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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4 interventions to help victims of trauma find hope and dignity

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Josh Goldstein (CFI) gives a keynote speech at the 8th Annual PCAF Pan-African Psychotrauma Conference in Nairobi, Kenya, a multidisciplinary event that focuses on psychological trauma in Africa’s war-affected societies. Photo: Josh Goldstein

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The Center for Financial Inclusion at Accion has made a Campaign Commitment to bring greater attention to the issue of aging and financial services and further support the inclusion of those with disabilities. Learn how you can join the global coalition of organizations working to help 100 million families lift themselves out of extreme poverty.

Read the full text of Josh Goldstein’s keynote speech.


>>Josh Goldstein, Vice President, Economic Citizenship & Disability Inclusion, The Center for Financial Inclusion at Accion

“Over a sixth of the world’s population has directly experienced armed conflict, torture, terrorism, sexual and gender-based violence, ethnic cleansing or genocide.”
— The Peter C. Alderman Foundation (PCAF) website

I recently attended the 8th Annual PCAF Pan-African Psychotrauma Conference in Nairobi, Kenya, a multidisciplinary event that focuses on psychological trauma in Africa’s war-affected societies. PCAF operates mental health clinics in Cambodia, Kenya, Liberia, and Uganda and conducts trainings for mental health professionals. At the conference,I was surrounded by global leaders from health care, academia, and a litany of organizations working in the mental health space.

At first blush, my placement at such an event might seem odd as my work focuses on disability inclusion for microfinance. But, I’d argue that’s more of a reflection of how society, and our industry, views mental disabilities — with reductive biases — rather than how they fit within microfinance.

I had the privilege of presenting a keynote to the attendees. I discussed whether it’s possible for trauma patients who have gone through a successful course treatment that includes counseling, medication, and livelihood trainings to become clients of microfinance institutions (MFI) and build small-sized enterprises. Immediately below is an abridged version of my speech, with the complete text linked at the end.

Can MFIs help victims of trauma find hope and dignity through self-employment?

Josh Goldstein_keynote speech_portAs a post-traumatic stress disorder (PTSD) survivor myself from the U.S., who received treatment, I believe with all my heart that in a just society poor people with mental health challenges should get the help they need so they can flourish as human beings. Unfortunately, in the international development world I come from, this great cause is barely on the radar — in spite of the fact that reaching the most destitute is at the urgent core of all international development work. Indeed, I share your outrage at the paucity of funding and support for community mental health from governments and foundations.

But, why self-employment for those with mental health issues like PTSD? Why not go find a job and work for a business that provides a regular paycheck? Isn’t that easier and more secure? Of course it is. Most clients of MFIs are what we call “necessity entrepreneurs” and would rather have such jobs than start their own businesses. But, the sobering reality of limited formal sector employment opportunities across Africa makes finding such jobs for persons with physical disabilities, let alone psychosocial disabilities, even more challenging than it would be otherwise. Even in my country, the United States, unemployment of persons with disabilities in the formal workplace remains unconscionably high.

But are such financial products like credit or savings a good idea for someone with PTSD? For example, would the effort to save or borrow money bring greater stress? There is no easy answer based on my cursory review of the very limited research studies to date — the results are ambiguous and prove nothing conclusive one way or the other. What we do know, thanks to PCAF Uganda Program Director Dorothy Kizza, is that relapsing back into mental illness is often caused by a lack of employment. So, on balance, the stress of not working may be equally or more stressful than paying back a working capital loan which at least holds the promise of a more hopeful future. My own hunch is that the answer will only be decided on a case-by-case basis and so no generalization is really possible.

What seems beyond doubt, as Crick Lund, a professor at the University of South Africa and CEO of PRIME, a consortium of research institutions and ministries of health, has written, “is [the] growing international evidence that mental ill health and poverty interact in a negative cycle. This cycle increases the risk of mental illness among people who live in poverty and increases the likelihood that those living with mental illness will drift into or remain in poverty.” A big-picture study from the Harvard School of Public Health and the World Economic Forum estimates that the cumulative global impact of mental disorders in terms of lost economic output will amount to US$16.3 trillion between 2011 and 2030.

I am happy to say that the Center for Financial Inclusion (CFI) and its allied partners working on disability inclusion have begun to demonstrate significant success in including persons with physical disabilities in microfinance in Bangladesh, Ecuador, India, Nigeria, Paraguay, and Uganda, and I hope we can expand this initiative to include persons with mental health issues.

However, achieving the progress needed to financially include people with physical disabilities is not the same as that of including people with mental health issues. Persons with psychosocial disabilities in Africa and in many other places in the world are, in the words of Nigerian healthcare advocate Ifesinanchi Sam-Emurwa, “doubly stigmatized” for having a disability and for that disability being a mental one.

And, to paraphrase remarks by Columbia University psychiatrist Dr. Evaristo Akerele, who spoke this past June at the only mental health session on psychosocial disabilities at the U.N. Conference of State Parties annual disability conference: The person with mental health issues is blamed for bringing what psychiatrists call depression, or anxiety, on themselves. Beliefs such as that God is upset with them, that drug use is to blame, that witchcraft is at work, are all common. In most places, the term “depression” is not culturally acceptable or even understood; there is not an accepted and shared nomenclature for describing mental suffering.

An interesting example of how this “double stigma” plays out also comes from Nigeria, in the financial services arena. The Central Bank of Nigeria recently earmarked US$20 million to financial service providers to make loans to persons with disabilities — a great step forward. But, it explicitly excluded persons with mental health disabilities as recipients of these loans.

So, what can be done to improve the situation? I want to suggest five of the biggest challenges we face and interventions that I believe we can undertake together to answer these challenges and improve the livelihood possibilities of persons with psychosocial disabilities. I hope this will form the beginning of an action plan.

Challenge 1: How can the staff of an MFI with no training in psychology even begin to identify clients with mental health issues if there are no common, agreed on terms of reference for describing distressed states of mind? How do we sensitize staff to work with this client segment?

It is relatively easy to determine a baseline of the numbers of persons with physical disabilities who are clients, by asking medically non-invasive questions (or just through observation) about their state of wellness. Unless a person with mental health issues self-discloses, it is impossible to know if they are suffering from a depressive, anxiety, or other disorder.

Intervention: Volunteers from the mental disability space, like attendees of these annual PCAF Conferences,can help financial service providers design survey questions that allow MFI staff to get a better count of current clients with mental health issues. These volunteers along with PTSD survivors themselves can help sensitize MFI staff on how to best reach out to persons with mental health disabilities. They can connect MFIs with community mental health leaders and, in particular, patient advocates. These learnings can then be incorporated into the Framework for Disability Inclusion so that a set of best practices can be developed and shared with MFIs from around the world.

Challenge 2: Access and support for basic capital and business training for persons with psychosocial disabilities is largely lacking.

Intervention: Connect PCAF graduates, and those of other mental health clinics that include business training, to microfinance providers, credit unions, self-help savings groups, and otherproviders offering group-based financial services as well as enterprise-building support to professionalize the business training and operations of the clinic patients. The natural intermediary to make first contact with the MFI or other provider might be the PCAF social worker, during their weekly or monthly follow up outreach to former PCAF patients in their villages, homes,and workplaces.

Just as CFI identified two or three institutions in India that were eager to do a pilot to include persons with disabilities in their programs, we can work to identify two or three MFIs in the PCAF countries of Cambodia, Kenya, Liberia, and Uganda who want to be leaders in including persons with psychosocial disabilities in credit and/or savings groups. Success is promising here since a portion of PCAF livelihood trainings are done in groups,suggesting that the transition to group lending methodologies could prove to be quite natural and comfortable.

Challenge 3: The United Nations (U.N.) does not do enough to recognize the importance of mental health disabilities — when it comes to collecting good statistics, when it comes to prioritizing it as a Sustainable Development Goal to reduce extreme poverty, when it comes to seeing therapeutic intervention as a significant part of the Constitution on the Rights of Persons with Disabilities treaty.

Intervention: Those working in this field and other interested parties should lobby the Washington Group on Disability Statistics (the U.N. body charged with disability statistics) to include a specific question on mental health in its so-called “short set” of questions that it provides to governments that do censuses and disability surveys. Similarly, while they’re still being shaped, pressure should be applied to modify the Sustainable Development Goals to include much stronger language on mental health.

Finally, there must be concerted lobbying by PCAF, and others, to ensure that in implementing the articles of the U.N. Convention on the Rights of Persons with Disabilities, the right to receive treatment for mental health ills gets equal billing with assuring the right to vote and enjoy equal protection before the law. If this does not happen, it will be much harder for mental health practitioners to obtain funding from governments and foundations to expand their community mental health programs — something critically important in countries like Burundi that have only one psychiatrist in the whole country!

Challenge 4: To create a new set of global standards and indicators for microfinance institutions and other financial service providers to follow that will establish the importance of and offer guidance on serving PTSD survivors and other persons with psychosocial disabilities.

Intervention: The CFI will work collaboratively to push the microfinance industry-wide standard-setters to add mental health indicators. With the help of key industry standard-setting groups, I believe that we can help to break down the attitudinal barriers that keep persons with psychosocial disabilities in extreme poverty unbanked and stigmatized. For example, I am delighted to announce that the Poverty Stoplight has offered to take the lead in creating a mental health indicator for its assessment tool. The Poverty Stoplight set of indicators, pioneered by Fundación Paraguaya and now used around the world, sees poverty as multidimensional and have developed a tool that allows the poor to measure their own poverty, broken down into different categories. Adding a mental health indicator could be a source of data that could be used not only by MFIs but by local community mental health leaders and other public health providers.

Freedom from Hunger in conjunction with the Microcredit Summit Campaign has just published a new guide called “Healthy, Wealthy, and Wise: How Microfinance Can Track the Health of Clients,” in which they share experiences in selecting and pilot-testing health indicators among four MFIs. The researchers asked questions around six health indicators: food security and nutrition, preventive health care, poverty, curative health care, sanitation and safe water, and attitudes. The results demonstrated the added value of health indicators when combined with poverty measurement in helping MFIs understand client well-being. Their “theory of change” is that with greater financial resources, the clients will be able to meet their essential needs as outlined above — like having cleaning water or improved nutrition. I have consulted with the guide’s author, Bobbi Gray, and she is very willing to work with us to see if we can help her develop a seventh indicator around mental health — which is great news.

My conclusion is that self-employment can offer dignity and hope to persons recovering from mental illness. And, that like persons with physical disabilities, many can make excellent clients. I think it is worth exploring how we can do more to connect to PTSD survivors with MFIs and other financial service providers to open their doors to PCAF clients and those of other clinics. At the very least, this initiative will help fight stigma and bring down attitudinal barriers. Let us see what works and what sticks. It is certainly worth a try.

Read the full text of Josh Goldstein’s keynote speech.


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The Microcredit Summits’ Commitment to Improving Lives

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With under 40 days to go, the 17th Microcredit Summit is rapidly approaching. CFI’s Josh Goldstein will be speaking during a plenary session focused on new innovations for microfinance and other financial inclusion…

2013 Partnerships against Poverty Summit Declaration

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From October 9 to 11 we held the Microcredit Summit in Manila on the theme “Partnerships against Poverty.” Delegates of the Summit drafted and approved the 2013 Partnerships against Poverty Summit Declaration, listing the principles that we will follow to insure that microfinance works as a worthy partner in the movement to end extreme poverty. This is the text of that powerful and inspiring Declaration.

We, the participants in the Partnerships against Poverty Summit, state collectively and enthusiastically, that:

EXTREME POVERTY CAN AND WILL BE ENDED BY THE YEAR 2030!

To reach this goal, we declare the following four commitments:

First, we commit to putting the poor first!

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