1. Integrating Microfinance and Health Benefits, Challenges and Reflections for Moving Forward Sheila Leatherman, Professor of Health Policy and Management Gillings School of Global Public Health, Univ. of North Carolina Freedom from Hunger Christopher Dunford, Marcia Metcalfe, Myka Reinsch, Megan Gash and Bobbi Gray

2. Remarks Why add health programs to microfinance What can be done to meet basic health needs How; a look at the evidence for “ what works” Summary; how can we move forward

3. Why Integrate Microfinance and Health ?  Opportunity to reach hundreds of millions globally 3500 MFIs - 190 million clients; incl. 43 mil. very poor families  Illness (w/cost) is barrier to progress out of poverty Evidence is strong and compelling  Microfinance – is a vast distribution channel for proven, simple, and low cost health interventions

4. How essential are health educ./services in helping very poor clients to move and stay above the $1.25 a day threshold? -Health spending can be a high portion of household annual income ; 22 percent in Bolivia and 67 percent in Burkina Faso* -Average of 17% of clients reported use of their business loan for health * -In W. Africa; clients spent up to 30% of income on malaria * -India; Annually 24% of all those receiving medical treatment fell below the poverty line because of high cost ( 20 million people) What can we learn from institutions that have been most successful in this area? * Freedom From Hunger data What can we learn from those institutions that have been most successful in this area?

5. WHAT must we do to improve health? Access Barrier; Financing Access Barrier; Appropriate health services and products Access Barrier; Good Information

6. Client Need or Barrier Examples of programs Information and knowledge  Health education  Health promotion and screening  Trained community volunteers Availability of effective Health products/ services  Direct delivery of clinical care  Health fairs /health camps  Linkages with/referrals to providers  Community pharmacies/dispensaries  Loans to health providers  Micro franchising health-businesses Financial ability to pay  Loans for medical care ( indiv./gp)  Health Savings ( indiv/gp)  Health microinsurance/prepaid care

7. Microfinance and Health What works ? What are best bets? 1.Global evidence review of literature 2. Case Studies; ex. BRAC, Pro Mujer 3. Microfinance and Health Protection (MAHP); Freedom From Hunger demonstration (Gates funded); 5 MFIs in India, Bolivia, Philippines, Benin and Burkina Faso

8. Microfinance-Health Integration What is being done? (89 MFIs, 2009) % of MFIs providing Health program Health education 79% Referrals 23% Direct health services delivery 22% Contracts w/health providers 20% Health micro- insurance 20% Health promotion events 16% 8

9. Evidence of Impact ; Health education combined with Microfinance Leatherman et al, WHO Bulletin, 2010 Reproductive Health Primary care for children Nutrition/Breastfeeding Diarrheal illness HIV Prevention Gender based Violence Sexually Transmit. Infections Malaria Tuberculosis

10. Interventions with Positive Benefit Leatherman et al, Health Policy and Planning, 2011 Health Knowledge Behavior change Use of health services Increase health system capacity Positive health outcome Health education X X X X Trained health workers X X X X x Linkages w/ providers X X X Loans to health providers X X X

11. Goal Where ? Intervention ?Result Improved access to health services BRAC/ Bangladesh + CRECER/Bolivia; health fairs Pro Mujer/Nicaragua primary health care In 2010 -reaching over 100 million with health services 24% receiving health service never had medical care before Increased pap smears for cervical cancer from 36% to 95% Ability to afford care Bandhan/India; health loans 33% would have delayed treatment without the loan 62% felt able to afford other necessities (food, education) Better health outcomes Ekjut/India; Participatory health education and planning 30 % reduction in newborn mortality > 50% in maternal depression

12. Integrating Microfinance and Health Benefits Multiple Stakeholders Benefits to the microfinance provider – Business benefits, ex. competitive advantage, retention of clients – Healthier and financially more stable clients – Achievement of social mission Benefits to Clients, households and communities – Financial protection – Better health access, knowledge and behaviors – Improved health status and productivity

13. Potential to contribute to health is clear The microfinance sector offers a unique opportunity to address critical health needs of the poor So how can we move forward? What are the barriers and how can they be addressed? How do we identify “ the best bets” among health programs? What mechanisms are needed for shared learning ? How can we speed the process of adoption and scale up?

14. THANK YOU

15. The End

16. Cost data; the question of sustainability MFI Program annual cost Per client MAHP Programs;Philippines; Gov’t insurance and PPP Burkina Faso; savings/loans Bolivia; health fairs India; health educ and products Cost to institution avg direct 0.29 $ avg indirect 1.59 $ Pro MujerHealth educ & clinical services Cost to client 29.00$ Health Education-INDIA KAS Foundation MCS Campaign ( 4 MFIs) Credit with health education ( CwE) Health education Cost to institution 1.20 $ ( first year only) 1.91 $

17. Ekjut (India): Participatory health education and action planning Randomized Control Trial (Population of 228,186, half assigned to treatment, half to control) ControlTreatment Change in NMR (per 1000 live births)+9.5% -32% Change in still births (per 1000 births)-9%-31% Change in early NMR (0–6 days)+12%-37% Change in late NMR (7-28 days)+2%-20% 17 Other key findings: NMR reduction not associated with increased care-seeking or health- service use. Home care practices showed significant improvement. Costs per newborn life saved = $910; Costs per DALY $33