Results of the Microfinance and Health Protection Initiative

In 2006, Freedom from Hunger launched the Microfinance and Health Protection (MAHP) initiative (led by Myka Reinsch and Marcia Metcalfe) to test the feasibility and impact of offering microfinance clients not only health education but also access to health services and products. Knowing that ill-health and inability to access health care are key factors both leading to and resulting from poverty and that the financial and time costs of illness and seeking treatment represent a large burden on their clients’ households, five well-established, large-scale and profitable microfinance providers joined the initiative to develop health protection packages for clients: in Benin, Projet d’Appui au Développement des Micro-Entreprises—PADME; in Bolivia, Crédito con Educación Rural—CRECER; in Burkina Faso, Réseau des Caisses Populaires du Burkina—RCPB; in India, Bandhan; and in the Philippines, Center for Agriculture and Rural Development—CARD.

The following is excerpted from an article in The Journal of Social Business (Metcalfe et al. 2012).

Freedom from Hunger and each provider partner conducted market research, identifying three main barriers to health protection:

    • Insufficient information about health risks, health-related behaviors and appropriate use of health services
    • Inadequate access to effective and appropriate health services and products
    • Inability to afford necessary health services.

Overall, the research showed that the clients wanted and needed both health services and financing products that would work together to improve access to preventive and routine care, while also protecting from the financial shock of more serious illnesses.

Context-specific packages of health services and products were developed with each provider and introduced in 2007. These packages varied considerably among the five providers, allowing for rich learning from these diverse experiments:

Bandhan (India)
Health Knowledge and Information: health education provided in monthly forums for entire communities by specialist health educators; education reinforced by individual home visits from trained community health volunteers
Access to Health Services and Products: during individual home visits, community health volunteers make referrals to local providers and offer oral rehydration salts, oral contraceptives, antacids, analgesics, antiseptic solutions, bandages and sanitary napkins for sale—products are sourced by Bandhan and sold to the volunteers with a small price mark-up and sold by volunteers with additional small price mark-up for the volunteers to keep
Healthcare Financing: lower-interest loans for purchase of health care and related allowed expenses

CARD (Philippines)
Health Knowledge and Information: health education at regularly scheduled microfinance group meetings facilitated by microfinance field agents
Access to Health Services and Products: contracts with network of private healthcare providers to provide services to CARD clients at negotiated discount of fees
Healthcare Financing: linkage to PhilHealth, the national health insurance program, by registering CARD clients with PhilHealth and providing them loans to finance premium payments

CRECER (Bolivia)
Health Knowledge and Information: health education at regularly scheduled village bank meetings facilitated by microfinance field agents
Access to Health Services and Products: mobile health services (both diagnostic and preventive) provided by private or public healthcare providers at “health days” organized by microfinance field agents in local communities; referrals to local healthcare providers by microfinance field agents and at “health days”; contracts with network of private healthcare providers to provide services to CRECER clients at negotiated discount of fees
Healthcare Financing: lower-interest loans for purchase of health care and related allowed expenses

PADME (Benin)
Health Knowledge and Information: health education at regularly scheduled village bank meetings facilitated by microfinance field agents
Access to Health Services and Products: distribution of insecticide-treated mosquito nets by the microfinance provider staff
Healthcare Financing: no specialized products.

RCPB (Burkina Faso)
Health Knowledge and Information: health education at regularly scheduled village bank meetings facilitated by microfinance field agents
Access to Health Services and Products: see below
Healthcare Financing: lower-interest loans for purchase of health care and related allowed expenses, offered to supplement individual health savings accounts from which healthcare providers are paid by the microfinance provider or reimbursement given to savings account holders who present valid receipts for allowed health-related expenses

Evaluation Research Results

Quantitative and qualitative data were collected from client interviews (some with baseline and endline analyses), focus-group discussions, interviews with staff and healthcare providers, and regularly reported MFI financial indicators. At PADME (Benin), a randomized, controlled trial (RCT) examined the impacts of health education in all-female and mixed-gender groups. Since it was not possible to measure health outcomes of the interventions within the available time and resources, the evaluation of benefits to clients was organized around the following key process dimensions of health:

    • Responsiveness. The extent to which programs addressed client need and demand.
    • Change in Knowledge and Behavior. Changes in client knowledge and health behaviors that would be expected to affect prevention and management of common diseases and planning for illness.
    • Improvements in Access and Use of Services and Products. Impact on client ability to access needed health services, including increased geographic access and affordability.

The research and evaluation studies were carried out over a two-year period. Detailed descriptions of research methods and the complete findings from studies at each MFI are available (see Freedom from Hunger Research Reports for the MAHP initiative).

The assessment of client responsiveness was based on client satisfaction, recommendation of services to others and intent to repeat use. Across all five MAHP programs, clients reported high levels of satisfaction with the availability and features of the health interventions, indicating they would recommend the services to others.

Regarding changes in health knowledge and behavior, in all five programs, clients received health education designed to improve both knowledge and behavior for the prevention and management of illness. New education modules were developed and delivered to focus on financial planning for health and rational use of available health services. The providers also offered previously designed educational modules on prevention and management of malaria, HIV/AIDS prevention and integrated management of childhood illness.

In India, where the education was targeted at maternal and infant health and hand-washing, we observed significant improvement of knowledge about maternal health, care of newborns, child-feeding, and management of diarrhea, but not for hand-washing.

In the Philippines, where CARD’s education emphasized the risks and costs of illnesses, the need to save money to prepare for health needs, and use of CARD’s discounted provider network, women reported saving more money for health-related expenses.

In Benin, credit with and without education on HIV/AIDS and malaria were randomly assigned to groups in different villages with a total of four different interventions: all-female groups with credit only; all-female groups with credit and education; mixed-gender groups with credit only; and mixed-gender groups with credit and education. The results indicate that villages receiving health education performed better than credit-only villages in knowledge gain and behavior change.

Of the four treatments, the mixed-gender groups with education performed better in knowledge and behavior change than all-women groups with education. This unexpected result is perhaps understandable in the context of rural Beninois culture in which women often rely on the financial and nonfinancial support or permission from men in their lives in order to make key decisions or implement changes.

It is of interest that the positive differences in health knowledge and behaviors at PADME were detected in samples of the general population in villages where village banks received education, and not just among PADME clients. This suggests impact beyond the firsthand participants in the credit and health education program. A similar spillover effect was observed at Bandhan, where clients reported much higher and statistically significant levels of providing advice to others on breastfeeding, ante- and neonatal care, and treating respiratory illness and diarrhea following the introduction of the health education program than before.

Overall, these results from health education are consistent with those from other research in which the combination of health education and microfinance services was associated with significant improvements in client health knowledge and practice (see post # 68).

Regarding more reliable access to health services (both geographic access and affordability), a range of mechanisms was developed to link or extend access for clients to local health services and products, in lieu of the microfinance provider developing and providing health services directly. Four of the MAHP providers included savings and/or loan products in their health programs, as requested by clients, to pay for and manage the costs of illness and accidents.

The findings suggest that creating linkages between microfinance clients and health providers resulted in several benefits: services were more geographically accessible, choice of providers was increased (especially private providers) and affordability was improved through negotiated discounts of fees. These results are insufficient to predict how much such health programs will increase appropriate use of services by MFI clients. However, the finding at CRECER that 24 percent of health fair attendees had never before seen a medical provider, along with clients at CRECER and RCPB who reported higher use of preventive services in the intervention areas as compared to areas where clients had less access to services, suggest that the health interventions will support greater access and use over time.

Microfinance clients used health loans and health savings as part of the array of financial instruments available to the poor to weather the impact of illness. While they continued to use informal sources (loans from families, moneylenders, savings groups, etc.), they strongly valued the reliability of the formal instruments available from microfinance providers.

Beyond the benefits observed for microfinance clients, the provider linkages also appear to yield community-level benefits. At Bandhan, the health educators and village-level health volunteers have forged informal relationships with public health providers and informal providers, meeting with them and inviting their attendance at community health forums to help improve accuracy and consistency of health information from all local sources and to coordinate efforts in support of improved health practices. For example, Bandhan’s health volunteers work with the public health service to extend local health campaigns, such as oral polio vaccine distribution. CRECER’s regular health fairs are open to relatives and friends of clients, and are periodically organized as multi-day, community-wide events with health education, screening and diagnostic services available for very low or no cost. CARD’s provider network that offers expanded choice and reduced costs for clients and their families is also intended to help retain health providers in the locale. Health providers of all types are in short supply in the Philippines, especially in rural areas, yet CARD has successfully recruited and retained a growing network of providers, who cite benefits that include increased number of patient visits and professional satisfaction from the opportunity to reach more of the underserved.

The MAHP initiative results forge a persuasive case for the effectiveness, even synergy, of microfinance-health integration. The business case for this cross-sectoral integration is less well developed but promising nonetheless. That business case is the focus of the next Theme Seven: Business Case for Credit-led Microfinance Integrated with Non-Financial Services?