Integration of group microfinance with various health and nutrition interventions has been the hallmark of Freedom from Hunger’s work for more than two decades. Neither the economic development field nor the health and nutrition fields have regarded this combination as an obvious winner! The notion that these aspects of human life are intertwined and mutually dependent is almost taken for granted, even if not well documented, but the idea of programming them together in one intervention package has been counterintuitive, if not a little loopy.
Those living in poor households have no problem seeing the potential benefit of this collaborative response to their major needs. Given their bodies and minds are just about the only productive assets they have, people living in poverty fully grasp the economic importance of good health and nutrition. However, they usually don’t have the money and information they need to maintain good health and nutrition in the face of the diseases and accidents that are so threatening in their environments—especially the threats to the most vulnerable in their households; infants, young children and pregnant and nursing women.
Money and information in the hands and minds of women are known to be a winning ticket for good health and nutrition of the whole family, especially the kids. How does one deliver these in the right way to massive numbers of women in poverty?
Credit with Education
This global question is what motivated Freedom from Hunger to experiment decades ago with ways to provide access to money through microfinance and access to health and nutrition by combining the money with key health and nutrition information through adult education. In the 1980s, the child survival movement was just hitting its peak, thanks to the work of UNICEF to emphasize a few simple interventions that could save huge numbers of young children, even in the absence of adequate health and sanitation services (structural adjustment programs had already gutted the ambitions of poorer governments to provide anything like the needed service infrastructure). At the same time, group microfinance designs were becoming known. Some of us at Freedom from Hunger asked ourselves: Why not put them together, both to save costs of delivery through a common point of service and to dovetail two fundamentally important services to women in poverty? Credit with Education was born in Mali and Thailand in 1989.
We knew this was an experiment, creating an unlikely marriage of two very different sectors of development, so we had to commit to early and energetic evaluative research in the context of our early program partnerships. What evidence did we find that this odd inter-sectoral combination of microfinance and health/nutrition actually leads to better health and nutrition practices? To answer, I excerpt from Freedom from Hunger’s Credit with Education Impact Review No. 3 by Barbara MkNelly and April Watson.
Credit with Education is a “unified” model of integration (see post # 64). The local microfinance provider sends a field agent out to the regular meetings of village banks of women, both to assist and oversee the village bank’s self-management and financial transactions (loan disbursements, repayments, savings deposits) and to facilitate at each meeting one of a series of short (15–30 minutes) “learning sessions” on a selected topic. The early emphasis was on child survival topics: breastfeeding, diarrhea prevention and treatment, infant and child feeding, and immunization. The education topic modules, each composed of several learning sessions, are designed to create and promote behavior change, based on the principles of dialogue-based education.
Impact Research Design
The impact research was done in Ghana and Bolivia. The design of these twin studies and their methodological caveats were covered in an earlier post (# 28), but I’ll recap the highlights here.
In both studies, two major survey and anthropometric (heights and weights) data-collection rounds were carried out—with different mother/child pairs participating in the two time periods. A randomized design was applied at the community level to minimize possible bias. Following baseline data-collection, study communities were assigned to either a program or control group. The control communities did not receive Credit with Education services until the evaluation research was completed.
Three sample groups of women with children under three years of age were included in the follow-up research: Credit with Education program participants of at least one year; nonparticipants in program communities; and residents in control communities selected not to receive the program for the period of the study. Women for the two nonparticipant groups were randomly selected from comprehensive lists of all women with children younger than three years of age.
Program impact was evaluated by comparing the magnitude and direction of change in the responses and measurements between the two data-collection rounds (three years apart)—program participants versus nonparticipants and residents in control communities.
Key Learnings about Changes in Health/Nutrition Practices
- In Ghana, significant improvement was seen across a range of practices and often there were dramatic differences in those practices between participants and nonparticipants.
- Both the range of practices which improved and the amount of improvement seen were greater in Ghana compared to Bolivia.
- The quality of the education received by participants affects the magnitude of impact.
- The most dramatic improvements in knowledge and practice were regarding exclusive breastfeeding in Ghana.
- Participants in both countries reported significant improvements in how they fed or breastfed the study child as compared to older siblings.
- In Ghana, it was demonstrated that improved household food security and positive behavior change by mothers, due to Credit with Education participation, actually leads to improved food intake of very young children.
Quality of Education Matters
The impacts of Credit with Education on the mothers’ practices relevant to the education objectives differed markedly between Ghana and Bolivia. The primary reason for the differences seemed to be the differences in quality of education implementation. In contrast to the education services in Ghana, which were consistently of high quality, the quality of education services in Bolivia varied greatly. This was particularly true in areas that had experienced considerable staff turnover and implementation challenges related to expansion and internal control. When the impact data were disaggregated to allow analysis of just the women who had received good-quality education, the impacts were similar to those in Ghana: program participants demonstrated positive and significant increases when compared to nonparticipants and/or residents in control communities.
Can Microfinance Change Mothers’ Health and Nutrition Practices?
These two studies provide strong indication that the answer is “Yes.” In the following posts, I will review other evidence that is both stronger methodologically and consistent with these results. We can say with fair confidence that to change health and nutrition practices, there has to be education; not just education, but education properly designed and delivered. Microfinance provides the platform on which the education rests. The microfinance service itself must be designed to support good-quality education as well as succeed in its own objective to smooth consumption and improve household food security to allow mothers to put what they learn into practice.