Health Outcome Performance Indicators will help us “understand clients”

PMD clients and health providers

Microfinance clients are linked with local healthcare providers by PMD in India.
– Check out the recording of the webinar and review the PPT presentation.
– Read the SEEP Network’s blog post recapping the webinar.

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On March 4, 2015, in collaboration with the SEEP Network‘s HAMED working group, we co-hosted a webinar called “Healthy, Wealthy, and Wise: How MFIs Can Track the Health of Clients,” to discuss how microfinance institutions and their partners can measure client health and well-being. Our regional director for Asia-Pacific, Dr. D.S.K. Rao moderated the webinar. Joining us in the webinar were Bobbi Gray (Freedom from Hunger), Sandhya Suresh (ESAF Microfinance and Investments Pvt Ltd in India), and John Alex (Equitas Group and Equitas Development Initiatives Trust in India).

Choosing Health Indicators. Click the image to see it enlarged.

The webinar was focused on addressing questions of application and use of tracking health outcomes and how MFIs benefit from collecting data on client health. The HOPI will help institutions to know who their clients are and understand their needs — a defining theme, according to Dean Karlan, of the World Bank’s forum on microcredit at the end of February, and one that we have written extensively on as well.

And, of course, there were many questions posed by the audience, and we have made and effort to collect and answer those questions in this blog post.

Our work with partners ESAF, Equitas, and other financial service providers in India as well as the development of the HOPI is made possible with the generous support of Johnson & Johnson.


Tom Shaw (Catholic Relief Services):

Please note that [adding health onto microfinance] is not unique to microfinance institutions (MFIs); it is also applicable and being applied through the savings group platform.

Bobbi Gray:

Agreed. While this discussion has focused on MFIs, there are a growing number of savings groups who have been adding health to their activities as well. We’ve also seen some health sector actors find that savings groups have been organically forming within their programs, so they’ve tried to formalize this process such that the savings group structure becomes a significant part of the program. John Snow International has an example of this in Nigeria.

I think it’s important to add that even within health programs, tracking health outcomes at the “patient” level is just as a significant activity as it is for financial service providers (MFIs and savings groups, alike). While there are population-based surveys that inform the work of the health sector, tracking health outcomes at a more programmatic level is not a simple task for them either because of the cost and time implications of collecting this data.

That’s why I think there is an important opportunity for finding ways to collaborate with health sector actors by using the data that MFIs are able to collect, since it could also be informative data that local health sector actors can also use. This data can be a vehicle for strengthening relationships across these two sectors.

Question 1

Vanina Gacioppo:

How is the health entrepreneur accepted by the community? (As there may be old “quacks” that may not be well prepared but the community have relied on them for years.)


Bobbi Gray:

Our experiences so far have shown that the health entrepreneurs become advocates for the members of their community. They are the link between the role that the MFI plays as well as the local health clinic. There is always the ongoing concern about developing a cadre of “quacks” but so far, we’ve seen existing midwives and community health workers take on these roles since it seems to be a natural fit.

DSK Rao:

In the particular case of ESAF’s Arogya Mithra (community health entrepreneurs) project, they are well accepted mainly because of the door step service (house-calls) a health entrepreneur provides. She comes to the villagers. In these villages, “quacks” are not common, but one finds less-qualified medical practitioners who do not provide door step services as the health entrepreneurs do.

Sandhya Suresh:

The health entrepreneurs are getting good acceptance in the community even though there are existence of other traditional practitioners, or even “quacks,” as the health entrepreneurs are community women and those who seek their services are known to them and hence they trust them.

ESAF has provided the health entrepreneurs with certificate and ID cards, which they can always produce in case people want to know about the authenticity.

Question 2

Stuart Coupe, Hand in Hand International, London:

I am very interested in the ESAF self-employed microentrepreneurs in the health sector. What services are community members willing to pay them for?

This question was posed and answered in the event, which was recorded and is available here:


Bobbi Gray:

I thought Sandhya’s answer during the webinar likely was enough, but it is important to point out that often, people are supposed to have access to many of the health products and services for free as they are provided by the local health clinic; however, the health clinics are often poorly or not consistently staffed and often poorly stocked with the items they should be getting for free.

Therefore, the market for the health entrepreneurs is to provide the products, at the market price, to their community members for the convenience of them being able to access the products when they need them. Plus, for some items, like sanitary napkins, they can purchase items in privacy.

DSK Rao:

The community may be willing to pay for multiple services, such as monitoring hemoglobin levels, cholesterol, etc., but ESAF has focused on monitoring hypertension and diabetes, the two most common and dangerous non-communicable diseases (NCDs). The two parameters which require frequent measurement and which could be easily measured in the field.

Sandhya Suresh:

At present, community members are willing to pay for checking the blood sugar and blood pressure. In addition, they are even willing to pay for cholesterol or thyroid checking; however, these are complicated processes and cannot have a quick result, so we are not doing it at present. We can train the health entrepreneurs to collect the blood samples for these tests, but they can be very risky considering their semi-literate status.

theories of change

Click the image to see it enlarged.

Question 3

Amy Petrocy, Health Program Coordinator at Friendship Bridge, Guatemala:

I’m interested in any experience you all may have with measuring changes in health beliefs/attitudes as a result of health education offered by MFIs and then the correlation with utilization rates of health services.


Bobbi Gray:

Freedom from Hunger has been designing short mini-surveys that align with our health education. However, we only look at utilization of health services, if this particular aspect is actually part of the module.

For example, the integrated management of childhood illnesses (ICMI) teaches women about the danger signs a caregiver should know that would signal the need to visit a clinic immediately and then it teaches them what they should expect when they are there for the checkup.

Part of the effort here, in the HOPI, comes as a result of the years of measuring changes from pre-tests to post-tests directly related to particular education efforts. While there may be some directly related attitude questions for certain education topics — for example, for water and sanitation, there might be an attitude about whether they agree it’s important to provide safe water to their family or whether they feel confident they can provide safe water — there is growing interest in the field to look more at attitudes as very strong indicators for tracking change.

We found, for example, in our youth financial services work that a young person’s satisfaction with their savings level or their confidence they could cover their typical daily expenses using their savings, was likely a stronger indicator of their financial capability than trying to detect this through a long series of questions to understand how much money they actually had. I think understanding whether a person feels prepared for future health expenses is likely indicative of their real ability — given they know what resources they have at hand to cover those expenses.

When it comes to utilization of health services, I also think it’s important to understand why people do not use the services — in the same way we have to understand why clients might not use a particular financial product — there may be attributes we can change in the short-term and those we can’t. For example, “I feel ashamed” of going to the doctor is a different intervention from “I can’t afford to go.”

DSK Rao:

There are numerous incidents of behavior change such as women ceasing to chew tobacco and reducing oil, salt, and sugar intake in one’s diet. Impressive changes have come in terms of distributing food equally to all family members, including adolescent girls and pregnant and lactating women.

John Alex:

Equitas has a 5-day skill training program on a not-for-profit basis through the Equitas Trust, where the women skill trainer trains 10-15 women for 3 hrs a day in select skills. At the end of each day, she delivers a lesson on non-communicable diseases (NCDs) namely blood pressure (BP), diabetes, cancer, types of tests in a year, and healthy eating habits.

We measure the knowledge level on a sample basis pre- and post-training, and the results showed that the knowledge improved and that they also learned ways to detect early warning symptoms.

Furthermore, feedback showed that many started going for mammogram test and pap smear test and wanted the trainers to also check their BP, sugar levels, and body mass index (BMI); this made us launch a pilot recently to test sugar levels at random at the end of the training, and they are ready to pay the cost. We are working to make this pilot be self-sustaining. Based on the success and pending getting funding, we will roll it across India, which could be a great health indicator.

Question 4

Do you think you can you measure the impact of your health program in a 6 – 8 months period? Don’t you think the time is too short… What do you think?


Bobbi Gray:

I think it depends on the health intervention. Some are meant to spur immediate changes, and others aren’t. For example, if we can convince a mother to give a child with diarrhea more to drink, she should immediately be able to put this behavior into practice. However, facilitating a household’s ability to install a new sanitation facility might take longer, particularly if households are facing competing financial obligations.

DSK Rao:

As it pertains to the affect on knowledge and awareness as well as the behavior change in improvement in diet, yes, 6-8 months is sufficient. We have seen changes in health seeking behaviors in that period; however, it may not be possible to see an improvement in health parameters.

Sandhya Suresh:

Well, if you have given a health education session, people will try to practice it as soon as possible if they remember it and are convinced about it. We can therefore see the change in the awareness levels and behavior change in them even after 6 to 8 months. But, if you want to measure the impact of a changed health practice, you will definitely need more time.

John Alex:

Equitas has two loan products with a tenure of 18 months and 24 months and option to repay in either fortnightly or monthly installments. I think 6-8 months is too short, and it should be on a continuous basis during every loan cycle.

Question 5


Which country in Africa is model now in developing financial health products?


Bobbi Gray:

We’ve worked with RCPB in Burkina Faso to develop a health savings and loan product. This is a commitment savings device that clients can use to save an established amount of money on a regular basis. Once they hit the minimum, they can use the savings as long as they have receipts showing that the money will be used to cover a health expense.

If the health expense is greater than the amount they have in savings, they can access a health loan, if desired, to make up the difference. There are also savings groups in Benin that also save for health. They save their normal amount with their group, and they save an additional amount on top of this for health expenses, using the same savings group mechanism for collecting and accounting for their funds.

There has also been a study by Pascaline Dupas looking at various savings strategies for health in Kenya that included products where clients simply earmarked their money, put money in a lockbox that was easily accessible, lock boxes that were more secure, etc. She found that most of the mechanisms worked to improve savings for health simply because they provided a safe place to keep their money that they wanted to earmark for health purposes.

While I don’t have the data at hand, I know there have also been some significant efforts in improving access to health insurance products as well, which should not be overlooked when thinking about financial services with a health objective.

Health indicators selected

Click the image to see it enlarged.

Question 6

Tessa Joy P., Research and Evaluation Specialist at Community Economic Ventures, Inc. (CEVI), Philippines:

Are the health indicators set of questions country-specific?


Bobbi Gray:

Some of them are, and some of them aren’t. Our original aim was to see whether we could find indicators that could work across most contexts and some of them seem to do this well.

For example, the question about whether a person has forgone seeking medical treatment because of the cost works well in all the contexts. For the water and sanitation questions, these questions are often fairly standardized, particularly if you rely on how the national demographic and health surveys articulate the questions and answer options.

However, depending on the key health problems in a country, one might tailor the questions more specifically to the context. For example, while we’ve yet to pilot these questions in West Africa, you could imagine asking about the use of insecticide treated bed nets. Whereas in Latin America, malaria and other infectious diseases might not be as common, and you might look more at chronic illnesses as well as the need for annual checkups to get one’s blood sugar or blood pressure checked.

This is not to say that chronic illnesses are not equally as frequent in places like West Africa; it simply means that an organization needs to think about which of these issues seems to affect their clients the most and where an MFI’s products and services might most directly influence improvements (i.e., improving financial access to mosquito nets, preventive care medical services, etc.)

Question 7

Joy May, branch accountant, CEVI, Philippines:

Can you please differentiate between key health indicator and additional indicator?


Bobbi Gray:

After the pilot-test MFIs (ESAF, Equitas, and others) completed their first assessments, we have discussed which of the indicators they might want to keep for further implementation of the surveys. While we tested up to 11 different indicators, we recognize that not all of these will feel really compelling to the MFI.

So, we’ve discussed which few they might choose to track over time. In ESAF’s case, they’ve talked about perhaps keeping water treatment as a variable that they’ll track with their poverty measurement efforts for every new loan cycle, but they might follow a sample of clients with a broader number of indicators every five years.

At the end of the day, we want MFIs to choose the smallest number of indicators they’ll track and actually use—over a longer period of time, since larger evaluations and studies have the flexibility to track a larger number of indicators. Which indicators are useful to track at every loan cycle for monitoring purposes vs. which indicators might you track for a broader picture of client outcome for more evaluation purposes (where you’d conduct more analysis, etc.)?

Research Results Equitas India

Click the image to see it enlarged.

Question 8

Joy May, branch accountant, CEVI, Philippines:

What are the health indicators Equitas is planning to finalize for health survey both in rural and urban areas?


John Alex:

We plan to ask about different types of water filters, and we will ask both men and women. In addition, we will also compare this data with a control sample of non-clients. And, finally, we plan to expand our data collection to more areas on a pan-India scale.

Question 9

Joy May, branch accountant, CEVI, Philippines:

Why is Equitas emphasizing low cost fruits? Can you please elaborate the relationship between fruit and nutrition? What about childhood nutrition specially children below 2 years?


John Alex:

When we say “fruits,” very often, clients would mistakenly imagine it as costly fruits like apple and oranges, etc., which may be a bit costly for these low income households. We would like to also add questions on the type of locally available fruits like bananas, ber, custard apple, papaya, sapota, and guava.

We also plan to add questions to find out if they have low-cost millets, which are very healthy, and add the same questions about child nutrition and a line on breast feeding.

Question 10

Joy May, branch accountant, CEVI, Philippines:

What would be your sustainability plan on your clients’ health indicator project?


Sandhya Suresh:

We have already incorporated two health indicators, which we will track for all the clients; for other relevant indicators, we shall conduct an annual Client Change Assessment.

Question 11

Joy May, branch accountant, CEVI, Philippines:

Do you have any plan to integrate your health program with government’s health program under National Rural Health Mission (NRHM)?


Sandhya Suresh:

Most of our health entrepreneurs are Asha Workers, or health workers appointed under the NRHM, so they are already known in the community. By offering the service that we have promoted, they get an extra income. They have received permission from their NRHM supervisor to charge the user fee for the services they are offering.

Research Results ESAF India

Click the image to see it enlarged.

The PPT presentation

Relevant resources

The SEEP Network | Mar 4, 2015

By Patrick Fine, Leith Greenslade | 26 February 2015

Cassie Chandler | Huffington Post Global Motherhood |

Hosted by FHI 360, Women Thrive, Johnson & Johnson
Wednesday, March 11, 2015 from 5:30 PM to 8:00 PM (EDT)
New York, NY

4 thoughts on “Health Outcome Performance Indicators will help us “understand clients”

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