New database tool can help you define and refine client outcomes

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Global Health Indicators Project
The Microcredit Summit Campaign has long been committed to promoting the uptake of measurement tools in the microfinance sector, especially the poverty measurement tools. Such tools provide MFIs the means to know for sure if they really are reaching the poorest. More recently, we have encouraged MFIs to implement these tools to track the movement of clients (hopefully) out of poverty. At the 18th Microcredit Summit next month, we have several sessions that will show participants the benefits and challenges of such tools, including the Client Outcome Performance (COPE) Indicators Database, which you’ll read about here.


>> Authored by Bobbi Gray, Freedom from Hunger

When I joined Freedom from Hunger several years back, I had the responsibility to carry on a decades-long commitment to research and evaluation. My predecessor, Barbara MkNelly, as well as my then-supervisor and president of Freedom from Hunger, Christopher Dunford, were already known for their contributions to the research efforts of the growing microfinance sector and the original set of SEEP/AIMS client assessment tools. Freedom from Hunger’s commitment to promoting easy-to-use and cost-effective tools also led to years of developing monitoring and evaluation systems for microfinance organizations that were coined as “Progress Tracking.” Fast-forward several years, and this is much better known as Social Performance Management.

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Celebrate improving maternal and child health in the Philippines

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Over the past 20 years, the Philippines has enjoyed an increase in life expectancy, improved access to education and economic opportunity, and a decrease in communicable diseases. However, maternal health has lagged behind, and as 2015 draws to a close, the world will be reflecting on the Millennium Development Goals like #5, “Improve maternal health.” Three development organizations took action in 2014 to tackle this challenge and are now celebrating what has been achieved, new partnerships that have been formed, and plans for moving forward.

Freedom from Hunger and the Microcredit Summit Campaign partnered with CARD Mutually Reinforcing Institutions (CARD MRI) to implement a project called “Healthy Mothers, Healthy Babies: Kalinga kay Inay.” The project is supported by an educational grant from Johnson & Johnson and will conclude at the end of 2015.

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Mental health matters for microfinance

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>>Authored by Bobbi Gray, Research Director, Freedom from Hunger

First of all, a disclaimer. I am by no means a mental health expert. Like many, I’ve had my own experiences which have led to interests into the causes and impacts of mental health issues as well as the coping mechanisms we might use when we or someone we know suffers from a mental illness.

It’s Mental Illness Awareness Week, as you might know, and it has reminded me of a conversation that Josh Goldstein, vice president of economic citizenship and disability inclusion at the Center for Financial Inclusion at Accion, and I started a while back. A conversation that also led to an exchange of ideas on his blog post “4 interventions to help victims of trauma find hope and dignity” in which he summarized his remarks at the 8th Annual PCAF Pan-African Psychotrauma Conference held in Nairobi, Kenya. (Josh’s full conference remarks can be found here.) During this conference, Josh tried to answer the question of whether microfinance institutions (MFIs) can help victims of trauma who suffer from mental health disorders, such as post-traumatic stress disorder (PTSD), to find hope and dignity through self-employment.

In his post, Josh suggests steps to be taken by our sector to be inclusive of those suffering from mental health disorders. In this post, I’ll address two of those steps:

  1. More linkages between mental health providers and MFIs can take place such that people have access to financial services and business and financial training.
  2. Create a set of global standards and indicators for MFIs and other financial service providers to follow that will establish the importance of and offer guidance on serving PTSD survivors and other persons with psycho-social disabilities.

While Freedom from Hunger works actively with our partners to link their clients to health service providers through our integrated approach, I can’t speak yet to having a lot of success on Josh’s first step above — i.e. the specific linkage to mental health service providers. Though this doesn’t mean there aren’t already bright spots. This (really interesting) Freakonomics podcast discusses how cognitive behavioral therapy (CBT) and cash transfers are being combined for child soldiers in Liberia. Spoiler alert, CBT plus cash transfers leads to men staying out of trouble, compared to getting only CBT or only a cash transfer.

On Josh’s second point, regarding the need to start by understanding and measuring the extent of psycho-social disabilities, we’re just dipping our toes in the water.

In the paper we produced called “Healthy, Wealthy, and Wise: How Microfinance Can Track the Health of Clients,” in which we share experiences in selecting and pilot-testing our Health Outcome Performance Indicators (HOPI) among MFIs, some of our initial testing around mental health indicators was limited and was initially driven by the acknowledgement that consequences of domestic violence should be better understood and tracked.

Since the publication of that paper, we’ve conducted research in Burkina Faso with 46 women that we followed over a 7-month period to better understand resilience. We tried to look at resilience holistically and included “attitude” questions in all 10 surveys we conducted. One survey focused entirely on attitudes and perceptions of one’s life. We pulled heavily from research conducted by Johannes Haushofer, who is a professor and researcher of psychology and public affairs at Princeton. He took variables from a World Values Survey and compared them to poverty status.

In the research in Burkina Faso, we compared self-perceived resilience status (i.e., “Based on what you consider to be a resilient household, do you believe your household is resilient?”) to a series of indicators, approximately 14 of which were attitude/perception indicators. We found that those who considered themselves resilient were also likely to report feeling supported, hopeful, capable of meeting one’s financial obligations, trustful of others, and not living one’s life “day to day.” They reported that they would try anything to improve their life. (This research will be available by the end of October through CGAP).

These indicators are just one slice of mental health — but it is a starting point. We have Haushofer’s research as well as our simple forays into developing the HOPI, which we think MFIs can use to measure and monitor client status. Given this headway, I think we all can have a greater appreciation of the power that positive or negative mental health can have on a person’s productivity and their likelihood of success with the types of financial tools we can provide.

For microfinance and beyond, I think we have the research we need to argue that mental health matters. (See this recently published paper in the Lancet regarding mental health research in Europe.) The direct costs (i.e., healthcare costs and productivity losses) and the indirect costs (i.e., wage and productivity losses of caregivers and family members) can be significant.

And mental health matters even if we’re not distinguishing between people with diagnosed mental health impairments versus the mental health challenges poverty often creates. In fact, in the book Scarcity by Sendhil Mullainathan and Eldar Shafir, we are challenged to recognize this. They explain how “scarcity captures the mind. The mind orients automatically, powerfully, toward unfulfilled needs. Scarcity…changes the way we think. It imposes itself on our mind. The consequence of having less than we want is simple: we are unhappy.”

I think we’ve all had periods of our life in which we can relate to what mental distress feels like. Your mental bandwidth is limited, and its hard to feel hopeful when you’re going through a trial. I wonder if we should assume that the starting point is that all clients we serve could benefit from mental health support given what we know about the psychology of poverty. Everyone deserves a financial product or process that helps them through life’s short and long-term crises — whether it’s a purely economic crisis, a visible health crisis like dealing with cancer, or a mental health crisis that has no obvious cause.

Obviously, this is easier said than done. But, over time, I’ve come to really value and appreciate what the mental health and psychosocial indicators can tell me about a person’s life. Even if a person’s poverty status hasn’t changed but their belief that their life is better and more manageable, I can see where that can be considered success.

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Philippines program provided 800,000+ women maternal health education and care

Summary:
CARD Mutually Reinforcing Institutions (CARD MRI), the Microcredit Summit Campaign, and Freedom from Hunger announced that under the “Healthy Mothers, Healthy Babies” program, some 800,000 women have received maternal health education in the past 5 months and 3600 women have received healthcare in the past 12 months. The project aims to improve maternal health alongside their microfinance services in the Philippines, accelerating achievement of UN Millennium Development Goal 5.


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WASHINGTON, D.C. [September 24]—Partners in a joint-program aiming to improve maternal health in the Philippines announced today that they provided more than 800,000 women with maternal health services in the past year. CARD Mutually Reinforcing Institutions (CARD MRI), the Microcredit Summit Campaign, and Freedom from Hunger began rolling out health education in April to poor and rural communities in Luzon, Mindanao, and, notably, the Visayas, which had catastrophic destruction in the wake of Typhoon Haiyan.

With the support of program partners, CARD MRI trained more than 1,000 account officers (AOs) in 14,650 centers to deliver the health education to CARD members. The AOs educated an average of 5,000 women per day over the last five months on important maternal health issues. Each woman received two hours of instruction on simple but important lessons like the food and nutritional supplements that pregnant and young women need and the importance of giving birth in a health facility.

“Helping poor communities through financial access is undeniably important in poverty eradication,” said Marilyn M. Manila, director of the Community Development Group at CARD MRI (a Filipino microfinance institution), “but this is insufficient to reach our goal. Poor health and having no access to health care service are a big part of continuous poverty in many countries. We realize the importance of good health of microfinance institutions’ (MFIs’) clients to help them continue improve their quality of life.” Ms. Manila also chairs the MFIs for Health, a consortium of 21 Filipino MFIs committed to providing access to health care services to poor communities.

At 30 years old, CARD MRI client Barrera is eight months pregnant with her fourth child. Barrera is one of the 3,634 women who received routine gynecological examinations and 2,222 mother and baby kits at four community health fairs over the last 12 months. Berrera attend the fair in Davao this July “for the ultrasound—to be able to see my baby. It was my first time.” More than 100 healthcare providers have participated in the four health fairs, and many more will. The next health fair will take place in very rural areas of Mindanao October 2nd and 3rd.

Community health fairs are important for improving maternal health in poor, rural communities where accessing health services is a challenge. Program partners organize health fairs with support from local foundations and professional associations like the Philippines OB/GYN Society, community health workers and private health providers, as well as the government: the Department of Health, local government units, and PhilHealth (the national insurance program).

Over the last 15 years, the Philippines has improved in many key indicators such as life expectancy, access to education, and infant mortality; however, maternal mortality has remained at unacceptably high levels. Delays in accessing medical care is a key bottleneck in achieving better results for mothers and babies. With 99 days to the end of the Millennium Development Goals and the Global Goals for Sustainable Development on the horizon, this collaboration to educate about and expand access to health services is critical for meeting the needs of poor communities. This project is supported by an educational grant from Johnson & Johnson.

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About CARD Mutually Reinforcing Institutions
The CARD MRI is a group of mutually reinforcing institutions with a common goal of alleviating poverty in the Philippines and improving the quality of lives of the socially-and-economically challenged women and families towards nation building. Based in San Pablo City in Laguna in the Philippines, CARD MRI has 1,845 offices located all over the country and has program/partnership offices in Cambodia, Vietnam, Laos, Myanmar, and Hong Kong. CARD MRI has 2.99 million members and clients as of July 2015 throughout the country, continuously providing them holistic and integrated financial and social services that help uplift their lives and eventually transform them into responsible citizens for their community and their environment.
www.cardmri.com

About Freedom from Hunger
Founded in 1946, Freedom from Hunger is a US-based international development organization that brings innovative and sustainable self-help solutions to the fight against chronic hunger and poverty. By partnering with local microfinance institutions (MFIs) and nongovernmental organizations (NGOs) throughout Asia, Africa and Latin America, Freedom from Hunger is reaching 5.7 million women, equipping them with resources they need to build futures of health, hope and dignity.
www.freedomfromhunger.org

About the Microcredit Summit Campaign
The Microcredit Summit Campaign (the “Campaign”), a project of RESULTS Educational Fund, is the largest global network of institutions and individuals involved in microfinance and is committed to two important goals: 1) reaching 175 million of the world’s poorest families with microfinance and 2) helping 100 million families lift themselves out of extreme poverty. The Campaign convenes a broad array of actors involved with microfinance to promote best practices in the field, to stimulate the exchange of knowledge and to work towards alleviating world poverty through microfinance. In early 2016, the Microcredit Summit Campaign will host the 18th Microcredit Summit in Abu Dhabi. The agenda will focus on “Mapping Pathways out of Poverty” and will feature innovations from the Africa-Middle East Region.
www.microcreditsummit.org

Media Contact Information
Microcredit Summit Campaign
Sabina Rogers
Manager, Communications and Relationships
+1 (202) 637-9600
rogers@microcreditsummit.org
Freedom from Hunger
Piper Gianola
Senior Director, Development and Communications
+1 (530) 758-6200 x 1018
piper@freedomfromhunger.org
CARD MRI
Cleofe Montemayor-Figuracion
Deputy Director, Corporate Communications
+63 (49) 562-4309 local 108
corpcomm@cardbankph.com; cardmri.corpcomm@gmail.com

Free ultrasounds draw thousands to community health fairs

A doctor provides free checkups as part of a health outreach program in the Philippines. Photo by: CARD MRI

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World leaders are convening in New York this week to finalize the Global Goals for Sustainable Development, an ambitious plan that will build on the successes and tackle problems where the Millennium Development Goals fell short. Freedom from Hunger and the Microcredit Summit Campaign are partnering with CARD Mutually Reinforcing Institutions (CARD MRI) to implement an 18-month project to address one of these MDG achievement gaps: maternal health in the Philippines. The project, “Healthy Mothers, Healthy Babies: Kalinga kay Inay,” is supported by an educational grant from Johnson & Johnson and will wrap up in December.

We have prepared a newsletter to let you know how things are going. To receive a copy of the newsletter, please sign up for our integrated health and microfinance news mailing list. Here is a sneak peek at the first issue of our Healthy Mothers, Healthy Babies: Kalinga kay Inay Project Newsletter.


Charyle is 32 years old and nine months pregnant with her fourth child. She attended the Davao City community health fair organized in July by CARD MRI, a Philippine microfinance institution (MFI), with partners from the MFIs for Health consortium.

Charyle was very excited to get an ultrasound. While Charyle goes monthly to a nearby health center for prenatal checkups, this was likely her first ultrasound. Charyle plans to deliver at a birthing center (an affordable alternative to a hospital for low-risk pregnancies). “I like it [the birthing center] better because it’s more personal,” she said. “I have PhilHealth, which helps with costs and point-of-care service.”

CARD has made a point to engage the local health insurance office of the Philippines’ national health insurance program, PhilHealth, in the fairs. Many women do not know the benefits or financial savings of PhilHealth membership, such as the fact that a year’s premium is less than a typical uninsured delivery. So, they provide orientation, enrollment of non-members, and other services to health fair attendees.

Irish (27) is four months pregnant with her first child. She has visited a health clinic three times already and plans to deliver at a regional hospital because she has hypertension. “So,” said Irish, “I think I will look at PhilHealth while at this health fair.”

Barrera (30) is 8 months pregnant with her fourth child. Barrera learned of the fair during her prenatal visit at the health center, which is within walking distance and offers free prenatal checkups. She said she decided to come to the fair “For the ultrasound — to be able to see my baby. It was my first time.” Berrera also plans to deliver at her local birthing center. “It is walking distance from where I live, and it is PhilHealth accredited, so free.”

Charyle, Irish, and Barrera were among 435 women who attended the two fairs; however, they were not typical in their prenatal care and delivery plans. OB/GYNs, general physicians, pediatricians, and other medical professionals provided services to these women that many normally would not be able to access or afford. In the four health fairs held so far, some 3600 pregnant and lactating women have gotten a free check-up.

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What else is in the newsletter?

Increasing Healthcare Access

Through “Healthy Mothers, Healthy Babies,” 8,000 women of child bearing age (primarily pregnant and lactating women) will receive education and preventive services through five community health fairs by the end of 2015. Women from the local community and surrounding areas access maternal health products and services like urine tests, OB/GYN consults, ultrasounds, sonograms, and vitamins provided by BotiCARD (part of the CARD family). Such services are otherwise unavailable them. The next health fair will be October 2-3 in rural communities in Mindanao. Contact Mharra de Mesa to learn more.

What’s in the Mother and Baby Kit?

health-kit_HMHB-PH_Oct2014_Courtesy-of-CARD-MRI

Building Capacity to Provide Health Education

What does it take to deliver maternal health education to 600,000 women? In January 2015, 17 CARD staff and 1 nurse took part in a training of trainers (ToT) on the maternal and child health education module, “Healthy Pregnancies Make Healthy Communities.” In March, four members of MFIs for Health — ASA Philippines Foundation Inc., KMBI, TSPI, and CCT — joined the Integration Workshop and ToT facilitated by CARD MRI. Learn how CARD is taking a leadership role in the Philippines to extend health products and services to more microfinance clients. Contact Cassie Chandler to learn more about the education module.

“MFIs for Health” Provide Health Services to Poor Communities

The Filipino “MFIs for Health” consortium expanded to 21 microfinance institutions (MFIs) in May when they inked a Memorandum of Agreement to provide access to health care services to poor communities. “The microfinance industry has grown so much over the past year,” Sen. Paulo Benigno “Bam” Aquino said. “It is crucial that the MFI industry should continue to innovate…and unlock more accessible opportunities that go beyond financing and bring it to our countrymen especially in the areas who have less opportunities.” Learn how the Filipino microfinance sector is mobilizing to improve the health of poor communities. Contact MAHPSecretariat@gmail.com to learn more.

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  2. Share your stories and find out what others are doing on the #GlobalGoalsLive hub
  3. Engage with us on Twitter, Facebook, and wherever you are using the hashtag #GlobalGoalsLive

Does anti-poverty work actually … work?

Photo credit: Giorgia Bonaga & Shamimur Rahman

Photo credit: Giorgia Bonaga & Shamimur Rahman

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The following blog post is re-posted with permission. Read the original article on Next Billion, “NexThought Monday – Does Anti-Poverty Work Actually … Work?: Three questions every ‘pro-poor’ group needs to ask themselves.”


>>Authored by Chris Dunford and Carmen Velasco

This month, the United Nations will celebrate achievement of Millennium Development Goal No. 1. The number of people living in extreme poverty has fallen by more than half, from 1.9 billion in 1990 to 836 million in 2015. How did this happen? Is it because of targeted anti-poverty programs, or is it due to broad-based economic growth, especially in China and India? If economic growth is the main cause, as it seems to be, further progress may be doubtful. Economic growth alone is unlikely to reach the residual hundreds of millions still living in extreme poverty.

Nor is it likely that anti-poverty programs, whether public or private, will lift this “bottom billion” from extreme poverty. For example, the U.S. poverty rate hovers around 15 percent of the population, nearly unchanged for decades, despite the hundreds of billions of dollars spent on U.S. anti-poverty programs. For another example, in poorer countries, microfinance was billed as a self-financing solution to deep poverty and became a darling of international development donors in the 1990s and “social investors” in the 2000s. Then smart social scientists tested the claims with sound field research and found little to no impact on poverty.

Is it reasonable, however, to expect anti-poverty programs, by themselves, to lift large numbers of people above an arbitrary poverty line? Given that the poor must overcome many burdens before they can seize whatever economic opportunities are available, perhaps we should ask a different question:

Do anti-poverty programs ease the burdens of poverty?

While the recent research into microfinance shows little to no increase of annual household income, on average, the same studies very often show that the burden of poverty is alleviated by giving microfinance participants access to money when they really need it during the year. Economists call this impact “consumption smoothing.” In plain terms, it means people get enough to eat throughout the year instead of going without adequate food for a day, a week, or even months at a time. If so, this is an impact worth celebrating, is it not?

Even with this more modest and realistic expectation, some anti-poverty programs are effective and some are not. We know this from our collective experience in anti-poverty work, with more than 70 years between us. We know the challenge is to distinguish what works from what does not. It is better to seek out “pro-poor” rather than “effective” anti-poverty work, because there are gradations of effectiveness. All programs have room to improve. “Pro-poor” programs actually strive to improve toward greater effectiveness. Transparency and accountability are not just about separating wheat from chaff; they are about improving.

How can we fully distinguish pro-poor programs from those that are not?

In a volunteer initiative called Truelift, leading thinkers of the “social performance” movement in microfinance (seeking social as well as financial return on investment) have hit upon a truth that applies to all anti-poverty work: Truly pro-poor programs provide the right answer to each of three straightforward questions.

First: Does the program work with people living in poverty?

Straightforward indeed! But how do you know a person living in poverty when you see one? More important: How does a program know them, recruit them, include them and keep others who are not poor from co-opting what the program offers?

Too many anti-poverty programs cannot answer this question. Regardless of legitimate reasons, these programs are flying blind in their poverty outreach and, therefore, their potential to impact poverty. “Blind” programs may be “wasting” precious resources on the “wrong” people — even though much good may be done. Such programs are not entitled to the “pro-poor” label — they need a different justification. Or, they can get serious about knowing the poverty status of the people they work with.

Second: Does the program design and adapt its services specifically for people living in poverty?

The staff of a pro-poor program changes and adapts the services and products they offer — intentionally and systematically, always listening carefully to people living in poverty and being clear about the benefits the program seeks to provide them. It is basic good business practice — know your customers, listen to them, design for them, satisfy them.

The Réseau des Caisses Populaires in Burkina Faso (RCPB) discovered while providing savings and credit services to groups of rural women that they wanted information about how to prevent and treat malaria, a disease that kills children and robs adults of far too many productive work days. At left, an RCPB animatrice (field agent) shows a women’s group how to understand the symbols on a take-home card that shows illiterate people how malaria is prevented and treated. (Image credit: Karl Grobl for Freedom from Hunger)

Third: Does the program track the progress of the people using its services?

It is not enough to reach out to people living in poverty and to design and adapt services to suit their needs and constraints. We must have some evidence that our work is helping them move in the right direction, even if not all the way to the intended destination. This is not just to show that our work is worthy of the money spent, but also to know how to improve our work. We need “real time” information about change in clients’ lives.

We operate programs in a world where sophisticated research into cause and effect is rare and likely to remain so. Logic, experience and some evidence indicates that programs providing the “right” answer to each of the three Truelift questions are likely to show positive impacts on people living in poverty, if and when sophisticated impact research is done.

It is not too difficult for managers, donors, investors, regulators and business leaders to ask these three questions and know when they get good answers. We can know a pro-poor program when we see one — and act to support it.

Truelift_RGBChris Dunford and Carmen Velasco are co-chairs of the Truelift Steering Committee.


Read the full article on Next Billion.

Learn more about Truelift.

Measuring client health outcomes using simple indicators

A local community health volunteer trained and supervised by Bandhan, an Indian MFI, meets with members of a local self-help group and their families. (Photo courtesy of Johnson & Johnson)

A local community health volunteer trained and supervised by Bandhan, an Indian MFI, meets with members of a local self-help group and their families. (Photo courtesy of Johnson & Johnson)

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>>Authored by Sabina Rogers, Communications and Relationships Manager

More than two years ago, we set out with Freedom from Hunger to develop and test a standardized set of health indicators as part of a Campaign Commitment we co-launched in 2013. This has culminated with the release of Healthy, Wealthy and Wise: How Microfinance Institutions Can Track the Health of Clients. The report describes our experience in selecting and pilot-testing a set of indicators. It will help you choose the right indicators for monitoring client health outcomes over time. And finally, the report summarizes key recommendations for developing “standardized” client outcome monitoring indicators.

We hope financial services providers and others will use our “health outcome performance indicators” (HOPI) to assess the health and well-being of clients and their families. We believe that wide usage of the HOPI would create short- and long-term value for practitioners (both health and financial services), social investors and donors, raters, and other actors. “Health” is a basic need that crosses all borders and all demographics, making the HOPI compelling measures for understanding client outcomes for financial service providers.

Four MFIs pilot tested the HOPI in 2014 (see below), and we shared results from ESAF’s and Equitas’ experiences in India in a webinar in March.

Financial Service Provider Country No. of Clients being served by FSP No. of clients participating in health indicators survey
ESAF India 450,000 700
Equitas India 1,344,361 551*
CARD Philippines 1,828,052 472
ADRA Peru 17,039 95

*Equitas had completed 234 surveys by the time we began data analysis. Therefore, the HOPI report only covers analysis for the first 234 data points

The HOPI measure 6 dimensions: poverty, food security and nutrition, preventive health care, curative health care, water and sanitation, and attitudes. The results from these four MFIs highlighted the added value of health indicators when combined with poverty measurement in helping MFIs understand client well-being. For example, the food security measure was useful to detect vulnerability; while very few clients in Peru fell under any of the poverty lines, 40 percent of them scored as food insecure.

We also found that whether clients treat their water was most frequently associated with poverty levels. However, to correctly interpret this measure, this dimension should not be used without assessing household drinking-water sources as well.

The curative health care dimension results were particularly informative and the questions have broad applicability across contexts. Results from the four MFIs showed that up to 60 percent of clients didn’t seek treatment because of costs. In Peru and the Philippines, we also learned that clients were not very confident in their ability to cover future health costs or to receive adequate medical care.

Because it’s so context-specific, the preventive health care dimension is the most complicated, yet it is also very important to include because it could be predictive of future health outcomes. As we look at adapting to new countries, national health surveys will be the most useful source for indicators.

While collecting the data was fairly simple, the bigger test will come from an organization’s ability to analyze and interpret the data so that action can be taken. In the pilots, we provided technical support to the four MFIs to analyze the data, but that level of input is not likely to be sustainable. Therefore, we are now developing an easy-to-use, Excel-based data collection and analysis tool for distribution later this year. If you are curious, then, about the health outcome performance indicators, here is what you should know:

  • They are practical to measure and monitor client health over time (annually or as part of other monitoring tools such as the Progress out of Poverty Index®).
  • They can be reported by clients in a monitoring survey.
  • They can be benchmarked to other regional, national, and global health goals and data.
  • They are reliable and are subject to change over time.
  • They will be relevant and useful for FSPs to measure and improve measures of program impact on client health and well-being.
  • They will provide donors, investors, government, health actors, and others with important information to guide decisions about support and social investment.

If you would like to learn how you can adapt the HOPI to your institution’s needs, contact Bobbi Gray (email) or DSK Rao (email).

Related reading

Building resilience for the world’s poor: The $1.50 challenge

Jeff Ashe_savings group women count money

Savings group women count money
Photo courtesy of Jeffrey Ashe

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Pathway

Savings groups (aka village savings and loans associations)


>> Authored by Jeffrey Ashe, Fellow, Carsey school of Public Policy, University of New Hampshire; Research Fellow: Global Development and the Environment, Tufts University

I read the recent World Bank News Flash entitled “International Funding for Financial Inclusion” [1]. In 2013 a total of $31 billion was invested in financial institution building, but what if just the grant proportion if this amount, $2.9 billion, was invested in training savings groups?

  • 200 million of the world’s poor (equal to all the microfinance borrowers today) would have a safe and convenient place to save and easy access to small loans (@$15 per group member).
  • There would be 10 million new savings groups in place in 2 million villages and many thousands of slum communities (@ 4 groups with 80 savings group members per village of 1,000 inhabitants).
  • These groups would mobilize and largely distribute $10 billion every year of which 30 percent ($3 billion) would be the profits from lending to members (@ $1,000 distributed per group of 20 per year) without outside funding.

This is possible since savings groups are able to:

  • Reach those that microfinance is not designed to reach profitably. Even the most motivated micro-lender cannot make money on $0.50 savings deposits and $30 loans.
  • Require a fraction of the staff. Saving for Change in Mali, a joint venture of Oxfam America, Freedom from Hunger, and Stromme Foundation, reached 450,000 women organized into 19,000 groups with 209 trainers. To reach the same number, a typical microfinance institution (MFI) would require a permanent staff of 1,500 [2]. Only a handful of trainers are monitoring Saving for Change groups in Mali today, with few signs that the groups are faltering.
  • Be promoted by local NGOs. Savings group promoters introduce a simple structure while the groups do the creative work of saving, lending, collecting, and record-keeping.
  • Virally self-replicate. The leaders of established groups train new ones at no additional cost.
  • Be profitable for very poor people. When the fund is divided at the end of each cycle, members receive on average $1.38 for each dollar saved [3].
  • Survive independently. A panel study of 331 groups in 6 countries over 5 years indicates a 90% survival rate [4].
  • Serve as a platform for other development inputs. Members launch their own projects, and disciplined groups with financial clout serve as platforms for government and NGO development initiatives and linkages to financial institutions.
  • Promote societal change. In Guatemala, savings groups banded together to elect women mayors. In El Salvador, ex-trainers are assuming roles in municipal governments.

Jeff Ashe_In their Own Hands_book coverWhat is the potential outcome? A randomized controlled trial and anthropological study of savings groups in Mali [5] funded by the Bill & Melinda Gates Foundation found that when only 40 percent of the eligible women had joined groups, there was a village wide (not only group member) effect. The findings included the following:

  • Reduction in chronic hunger with the greatest reduction among the poorest.
  • Increased assets, largely in the form of livestock that could be cashed in when money is scarce.
  • A one-third increase in savings from all sources, including traditional savings clubs (ROSCAS).
  • The substantial word-of-mouth spread of the methodology at no cost to the program.
  • Increased social capital.

Simply stated, the grant funding from a single year of financing financial inclusion could be translated into a modest increase in resilience for 2 billion of the world’s poorest at a cost of one dollar per villager: 2 million villages @ 1,000 inhabitants per village.

Savings groups work because they catalyze the capacity of the poor to achieve their own financial inclusion when provided a simple structure and a bit of training to do so. They represent a crucial component of a strategy for financial inclusion that also includes savings, credit, insurance through institutions, programs targeting the ultra-poor, and conditional cash transfers. This, in addition to the informal means the poor have long used to manage their finances.

Related resources


Sources

[1] Estelle Lahaye and Edlira Dashi, “Spotlight on International Funders’ Commitments to Financial Inclusion“. CGAP, 25 March 2014.

[2] David Roodman, Due Diligence: An Impertinent Inquiry into Microfinance. 2011

[3] SAVIX panel study of 331 randomly selected groups. http://savingsgroups.com/

[4] Ibid.

[5] Karlan, Dean, Jonathan Morduch, Mamadou Baro. “Final Impact Evaluation of the Saving for Change Program in Mali, 2009-2012“. Innovations in Poverty Action, Bureau for Applied Research in Anthropology (BARA), University of Arizona, April 2013.

Six learning opportunities for the “Six Pathways”

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>>Authored by William Maddocks, director of the Sustainable Microfinance and Development Program (SMDP) at the University of New Hampshire’s Carsey School of Public Policy

New scrutiny has focused on what microfinance can’t do, and the evidence is growing that microfinance, de-linked from a social change paradigm, is simply another way to provide basic financial services to people historically excluded by the market. The new theme for the Microcredit Summit Campaign for 2015 of “financial inclusion to end extreme poverty” and the Six Pathways show promise in getting us there and can succeed in challenging extreme poverty if social change and equity are embedded as core values by those who fund, design, and implement these strategies.

These six pathways promoted by the Microcredit Summit Campaign touch on many of areas of the Carsey School of Public Policy’s current work. Using each pathway as a prompt, we will take a brief look at these themes and how you can get involved and learn more.

The Six Pathways

1) Mobile money linked with agent networks in low-income communities and other technological innovations

The SMDP New Hampshire Certificate 2015 in June will feature a session facilitated by Joyce Lehman, formerly with the Bill & Melinda Gates Foundation on branchless banking and the Digital Revolution. If the infographic from Kenya tells us anything (below), it’s that digital financial services are growing exponentially beyond just transfers and remittances to group savings & loans, agricultural inputs insurance, water services, off-grid lighting, and more. Come to New Hampshire, USA, this summer to learn about this exciting frontier of financial inclusion from the unique perspective of a former donor who worked on the ground floor of paving the digital finance highway.

Infographic: Kenya's journey to digital financial inclusion

Kenya’s journey to digital financial inclusion (by Simone di Castri and Lara Gidvani – July 2013)
Source: GSMA

2) Ultra-poor graduation programs

Jan Maes, who has worked in designing graduation programs with Trickle Up and other organizations, will present findings during the SMDP New Hampshire Certificate on the effectiveness and challenges of using these strategies to move the ultra-poor into self-sufficiency.

3) Microfinance savings and/or borrowing groups linked with health education, health financing, and health product delivery

Kathleen Stack, vice president of programs for Freedom from Hunger, will make a virtual presentation at the SMDP NH on Microfinance and Health Protection (MAHP) initiatives that they are implementing with our friends, CARD MRI in the Philippines and the Microcredit Summit Campaign, and in other locations. Read more about the project, Healthy Mothers, Healthy Babies, and how these three organizations, with the support of Johnson & Johnson, are helping address maternal and child health needs.

Photo courtesy of the Carsey School of Public Policy

Photo courtesy of the Carsey School of Public Policy

4) Agricultural value chains that reach to small-scale producers

Understanding markets is more than just knowing about products. The field of inclusive market development is moving from the linear value chain approach, to applying a systems approach that looks for, and adapts to, feedback from the system. Carsey has just launched SMDP Online and one of our first courses, “Understanding and Adapting to Complex Markets” will help practitioners understand complex adaptive systems and apply these concepts to their current work. SMDP Online course facilitator Mary Morgan, with more than 20 years of experience in development, promises a challenging and very practical learning experience for market development professionals.

5) Savings groups (aka village savings and loans associations)

One of the most promising strategies for reaching people that commercial microfinance has failed to reach are savings groups (SGs). Today more than 10 million people use SGs for saving, lending, building financial security, and social capital. Carsey has been a leader in savings groups training and learning events for several years and continues to expand opportunities to learn about this growing area of financial inclusion.

The SMDP Online will offer a blended course, “Savings Groups: Building Scale and Impact through Adaptation and Experimentation,” facilitated by Nanci Lee. This course will meet online for several months and then face-to-face in Lusaka, Zambia, during the SMDP Zambia, which occurs right before the next global gathering of SG practitioners, donors, researchers, and others at the SG 2015 conference also in Lusaka from November 10 to 12.

The lock box of a savings group in Africa

The lock box of a savings group in Africa
Photo courtesy of the Carsey School of Public Policy

6) Conditional cash transfers (CCTs) linked with mobile delivery and asset building

Reaching as many as 129 million people worldwide, CCTs work at a scale that few other anti-poverty programs can reach. Governments working with visionary partners like Fundación Capital can roll out programs that provide support, change social norms, and make a measurable impact on improving the lives of poor families. In the Dominican Republic, Fundación Capital has partnered with the Government’s ProSoli program and Banco ADOPEM and Banco Pyme BHD to connect savings groups with a CCT voucher program and bank linkages.

You can learn about this exciting pilot program by watching Jong Hyon Shin, Fundación Capital’s country project coordinator for the Dominican Republic, and her former professor (and Carsey Fellow) Jeffrey Ashe. (Watch the SEEP Network’s Taking Savings Groups on the Road Webinar Series.)

Relevant resources

Measuring what’s important: client transformation

Research Results ESAF India

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Published on the Center for Financial Inclusion’s blog April 15th.

Measuring Transformation

>> Posted by Bobbi Gray, Research Director, Freedom from Hunger

While recent research indicates that access to and use of microcredit alone is not transformative for the average client served (see “Where Credit Is Due“), there has been very little discussion about the types of indicators being used to measure “transformation” in the ongoing debates. In fact, it seems that we all have accepted the general findings that microcredit has only had modest impacts on, along with other indicators of poverty and well-being, education, health, and social capital because the randomized controlled trials (RCTs) have said so. There needs to be greater thought and debate about the choices of indicators used to support these conclusions.

Freedom from Hunger over the past 20-plus years has integrated health with microfinance and helped build a body of knowledge indicating that microfinance plus health services can enhance health outcomes. In an ongoing partnership with the Microcredit Summit Campaign, supported by Johnson & Johnson, we have pilot-tested a series of health indicators that financial service providers (FSPs) can use to track client health outcomes. This pilot test was built on years of experience of evaluating health outcomes with our FSP partners, as well as on similar experiences of developing common tracking indicators in the health sector. We created a list of criteria to assess the types of indicators we felt would be meaningful to track—for individuals with and without health services – which included dimensions of feasibility, usability, and reliability. Initial results have been shared in several webinars with SEEP and the Social Performance Task Force.

It’s important to note that this pilot test effort was not about “proving” impact, but rather developing common techniques for monitoring client outcomes that FSPs could use over time. However, this experience has shown how difficult it is to identify indicators that best measure certain health outcomes. What initially might appear as an intuitive indicator to use — for example, how often a person reports being ill or seeking medical treatment — is found to be more difficult than expected. Morbidity — or reports of illness — is not an easy measure for health sector actors or those who directly work to improve health outcomes because it is influenced by the seasons, by specific efforts, and other factors, so care has to be taken when interpreting results. Reports of seeking medical treatment are complicated by whether people are satisfied with the services they can seek and may not always reflect financial capability but preferences or lack of available health services.

Read the rest of the article

Relevant resources

Partnership building to reduce the Philippines’ maternal mortality rate

health-education_HMHB-PH_Oct2014_Courtesy-of-CARD-MRI

Women learn about family planning techniques while they wait for their exams at October’s community health fair.

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Pathway

Microfinance savings and/or borrowing groups linked with health education, health financing, and health product delivery


>>Authored by Camille Rivera, Senior Program Associate, and Sabina Rogers, Communications & Relationships Manager

HMHB_CMYK_English_BeveledWith the 2013 Partnerships against Poverty Summit in the Philippines, we wrote a new chapter in the evolution of the Microcredit Summit Campaign. The 16th Microcredit Summit focused on how public-private partnerships could combine expertise from the field of microfinance with other areas to develop more efficient and sustainable services for the extreme poor.

We have since created one such collaboration in order to address the problem of stubbornly high maternal mortality rates in the Philippines. While the country has experienced strong economic growth in recent years and the government has instituted a national hospital insurance scheme, PhilHealth, maternal mortality is at 221 per 100,000 live births. The Philippines are far off track of their maternal mortality MDG of 52 deaths per 100,000 live births.

It is a long way to go from 221 to 52 in the next few months, but when offered the opportunity to scale up in a short period of time our integrated health and microfinance methodology, we (with Freedom from Hunger) jumped at the chance. In partnership with a local partner CARD MRI (the largest social development organization providing micro-financial services in the Philippines) and with the financial and strategic support of Johnson & Johnson, we are implementing the Healthy Mothers, Healthy Babies project (HMHB, or “Kalinga Kay Inay” by its name in Tagalog).

Photo credit: Cassie Chandler

Photo credit: Cassie Chandler

How it works

The idea is simple: offer free health check-ups and behavior change education on health topics to pregnant and lactating women to create positive health outcomes. By the end of 2015, CARD and other MFIs will educate 600,000 women to improve maternal health and safe deliveries of infants, birth outcomes, and reduce preventable maternal death; and 8,000 pregnant or lactating women will be directly connected to relevant services and products. CARD and partners have held two community health fairs so far, and for many of these women, it was their very first gynecological exam.

At these health fairs, CARD sets up tents to give shade to those waiting outside. Inside the building, as the women wait for their preliminary exams (and, if necessary, ultrasounds), they learn about family planning. The volunteer health providers (doctors, OB-GYN, midwives, and others) write prescriptions for those who need medications, and BotiCARD (a CARD MRI institution) fill them for free in a tent set up outside.

CARD has found their collaboration with local government and public health units to be vital in getting higher-than-expected turnout to the fairs as well as for identifying local health providers for CARD members. Local administrators of PhilHealth have joined our January health fair and provided services to 179 health fair patients ranging from members’ renewal enrollment, new enrollment, membership updating, and printing of members’ data information.

Making these changes lasting changes

More importantly to us, through this endeavor, we are working to improve the scalability and sustainability of delivery of health education and related services to millions of women and children in the Philippines. Inspired by the 2013 Partnerships against Poverty Summit, the Campaign’s role in the HMHB project is to reach beyond the traditional microfinance actors and facilitate a partnership-building process for the “MFIs for Health” consortium, a group of 18 MFIs who are banding together to increase access for their communities to health-related products and services.

A doctor provides free checkups as part of a health outreach program in the Philippines. Photo by: CARD MRI

A doctor provides free checkups as part of a health outreach program in the Philippines.
Photo by: CARD MRI

We are talking with several foundations, corporations, and associations to identify specific ways that they can work with us and MFIs for Health to increase access to and improve delivery of healthcare services. The Zuellig Family Foundation (ZFF) and JPHIEGO in the Philippines are two organizations that have joined forces with our alliance — whether formally or informally. They have facilitated introductions to local government units (LGUs) and the Integrated Midwives Association of the Philippines to recruit healthcare providers as volunteers for the health fair and get their help spreading the word to their patients. In fact, ZFF and CARD are working with the Rural Health Unit (RHU) in the Visayas to coincide the RHU’s “Buntis Congress” (Pregnant Women’s Congress) with CARD’s April community health fair. Through this coordination, we are pooling resources and thus gain a larger potential impact for the community.

April is the Month of MicrofinanceLearn more

April is the Month of Microfinance
Learn more

This strategy behind HMHB, to facilitate partnerships between microfinance actors and players in other sectors, parallels efforts to create more integrated approaches to solve the most pressing needs of the extreme poor. In this case, we are addressing maternal and child health; in Ethiopia, it could be fistula and, in India, it could be non-communicable diseases.

Because MFIs meet regularly with large numbers of clients, they serve as an ideal platform to convey health information and services to clients who often build relationships of trust with their loan officers, as well as other members in their group. These exchanges can also have a replicator effect as clients are encouraged to share the information with their family members and others in their community.

By forging partnerships across sectors and bringing in non-traditional actors to microfinance, the Campaign is maximizing the best aspects of each player and (hopefully) helping the Philippines reduce their maternal mortality rate to 52 deaths per 100,000 live births.

Relevant resources

Millennium Development Goal 5: Progress and challenges in maternal mortalitySource: The Institute for Health Metrics and Evaluation

Millennium Development Goal 5: Progress and challenges in maternal mortality
Source: The Institute for Health Metrics and Evaluation

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.
RESOURCES: 
– 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.

Comment

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.)

Answers

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: https://vimeo.com/121303535.

Answers

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.

Answers

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?

Answers

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

Pierre Claver NKUNZABAGENZI:

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

Answers

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?

Answers

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?

Answers

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?

Answers

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?

Answers

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?

Answers

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)?

Answers

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

The importance of measuring client outcomes

Outcomes process

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The World Bank is hosting a day-long event today (as I write this, actually) presenting lessons and implications of the latest research on microcredit. Based on the swiftness of my Twitter feed, the event, “Financial Services for the Poor: Lessons and Implications of the Latest Research on Credit,” is very popular and timely. (You can follow it using the hashtags #WBlive and #Microcredit2015.) Much of the evidence shared this morning (when they had a live video feed of the event), confirmed our understanding that microcredit alone is not enough.[1]

Indeed, the speakers in the 10 AM session (agenda), in response to an audience question, “If you had $1 million, how much of it would you put toward microfinance?”, recommended that we should invest our money in human capitol, namely early childhood education and conditional cash transfers (CCTs).

We would add health-related products and services: from health education for positive behavior change to healthcare delivery, and everything in between. We also believe that it is essential to measure and track the client outcomes of our interventions over time — be they microcredit, savings, insurance, or non-financial products and services.

On February 4th, the Social Performance Task Force (SPTF) Outcomes Working Group hosted a virtual meeting on the “Selection of Outcomes Indicators.” The purpose of this working group is to develop practical guidelines for credible measurement of and reporting on outcomes, drawing on experience with different approaches and tools.

Frances Sinha of EDA Rural Systems introduced the session and explain how theory of change connects to indicators. Bobbi Gray of Freedom from Hunger explained the criteria applied to developing outcomes indicators — including a new set of Health Outcome Performance Indicators (HOPI) in partnership with the Microcredit Summit Campaign — and lessons learned. Anne Hastings of the Microfinance CEO Working Group discussed their plans for laying the groundwork for a common measurement and monitoring system.

Feb 5th meeting resources

If you would like to learn more about the pros and cons of the Health Outcomes Performance Indicators, join us on March 4th with the SEEP Network’s HAMED Working Group for the webinar, “Healthy, Wealthy, and Wise: How MFIs Can Track the Health of Clients.”


SPTF’s Outcomes Working Group will host a repeat of their December 14th virtual meeting on Tuesday, March 3rd at 4 AM (EST) // 9 AM (GMT) // 12 PM (East Africa) // 2:30 PM (India). Panelists will discuss the Theory of Change and how it helps us think about what to measure and when.

Recordings and materials from the original meeting (December 14th) are available online.

Speakers:

  • Frances Sinha, EDA Rural Systems
  • Anton Simanowitz, Independent consultant

The idea of a Theory of Change is now increasingly applied to strategic planning. It is beginning to be applied to measurement of change. This webinar will review the framework of a Theory of Change and to discuss how it can help an institution think through the ways in which it aims to achieve change, what inputs lead to what outcomes, and the time frame for expected change to take place. These are questions that are fundamental to appropriate research design and help in identifying relevant outcome indicators (short-term and long-term) and in analyzing the data to reflect a relevant sequence of inputs, outputs and outcomes.

About the Outcomes Working Group

  • Facilitator: Frances Sinha, director of EDA Rural Systems (India) and SPTF Board member.
  • Purpose: Develop practical guidelines for credible measurement of and reporting on outcomes, drawing on experience with different approaches and tools.
  • Introductory presentation

[1] Social Performance Task Force (SPTF) “Repeat session of the Outcomes Work Group: Theory of Change” WebEx meeting.

Tuesday, March 3, 2015 at 4:00 am | Eastern Standard Time (New York, GMT-05:00)

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Meeting number: 315 311 993
Meeting password: sptf

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Healthy, Wealthy, and Wise: How MFIs Can Track the Health of Clients

A doctor provides free checkups as part of a health outreach program in the Philippines. Photo by: CARD MRI

A doctor provides free checkups as part of a health outreach program in the Philippines. Photo by: CARD MRI

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Join us on Wednesday, March 4th at 9:30 AM (ET / GMT – 5) for “Healthy, Wealthy, and Wise: How MFIs Can Track the Health of Clients,” a webinar co-hosted by the SEEP Network to discuss how you and your partners can measure client health and well-being.

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Wednesday, March 4th at 9:30 AM (ET / GMT – 5)
What time in your country?

The webinar will feature presentations from two of India’s leading microfinance institutions, ESAF Microfinance and Equitas Micro Finance Pvt Ltd. They will share the results of the “Empowering Poor Women through Integrated Health and Financial Services in India: Measuring Impact of Health and Microfinance” project led by Freedom from Hunger and the Microcredit Summit Campaign.

With funding support from Johnson & Johnson, these two organizations set out in 2014 to develop and test a standardized set of “Health Outcome Performance Indicators” (HOPI) that can be used by microfinance institutions (MFIs), self-help promotion institutions (SHPIs), and other financial service providers (FSPs) to monitor the health outcomes of clients over time. The HOPI relied on a cross-sectoral collaborative process, including the involvement of the SEEP Network’s HAMED Working Group members, health sector experts, investors, and practitioners who provided input during the indicator selection process as well as the analysis and interpretation of the data.

The webinar will focus on the following questions:

  • Do the benefits of tracking health outcomes outweigh the costs of the ongoing client data collection?
  • You may be asking yourself, why do we care? If MFIs don’t have health programs, what do they get out of collecting data on client health?
  • Why not just collect the PPI data? Did this give MFIs a better picture of their clients’ vulnerability than what the PPI alone can tell them?

Why the Health Outcome Performance Indicators are important:

  • They are practical for FSPs to measure and monitor client health over time (annually or as part of other monitoring tools such as the PPI).
  • They can be reported by clients in a monitoring survey.
  • They can be benchmarked to other regional, national, and global health goals and data.
  • They are reliable and are subject to change over time.
  • They will be relevant and useful for FSPs to measure and improve measures of program impact on client health and well-being.
  • They will provide donors, investors, government, health actors, and others with important information to guide decisions about support and social investment.

Speakers:

Bobbi Gray, Research & Evaluation Specialist, Freedom from Hunger, USA; and Facilitator, SEEP Network HAMED Working Group
Sandhya Suresh, Senior Manager, ESAF Microfinance and Investments Pvt Ltd, India
John Alex, Vice President and Head of Social Initiatives, Equitas Group; and Program Director, Equitas Development Initiatives Trust, India

Moderator:

Dr. DSK Rao, Regional Director for Asia Pacific, Microcredit Summit Campaign, USA


This webinar is hosted by SEEP’s Health and Market Development Working Group (HAMED), in partnership with the Microcredit Summit Campaign.


Bobbi Gray, Research & Evaluation Specialist, Freedom from Hunger, USA

Bobbi joined Freedom from Hunger in 2004. She leads research and evaluation efforts and works closely with the organization’s partners to determine solutions for assessing and measuring the social performance and impacts of integrated financial and non-financial services for adults and youth, including feedback of this information to stakeholders for decision-making. She has experience with both quantitative and qualitative methodologies, including sampling and analysis methodologies such as Lot Quality Assurance Sampling, financial diaries, qualitative “impact stories,” and Randomized Control Trial evaluations. In the past year, Bobbi has focused on working with a cross-sectoral team of experts to design a short-list of client outcome indicators focused on client health. She is also the Facilitator of the Health and Market Development (HAMED) working group at the Small Enterprise Education and Promotion Network (SEEP). She holds a Master of Public Administration degree in International Management from the Monterey Institute of International Studies, a Bachelor of Arts degree in French and Spanish from Texas Tech University, and speaks both languages.

Sandhya Suresh, Senior Manager, ESAF Microfinance and Investments Pvt Ltd, India

Sandhya Suresh works as senior manager with ESAF Microfinance and Investments Pvt Ltd based in the southernmost part of India in the state of Kerala. Ms. Suresh is a development professional with over 16 years of experience in the social development sector. Her primary interest and work is in social research where she likes to engage with low income women who struggle both socially and economically to keep up to the expectations of her family and community. She has engaged with ESAF’s beneficiaries in various capacities as a trainer, strategy developer, project coordinator, and team leader managing social research (including impact assessments). As an SPM champion with ESAF Microfinance, she has tried to oversee and guide the operations towards adhering to responsible finance and client protection principles. Ms. Suresh possesses a Master’s in Development Communications and has actively participated in the working groups that developed the Universal Standards of Social Performance and also in the development of SPI4 the assessment tool to measure SPM.

Ms. Suresh remains fully committed to the cause of bringing positive change in the lives of poor women through the platform of microfinance where in women are in a position to reduce the vulnerability attached to insufficient finances to meet the food, education, and housing expenses that are fundamental to every human being.

John Alex, Vice President and Head of Social Initiatives at Equitas Group and Program Director, Equitas Development Initiatives Trust, India

John Alex, after graduating in agriculture and rural development, started his career as a Group II Gazetted Officer in Tamil Nadu State Government and served as an extension officer (agriculture) and block development officer in North Arcot District, Tamil Nadu from 1979 to 1983. Mr. Alex joined the Indian Overseas Bank as a probationary officer and served as agriculture field officer, branch manager, regional assistant chief officer, senior manager, and chief manager in various branches in Tamil Nadu and Andhra Pradesh from 1983 to 2008. Mr. Alex joined the Management Team of Equitas in 2008 and conceptualized and set up the team for social initiatives with a clear focus to address a larger spectrum of requirements of clients in the field of health, education, skill development, food security, and placement for unemployed youth.

Dr. DSK Rao, Regional Director for Asia Pacific, Microcredit Summit Campaign, USA

Dr. D.S.K. Rao is the regional director of the Microcredit Summit Campaign and is based in Hyderabad, India. The Campaign draws heavily on his wide experience and familiarity with the microfinance sector in Asia.

Dr. Rao is a certified trainer of poverty measurement tools, including the Cashpor House Index (CHI), Participatory Wealth Ranking (PWR), and the Progress out Of Poverty Index (PPI).

He is presently implementing, in collaboration with Freedom from Hunger, a project in India funded by Johnson & Johnson in which he is providing technical assistance to local microfinance partners to integrate health and microfinance. Dr. Rao is working on health integration with some of the largest and most reputed MFIs in India. He also coordinated with Equitas and ESAF in piloting the Health Outcome Performance Indicators (HOPI) project.

Op-ed Published on Devex: Microfinance is the key for the Philippines to meet MDG 5

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An op-ed by the heads of Freedom from Hunger, the Microcredit Summit Campaign, and CARD MRI. Continue reading