and tough
physical and economic environment, the traditional supply chain for the services was unfeasible. Some
of the challenges are briefly discussed as under.

Physical Challenges
Physical challenges were the remoteness and difficult outreach of the district. The physical infrastructures of the district, such as roads, transports, electronic communication systems and proper markets,
were inadequate. The extreme weather4 in the district also added hindrances to the mobility of local
people. District’s population stood at 858,376.5

Socio-economic Challenges
The household survey revealed that the community behaviours and social factors were dictated there by
cultural realities affecting the women health issues, such as early marriages, low literacy rate, women’s
unequal access to resources, and their lack of decision-making power in families and societies. Low
socio-economic conditions increased the burden of work on women with no leisure, and low access to
health facilities lead to poor health and nutrition status of women in the district (HANDS, 2008, p. 35).
Most of the women were contributing in household income but remained unrecognized economically
and socially, as they claimed themselves unemployed. Only half of them received some cash to spend at
their will. 74 per cent of the population in the area was living below the poverty line with a literacy rate
of 6 per cent (Bureau of Statistics, 2006). Overwhelming majority of women was illiterate, and had poor
knowledge regarding their health, especially, regarding family planning. As per HANDS
(‘Introduction’, 2008), Umerkot district is one of the poorest districts in Sindh. Consequently,
home deliveries are very common by unskilled birth attendants as 70 per cent deliveries are at homes


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(with trained, untrained and sometimes even without birth attendants), and highest maternal death in the
country has been recorded in this district. There is inadequate knowledge and poor practices for family
planning as only 9 per cent of the married women were using contraceptives and more than 50 per cent
women did not know the place from where to get contraceptives. Poverty has been described as one of
the main reasons for unwanted pregnancies as women are made to choose between buying contraceptives or feeding their families as reported in national study on ‘unwanted pregnancy’ (Population Council,
2003). The mean reported cost of contraceptives at government facilities is `75 and at private facilities
it is `125.0. Hence, there is a need for creating awareness and provision of accessible health care and
family planning services at low cost which should also be acceptable to them. According to the Pakistan
Participatory Poverty Assessment (Government of Sindh, 2007), 15 per cent married women aged 15–49
in the lowest quintile have ever used contraceptives as compared to 25 per cent of those in the highest
quintile in Umerkot. A reflection of the reproductive health challenges faced by the people of Umerkot
district and HANDS in the management of MARVI project can be seen by the tragic death of Dharma
which was documented by HANDS team and reproduced in the Box 1.

Supply Chain in Non-profit Organizations
The Council of Supply Chain Management Professionals (CSCMP) has defined supply chain management (SCM) as: ‘SCM encompasses the planning and management of all activities involved in sourcing
Box 1. Too Far, Too Little, Too Late
Pakistan having a population of 160 million is the world’s sixth most populous country. Health status of
Pakistani population remained grim for long. Even today the maternal mortality in Pakistan is 276 maternal
deaths per 100,000 births. The ratio increases to 785/100,000 live births in Sindh province, thus depicting alarming picture of the MNCH indicators in this province. Every year around 25,000 women die from
complications of pregnancy and child birth and millions more suffer ill health and disability.
Dharma is one of those unfortunate mothers who could not survive while giving birth to a new life.
Dharma, aged 20 years from village Vehro Sharif at a distance of 8 km from Umerkot town, could not reach
the right hospital at the right time due to her poverty, low level of awareness and physical hindrances in
the district. HANDS team which visited the village to document the case was informed by the deceased’s
unemployed husband, Baksu: ‘Subject to poverty we could not consult a qualified gynecologist. However, we
managed to consult a general physician who advised us to take Dharma to Laal Bati Hospital (Referring to
Civil Hospital Hyderabad; commonly known as Laal Bati). Accordingly, we took her to hospital for operation
so that her life could be saved.’ Before she was shifted to Hyderabad Civil Hospital, it was too late as baby
in her womb was already dead. One of the family members of Dharma stated that, ‘Doctor revealed that
deficiency of blood is primary reason due to which Dharma could not survive.’
Dharma’s mother-in-law shared with the team that ‘After operation, Dharma became unconscious and
doctor informed us that she is in coma, consequently she died after a day.’
Dharma’s family members and relatives further informed HANDS team that it was Dharma’s first pregnancy. Besides anemia, fits and swelling upon her lower limbs were the initial symptoms observed but could
not get timely medical help.
Source: Small case (unpublished) study written by the HANDS MARVI-Field team.


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and procurement, conversion, and all logistics management activities’ (Ballou, 2007, p. 4). The objective
of SCM is to incorporate activities across and within organizations for providing the customer finished
goods and services. Though the supply chain of all kinds of organizations—public, private and nonprofit organizations—may be similar, managing SCM of each type of organization is different. The
prime objectives of the three kinds of organizations are different from each other, as Firstenberg (1996)
and Drucker (1998) state that non-profit organizations may be drastically different from a for-profit
organization. Public sector organizations are primarily to maintain the social order while actualization of
social vision and earning profit are secondary and tertiary consideration (Brown & Korten, 1989).
According to Hay (1990) for profit organizations maximize their profits by managing value chain effectively, while for a non-profit organization monetary return is not an objective in financial terms. However,
the surplus created, if any, by non-profit organizations through their operations are used to meet its own
expenditures or for the extension of their existing services. The non-profit organizations are formed to
work for improved living standards of people through provisions of increased literacy level, increased
health facilities, gender equality and eliminating racial discrimination (Rahman, 2004). Hence, nonprofit organizations’ feasibility is not based on rate of financial return (RoR) or return on investment
(RoI), rather their feasibility is based on relatively less measurable outcomes, such as increase in awareness leading to improved socio-economic practices of the community where they are working. For this
reason, non-profit organizations keep finding innovative ways and means of community development to
reach out to the target groups by mobilizing resources from the ‘strategic philanthropists’.6 In fact, this
innovative practice is an appealing factor to a type of philanthropists who are willing to take risks to see
the change in the current service system, which need a radical transformation and a distinctively different
way of serving the community (Deaton, 2011). Innovative supply chain for MARVI projects might have
various backgrounds but one of these may match Deaton’s argument.

Response to the Challenges
There is a severe shortage of accessibility and availability of maternal and child health products and
contraceptives in Umerkot; as low as 9 per cent of the married women were using contraceptives. There
are various reasons for the low availability or the low accessibility for the usage of contraceptives and
other maternal health care products in the districts, but the most obvious reasons are the economic,
lack of communication and accessibility to the places from where these products can be availed.
HANDS, therefore, intervened to establish a network of social marketing by developing MARVI workers
who played their roles as community change agents. These workers provided the health services,
products and awareness at the door steps of the community. The products included clean delivery kit,
contraceptive pills, condoms, sanitary pads, ORS, iodized salt, pregnancy test strips, essential medicines
(Appendix 1). Coming to the innovative approach for the MARVI project, HANDS was benefitted by the
basics of the subject ‘social marketing’, such as ‘the application of the ideas, processes and practices of
the marketing discipline to improve conditions that determine and sustain personal, social and environmental health and well-being’ (Kotler & Zaltman, 1971). Kotler and Andreasen (1996, p. 5) define social
marketing as differing from other areas of marketing only with respect to the objectives of the marketer
and his or her organization. The principles developed by the scholars of social marketing revolve around
the following points:


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• Development of a deep ‘insight’ into people’s lives, with a clear focus on what will motivate
people to change in any given situation
• A compelling positive ‘exchange’ proposition based on community’s analysis
• The development of a service system that assists a person voluntarily towards a socially beneficial
behaviour
• A competition analysis of internal (psychological factors, pleasure, desire, risk-taking, etc.) and
external factors (wider influences competing for the audience’s attention, time and behaviour,
promoting and reinforcing alternative or counter behaviours)
• Understanding and developing interventions that make it more likely that people will adopt a
particular behaviour

MARVI’s Supply Chain
Benefiting from the principles of social marketing, HANDS developed its supply chain at the three
levels as follows:
• HANDS’s involvement
For the supplies required by the project, purchase request is submitted by the MARVI project
coordinator to HANDS chief operating executive through general manager operations at the head
office. On approval of the requisition, the operations department forwards the same to procurement department. The procurement department calls quotation through approved contractor or by
advertising demand in newspaper/website to collect the best rate on the basis of quality and cost.
Then the rate is sent to purchase committee/board for approval and after approval purchase order
is issued to the supplier. The products are received with delivery challans at the HANDS head
office by the warehouse management (store keeper). The supplies are issued under proper delivery
challan to production house where supplies are packed and again returned to warehouse for
storage as inventory. Supplies to district offices are made as per demand of the district executive
manager (DEM), time to time.
• Operations in district
Products are issued from district office to health promotion associates (HPAs) and MARVI
workers (MWs), who sell the products to the community at subsidized rates. MWs and HPAs are
responsible for maintaining computerized management information systems (MISs) for the
supplies received, sold and inventories at hand at the district office. Financial transactions are
compiled by the HPAs under the supervision of executive manager and cheques/cash for the sold
products are sent to finance department head office, where a separate account is maintained for
MARVI project.

HPAs and Their Responsibilities
The HPAs are selected from the community. The minimum qualification of an associate is SSC (10 years
of schooling), but there are many HPAs who have bachelor’s degrees (14 years of education). The HPAs’

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incentives are salaries plus commission. They use their own transport. Each HPA supervises 35 to
40 MWs while they are managed by the district executive manager. The HPAs perform the following
responsibilities in their operating areas:
•
•
•
•
•
•
•
•
•

Develop liaison/linkage with MWs, TBAs and community groups
Provide marketing and technical support to MWs/TBAs
Provide supplies to the MWs at their door steps
Supervise the MWs’ financial and progress reports
Facilitate MWs in creating demand for RH and FP products by having frequent visits to the MWs’
areas of operations on their requests
Send reports to the district executive manager regarding the activities from the field on monthly
basis
Create training opportunities for MWs and TBAs in the district and outside the district
Conduct research to get feedback from the Community Based Systems (CBS)/Para Development
Committee (PDC) members for bringing improvement in the delivery systems of the supplies
Organize health sessions in the district in collaboration with project associate/LHV with MWs

Results
After the completion of three years of the MARVI project an end line evaluation of the project was
conducted in the month of June and July 2011 to assess the progress made against the benchmarks set for
the project. The results of the project are summed up under the broad and comparative results heads
separately.

Broad Results
The broader results of the project are that 350 MARVI houses have been established serving as hub of
project activities, where printed health education material, posters and flip charts referral plan and list of
blood donors have been displayed. In numbers, 96 per cent women, in the project area, are aware of at
least one modern method of contraception and 85.5 per cent women have knowledge about injectables
and oral pills. Now the family planning users are 22 per cent in comparison to 9.3 per cent found in
baseline. There is thus an increase of 13 per cent in current user of family planning from the baseline.
93 per cent of the project area’s women know about MARVI workers who provide the medicine and
health products. 65 per cent of women know about the availability of family planning methods with
MARVI workers. 56.2 per cent women identified MARVI House as a source of family planning methods
(see Appendix 2).

Comparative Results
Specific Objective 1: Increase awareness and promote positive behaviours regarding RH and FP through
enabling environment in target areas.


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Expected Outcomes
a. A functioning behaviour change communication (BCC) strategy in place at the village level, in nonLHW areas through trained CHWs and health groups resulting in increased community awareness
of maternal/neonatal health and family planning issues and improved health seeking behaviours.
b. Trained and skilled TBAs available to conduct safe deliveries, to identify danger signs during
pregnancy and use referral system/facility for complicated pregnancies and deliveries for facilitybased care.
Project Success Indicators
• 50 per cent of the deliveries conducted by skilled health care providers.
• 100 per cent of the deliveries conducted at home by trained TBAs utilizing safe delivery kits.
• 50 per cent of the pregnant women on complications used referral system/facility.
• 50 per cent women with complication after using family planning methods used referral system/
facility.
• 40 per cent of the women have utilized saving and credit programme for seeking health care.
Specific Objective 2: Increase access to essential RH and FP products and services through community
involvement.
Expected Outcomes:
a. Basic RH and FP products and selected services available within villages through trained CHWs.
b. Accessibility and availability of comprehensive family planning services including surgical
contraception and post-abortion care in targeted private health facilities in the project area.
Project Success Indicators:
• 50 per cent of families practicing modern family planning methods (contraceptive prevalence).
• 70 per cent of pregnant women seeking ante-natal and postnatal care from skilled health care
providers.
• 90 per cent coverage of tetanus toxoid immunization in pregnant women.
• 40 per cent increase of health facilities utilization for comprehensive family planning services.
Specific Objective 3: Improve RH and FP quality services in public and private sectors of the district.
Outcomes:
a. Management capacity of district health managers enhanced through providing them necessary
training in quality of care, monitoring and evaluation through an MoU.
b. Quality care assurance through provision of Women Friendly Certification of public and private
health care facilities by the district government.

Conclusions
HANDS’s MARVI project, funded by David and Lucile Packard Foundation, started for three years from
2007 to 2010 for the marginalized people of the district Umerkot with an objective of providing RH and

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FP medical facilities. At the end of the project in 2010, the evaluation revealed that the project had
achieved its target and has become a source of continued awareness of health, supplies for the family
planning and income generation to the local women. As a result, the donor of the project has extended
the project as MARVI Phase II with enhanced services in the district Umerkot.
MARVI project’s supply chain has been found effective in the area as it is evident from the high level
of involvement of the men and women in the project as a receiver from and contributor to the project
(Appendix 3). Besides, the project has been also approved by the donor for Phase II from 2011 to 2013.
Due to the success of the supply chain model of this project, HANDS has replicated this model with
other partners in five more districts—Thatta, Badin, Karachi Rural, Jamshoro and Jacobabad districts
of Sindh.
There could be various reasons of the success of the MARVI projects, such as HANDS staff’s commitment to reach the place where people need them, HANDS’s 33 years experience of the integrated
development or innovative thinking of the MARVI project’s team or HANDS’s able leadership. One
more reason for the success can be attributed to the HANDS’s focus on the capacity building of
community and staff since its inception. Along with its service delivery, HANDS has also established a
training institute which is providing in-house training to the HANDS staff and also building capacity
of the NGO sector on demand. On the training and capacity building of staff, HANDS has spent
`6.431 million in the year 2009–2010 (HANDS, 2011).

Appendices
Appendix 1. Supplies and Products for MARVI Project
Following are the products supplied on regularly basis to MARVI workers through HPAs.
• ORS, Syp. Septran 50 ml, Tab. Septran, Tab. Septran DS, Tab. Ferrous Sulfate, Tab. Folic Acid,
Syp. Amoxil 250 mg, Syp. Amoxil 125 mg, Drop. Amoxil 125 mg, Tab. Paracetamol, Syp.
Paracetamol, Tab. Navaquine, Syp. Navaquine, Polyfax Eye Ointment, safe delivery kits, sanitary
pads, iodized salt, pregnancy test, Tab. Ponstan, rubber condoms, contraceptive pill, Syp. Vento line
List of MARVI Kit
Following are items included in MARVI Kit supplied to MARVI workers during the training.
1.
2.
3.
4.
5.
6.
7.
8.
9.

Regzine/Iron Bag for MARVI workers
Measuring tap
BP apparatus
Stethoscope
Adult weight machine
Child weight scale/SaltScale with Trouser
Bandage (3 inch)
Cotton roll (250 grammes)
Pyodine


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10.
11.
12.
13.
14.
15.
16.
17.
18.

Polyfax Cream
Cotton wool (400 grammes)
Sticking Plaster I × 5mm
Pencil Torch with two cells
Clinical thermometer
Scissors
MIS registers
Pencil, eraser
Sharpener

Appendix 2. Detailed Project Result
Knowledge of MARVI Workers of Family Planning
All the MARVI workers (100 per cent) had knowledge about family planning and all of these had knowledge about pills and condoms while 93 per cent knew about injectables, 80 per cent knew about tubal
ligation (TL) and vasectomy, 70 per cent knew about intra-uterine contraceptive device (IUCD) and
30 per cent MARVI workers have knowledge about other methods too.
100

100

93

80

70
30

Pills

Condom

Injectable

TL &
Vasectomy

IUCD

Others

Figure 2A.1. Knowledge of MARVI Workers regarding Family Planning Methods

Knowledge about Contraceptive Methods
Ninety-six per cent women knew about at least one modern method of contraception as compared to
95 per cent in mid-term review (MTR). Women’s knowledge about injectables was found to be 85.5 per
cent and about oral pills almost 83 per cent, it was 59 per cent and 62 per cent in baseline, respectively.
Knowledge of modern contraceptive methods among the women community-based organizations
(CBAs) increased from baseline.
Current users
In the end evaluation current users of family planning were 22 per cent in comparison of 14.5 per cent in
MTR and 9.3 per cent in baseline.

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Injectable

Oral Pills

Condom

IUCD

Tubal Ligation

Vasectomy

Others
0

20

40
End Evaluation

60
MTR

80

100

Baseline

Figure 2A.2. Women’s Knowledge of Family Planning Methods

It reflects that there was an increase of 13 per cent in current user of family planning from the
baseline.
Source for Family Planning Methods
In the end evaluation, 56 per cent women identified MARVI House as a source of family planning
methods in comparison to 41 per cent in MTR. 22 per cent women considered the government health
facilities, the same percentage of women identified the private health facilities and 5.1 per cent women
reported others as sources of contraceptives, while in MTR government health facilities and private
health facilities were pointed out as 31 per cent and 28 per cent, respectively.
Assistance during delivery by medically trained birth attendants is considered to be effective in the
reduction of maternal and neonatal mortality.
It was also found that in End line Evaluation, 36 per cent deliveries were attended by skilled birth
attendants (SBAs) while 36 per cent were conducted by TBAs. In baseline, 68 per cent deliveries were

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25
22
20
14.5

15
9.3

10
5
0

Baseline

MTR

End Evaluation

Figure 2A.3. Current Users of Family Planning Methods

Table 2A.1. Source of Family Planning Methods
Availability of Family Planning Methods

Baseline

MTR

End line Evaluation

25.6
74.4
0

31
28
41

22
22
56
5

Public health facilities
Private health facilities
MARVI House
Others

36%

64%

SBAs

Figure 2A.4. Deliveries Conducted


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assisted by TBAs and 32 per cent by SBAs. It showed an increase of 2 per cent in SBA’s attended
deliveries.
According to Pakistan Demography and Health Survey (PDHS) 2006–2007, 39 per cent of births took
place with the assistance of a skilled medical provider (doctor, nurse, midwife or lady health visitor).
TBAs assisted more than half (52 per cent) of the deliveries, friends and relatives assisted 7 per cent of
deliveries, and LHWs assisted less than 1 per cent of the deliveries.

Appendix 3. Story of Gomi
Gomi lives in a remote village named Manro Meghwar in Union Council Mir Wali Muhammad, Umerkot
district, Sindh, Pakistan. She is a housewife, living with four children and her husband here since last
15 years when she got married. She got education up to class five from her grandfather as there was no
further education facility available in her village. She is one of the educated females of the village. She
works in agricultural field with the family whole day to contribute to the needs of life.
Pardeep, husband of Mrs Gomi, is a tailor master working at the nearest bus stop Bodar farm, has
done matriculation and could not continue further education as he got married and responsibilities of
family increased and had to earn for them.
In October 2007 HANDS and Thardeep Rural Development Program (TRDP) with the support of
‘The David Lucile and Packard Foundation’ started to implement a project on RH and FP services for the
marginalized community in district Umerkot, because only 56 per cent population of Pakistan was covered by LHWs, and there was also lack of RH and FP services there. Initially baseline survey was conducted and it was observed that most of the deliveries were conducted at home (63 per cent), with
unskilled persons (63 per cent) and in unsafe and unhygienic conditions (91 per cent). Gomi said:
I am very much interested to serve the poor community in the field of health because there are many health problems are there because of no education especially in females and not in access to any female care provider nearest
to them. As HANDS/TRDP team came to our village and held meeting with the community members, briefed
them about the start of services to their community through their participation. By the discussion and decision
of our community members nominated me as MARVI Worker and sent for the six days training with the community’s traditional birth attendant. I had always thought to see the world beyond my village. My happiness had
no limit, but at the same time, I was afraid as to how will I learn from the training and would I be able to work in
my village as a health care provider? Will they trust me and get services from me?
We went to Umerkot to attend the training. During the six days training, with the behavior and communication
skills training, I learned a lot. Training was conducted in a very polite way by a female trainer. I was taught how
to work in community door by door? How to motivate peoples to adopt healthy habits? How to check and confirm pregnancy? How to measure the weight of pregnant ladies, and why it was necessary to check them during
pregnancy and be familiar with the knowledge of danger signs of pregnancy? How newborn care and post natal
care was provided to mothers? What was the importance of maternal and child immunization? What should be
the nutrition of pregnant lady, mothers and child? What were the needs of a female and how could we meet them
hygienically at low cost? How social marketing could be done from door to door with the reproductive health
and family planning services in privacy to the female? Training was conducted in my mother tongue and the full
participant’s engagement. On the last day a MARVI bag was issued which contains some basic medicine, family
planning products and instruments for measuring weight, BP, height and temperature. Accompanied traditional
birth attendant also got six day training on conducting safe home delivery hygienically with use of hygiene
techniques as well as antenatal, natal and postnatal care of females.



143

As she returned village after completing the training, she started field work.
After going around the village for many days, I felt that, the villagers were not ready to accept me as a health
care provider. They asked as to how could they believe that I had learned things during my training. I was teased
but I never lost interest. I always thought as to how I could build their trust and how I could increase my social
marketing of the reproductive health product to earn some money to support my family? I discussed with my
husband about the situation and finally we decided to get help from a nearest health facility’s health care provider. I had arranged a local calendar event where all of the females of my village were invited. With the help of
lady health visitor and local vaccinator health awareness session was given to the participants. I started regularly
visits to the village houses and provided care to the mothers and pregnant ladies. Many of the cases referred to
the health facility for vaccination and antenatal checkups by doctor. After three months of my training there was
a knock at my door. I found that a person of my village was standing at my door with his two years old son in
his lap. He showed me the child, the baby had high fever, so much so, that the child was going into convulsion.
I had been taught in the training that, in such situation the child is to be given cold sponging and two tea spoons
of syrup Paracetamol immediately. I did that and after half an hour the condition of child improved, I checked
the temperature which was at 99 and I told child’s father that it was now safe to take to the doctor. On the next
day that person came to my house. He called me and my husband and told us that the doctor in the clinic had
informed him that the timely first aid to the child in the village had saved his life. He had tears in his eyes. He
said that they were proud of MARVI WORKER. That day I was really happy to see that I could do more for my
community as well as for my family. Now all the people respect me as a MARVI WORKER and I try to help as
many people as possible.

In a small home she has established MARVI Markaz where she is providing RH and FP products,
such as contraceptives, sanitary pads for female hygiene, safe delivery kits and essential medicines in
privacy. With the help of her husband she is also providing family planning services to the male population of the community.
Under the social marketing programme HANDS team provides RH and FP products and essential
medicines at her door through health promotion agent at the 50 per cent subsidy rate while she is selling
at the actual retail price. Thus, she also makes income. She works hard and sells products of `4,600 and
thus earns about `2,300.
Gomi has also formed Para Development Committee (PDC) with 25 members and collects monthly
savings from all the members. Through the PDC she gets microcredit from TRDP. She has started a small
shop for ladies in her home. She refers cases for tubal ligation to PWD tubal ligation camps. She arranges
weekly gatherings at MARVI Markaz where health and other social issues are discussed.
Notes
1. Sindh is a southern province of Pakistan.
2. ‘Umar Marvi’.
3. Mustaghis-ur-Rahman’s interview with Dr Muhammad Aslam Khan, General Manager Operations, HANDS, on
2 January 2012.
4. It is very hot in the summer and very cold in the winter. Temperatures frequently rises from 40°C to above 50°C
from May to August, and the minimum average temperature is 6°C during December and January with dry air.
The annual rainfall averages about 16 cm, mainly during July and August.
5. Gender breakup of population is 446,355 males and 412,021females in the district. 49 per cent of the population
of the district is non-Muslim.


144


6. Laura Deaton, a leading management consultant, used the term ‘strategic philanthropists and entrepreneurs’
for the philanthropists who extend financial support to the innovative NGOs. Deaton’s article ‘The Nonprofit
Support Life Cycle and Crossing the Chasm’ is influenced by Geoffrey A. Moore’s seminal work for the technology industry called ‘Crossing the Chasm: Marketing and Selling High-Tech Products to Mainstream Customers’.

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Mustaghis-ur-Rahman is Professor of Management and Social Sciences at SZABIST (a private chartered university). [E-mail: mustaghis@szabist.edu.pk]
Sheikh Tanveer Ahmed is Executive Director of Health and Nutrition Development Society, a Karachi
based integrated development NGO. [E-mail: tanveer.ahmed@hands.org.pk]


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