We have seen good evidence (post # 66) that group-based microfinance can integrate successfully with education for mothers to improve their childcare practices; in particular, infant feeding and diarrhea management. Public health experts insist that this kind of intervention is crucial for child survival and development to healthy, productive adult life. It is also a relatively easy intervention that equips mothers to improve their children’s health solely through their own efforts, not dependent on external services. Usually, however, the mothers themselves do not ask for such education, being unaware of the deleterious effects of their traditional practices. Moreover, the education is immediately applicable to only a subset of the typical membership of a microfinance group – around 20 percent are mothers with infants and toddlers. That is, this educational intervention is not demand-driven, even if the women who engage in it are grateful for the life-saving information and support they gain.
In sharp contrast, malaria in Africa and other tropical areas affects everyone regardless of age and is so prevalent and debilitating (the leading cause of workdays lost to illness and a major cause of death among children) that there is high demand for any intervention that can help people prevent or treat malaria. While prevention is relatively easy to teach, however, there is dependence on external sourcing of materials (mosquito nets). And treatment is complicated to teach and depends even more on access to good-quality clinical services. Can microfinance play an important role in helping client households deal with malaria (and by extension, other major infectious and chronic diseases)?
In response to its West African financial service partners, Freedom from Hunger, with a grant from the GlaxoSmithKline Africa Malaria Partnership, developed a dialogue-based malaria education curriculum to be integrated with the village banking services of credit unions and rural banks. You can get a really good feel for the setting and method of this education from this photo and caption (the “local partner” mentioned is the Burkina Faso credit union federation, Réseau des Caisses Populaires du Burkina – RCPB).
To determine the effectiveness of the malaria education delivered in this way, a randomized trial was designed by Robb Davis and Bobbi Gray of Freedom from Hunger and conducted by Bobbi with two rural banks in Ghana that implemented the malaria education with their clients. Analysis and presentation of results was greatly assisted by researchers at Brigham Young University, led by Ben Crookston (now at the University of Utah). Together they published the research results in 2009 in the prestigious Transactions of the Royal Society of Tropical Medicine and Hygiene.
Bobbi also wrote a summary for Freedom from Hunger’s Impact Review series, most of which I repeat here. Note that subsequent randomized trials (RCTs) in Benin and Mali looked for impacts of very similar malaria education done with village banks supported by a specialized microfinance institution and savings groups supported by social service NGOs, respectively. In future posts, I will report findings from these RCTs, which looked at much more that malaria education impacts. For now, I will just say the malaria-related results are consistent with what was found in Ghana.
Freedom from Hunger pursued a randomized control trial evaluation of the malaria education to measure changes in knowledge, attitudes and behaviors pertaining to malaria. A baseline and follow-up survey were conducted between October 2004 and April 2006. Malaria education and diarrhea education were randomly assigned at the community level by Brakwa-Breman Rural Bank in Central Region and Afram Rural Bank in Eastern Region. Within those communities were village bank members who received malaria education (“malaria clients”) or diarrhea education (“diarrhea clients”) along with access to credit as well as community members (non-clients) who did not receive credit or education. The purpose of this design was to allow for measurement of the added benefit of the malaria education, to account for natural information exchange in a group-lending environment, and to measure for spillovers from malaria clients to community members not participating in credit or education. Survey respondents were women of reproductive age with at least one child under the age of six.
In addition to Freedom from Hunger’s malaria education, there were other malaria initiatives occurring in the program areas during the time of this study. Thus, in many indicators and for all groups studied, there were significant improvements from baseline to follow-up in knowledge and behavior. However, malaria clients consistently improved more than both diarrhea clients and non-clients. The following indicators highlight where malaria clients excelled in relation to the other groups:
- Malaria clients were more likely to recognize that mosquitoes alone cause malaria. They were also more likely to understand the role of the parasite and were able to describe the entire transmission process compared to other groups.
- Malaria clients were more likely to know that both pregnant women and children under the age of five are most vulnerable to malaria.
- Almost 100 percent of malaria clients at follow-up indicated that insecticide-treated nets (ITNs) were the best protection against malaria. Half of malaria clients owned a mosquito net and 11 percent owned an ITN. Malaria clients were more likely to own an ITN.
- Malaria clients were more likely to have women of reproductive age and children under the age of five sleeping under an ITN.
- Malaria clients were twice as likely to have re-treated a mosquito net in a last six months. The most common reasons for non-use of mosquito nets were lack of affordability and lack of local availability.
- Almost 90 percent of all malaria clients indicated they shared messages from their malaria education sessions with other members of their community, particularly regarding the role of the mosquito in malaria, the use of ITNs as the best protection, and how to treat a child with fever.
From a programmatic standpoint, the malaria education was a success. Despite the presence of other malaria initiatives in the program area, participants in Freedom from Hunger’s malaria education saw greater marginal increases and significantly better outcomes. This indicates that the malaria education complemented the other activities to increase knowledge and positive behaviors. Yet, even the increased knowledge and behaviors often were impeded by gaps in a family’s ability to access promoted prevention methods such as ITNs. Microfinance can help a family purchase an ITN; however, there needs to be coordination with initiatives to increase local availability of ITNs for sale, particularly in rural communities.
In short, a microfinance-based health intervention can substantially complement other interventions occurring in the same area. But microfinance-based interventions in isolation from sources of mosquito nets and providers of treatment services are unlikely to lead to substantial prevention or treatment of malaria (and by extension, other infectious and chronic diseases).