The last two posts (# 66 and # 67) described important research findings by Freedom from Hunger. For a broader global view of the effectiveness of integrated microfinance and health services, I turn to a couple of surveys done just a few years ago.
First is a survey of 89 integrated microfinance-health providers, fairly evenly distributed around the world. This revealed that 80 percent provided group-based education. Referrals to health providers, the direct provision of health services, and/or health micro-insurance were also reported by 20 percent of the providers. A provider can offer more than one health service; many in this 20 percent were also among the 80 percent providing group-based education. Additional interventions were mentioned, such as facilitating access to affordable medicines, healthcare vouchers, and support for community water and sanitation, mobile services or treatment for a single health condition such as tuberculosis.
Second is a 2011 literature review in Health Policy and Planning by Sheila Leatherman, Marcia Metcalfe, Kim Geissler and me. The review covered impact study reports published up to June 2010 in English-language, peer-reviewed journals. A lot has happened in the past three years, so it may be time for an update. Still, the up-to-June-2010 review offers a lot to help us understand the health effects of integrated microfinance-health services.
For inclusion in the review, the articles had to have clearly defined research designs producing objective evidence, as well as a focus on one or more organizations offering some form of microfinance with single or combined health services of any type, including:
- health education and promotion
- direct provision of healthcare services
- health-related financial services (health-oriented loans, savings or micro-insurance)
- community health workers
- linkages to the provision of health services
- micro-loans to private health providers for improved capacity or infrastructure
- access to health-related products such as pharmaceuticals, mosquito nets, etc.
The literature review identified 17 articles meeting the criteria for inclusion, sorted by study design and categories of health-related interventions. The articles were categorized into three study-design types: 11 studies used pre- and post-intervention measurements in treatment and control groups; five compared post-intervention measures in treatment and control groups; and one compared pre- and post-intervention measures in the same group.
Most of the studies assessed the impact of health education and health promotion activities on some aspect of client health knowledge and practice. The majority of studies found significant improvement in client health knowledge when microfinance services were combined with health education, whether this was provided by microfinance field agents at regular group meetings or by community outreach with trained community health workers. One study reported the diffusion of health information in the broader community beyond the targeted population of the program.
Beyond improved health knowledge, multiple studies assessed and found improvements in self-reported changes in health practices of microfinance clients related to leading causes of morbidity and mortality among the poor, such as diarrhea (the most common cause of illness and the second leading cause of child death in the world). Changes in behavior were reported in a diverse range of health areas including reproductive health, malaria and gender-based violence. These effects have significant implications, if they are able to reach large populations, for mitigating the negative impact of common morbidities and threats to health and life.
Several studies assessed the impact of education on use of health services. For example, a study in Malawi, Thailand and Guatemala found significant increases in the percentage of women seeking care for signs of sexually transmitted infection and seeking primary care for child health. Increased utilization of preventive services was found in several studies, including vaccination uptake in the Dominican Republic and cancer screening in Honduras and Ecuador.
There are multiple studies that included changes in health status or other outcome indicators. Integrating the delivery of health education with microfinance resulted in positive outcomes in a number of significant areas, including the following:
- reproductive health
- prevention and primary care for children
- child nutrition and breastfeeding
- child diarrhea
- HIV prevention
- domestic abuse/gender-based violence
- sexually transmitted infections.
The authors of the literature review conclude that the evidence supports the adoption and testing of various methods of integrating microfinance and health services. However, the challenges in doing so are not trivial. Implementation of these health-related services requires knowledge and competencies beyond those necessary for microfinance alone, adjustments in administrative systems, quality control of service delivery, additional types of communication and education capabilities, and ongoing co-operation and co-ordination with the official policies and systems of both private and public sectors.
This review identifies the weaknesses of applied research in this field. Notable are gaps regarding study of the range of health interventions that are or could be integrated with microfinance programs. Most of the studies examined the impact of only health education and training to improve health knowledge and change behaviors, mainly because health education is by far the most common intervention integrated with microfinance. Even in health education, however, there are significant gaps, such as education about chronic disease.
The review found little research on the impact of health financing options (offered with other microfinance services) to facilitate affordability. A study in Uganda indicates that participants with health insurance were less likely to delay seeking care for malaria than those without, and a higher number of those without insurance were admitted to the hospital, suggesting that those with insurance seek care earlier when the disease is less severe.
However, since June 2010, there has been a blossoming of new research and results on the impacts of health insurance (not always specific to microfinance clients). Many such research reports can be found at the Microinsurance Innovation Facility. They offer a picture of impacts that is consistent with the findings regarding malaria care seeking in Uganda. In general, the insured show a higher probability of using hospitals and other health services than the uninsured and at a reduced cost.
The literature review concluded that organizations which currently offer microfinance and are seeking to add health-related services need information – in order to make judicious decisions regarding which programs and interventions are the best investment for their clients and also feasible and reliably sustainable for the institution. Usually these organizations operate very leanly, dealing with considerable complexity and adversity; they simply do not have the luxury of testing to compare multiple options.
The next post reviews the results of the Microfinance and Health Protection initiative, which was launched in 2006 by Freedom from Hunger to address the information needs of these microfinance providers.