HIV & AIDS and Microenterprise Development Working Group

microLINKS Speakers Corner Synthesis: Why Integrate Microfinance with Health Services?
Author

Kristen Eckert, The SEEP Network

note
November 2010

Table of Contents
3 Introduction 4 Health Education Services 6 Health Financing and Insurance 8 Ongoing Discussion to Lead Up to the November 2010 SEEP Annual Conference 8 Next Steps 9 Additional Resources

Introduction
AIDS is the leading cause of death worldwide for people aged 15-49. There are more than 33.2 million people living with hIV & AIDS, nearly 22.5 million of which live in sub-Saharan Africa. Approximately 6,000 people die every day from AIDS.1 In response to this ongoing global challenge, The SEEP Network began a cross-sectoral initiative to bring together microenterprise development and public health professionals to confront and combat the challenge of poverty in the context of hIV & AIDS. one product of this initiative is the SEEP Network Guidelines for Microenterprise Development in HIV & AIDS-Impacted Communities: Supporting Economic Security and Health. The SEEP Guidelines, designed for health professionals, microenterprise development practitioners, and policy makers, offer strategic guidance for simulating a positive spiral of economic security and well-being for people and communities affected by hIV & AIDS. From october 5 to october 6, 2010, the SEEP Network hIV & AIDS and Microenterprise Development (hAMED) Working Group participated in the Microlink Speakers Corner Why Integrate Microfinance with Health Services? hosted by the uSAID Microenterprise Development officer and facilitated by Marcia Metcalfe and Bobbi Gray of Freedom From hunger, a hAMED member organization, and Anna Awimbo, Dr. DSK rao, and Pepper Whaling of Microcredit Summit Campaign. The discussion explored the benefits and challenges for both clients and institutions of integrating health services with microfinance projects with a focus on the scalability, cost-benefit analysis, and sustainability of integration. Key discussion topics included: • health Education Services • health Financing and Insurance • Linkages/Access to health Care Providers and health Products The Speakers Corner dialogue can be found on the Microlinks website: http://microlinks.kdid.org/ groups/speakers-corner/speakers-corner-40-whyintegrate-microfinance-health-services. For more information on upcoming uSAID Speakers Corner events, visit microlinks.kdid.org. hAMED looks forward to continuing this discussion and future related activities on the new Ning web platform: http://seepcommunity.com/group/ hivaidsandmicroenterprisedevelopment.

1

Source: uNAIDS, November 27, 2007.
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Health Education Services Why Integrate Education Services? Freedom From Hunger
Microfinance and Health Protection Initiative found statistically significant behavioral changes in clients receiving health education through MFIs. These clients benefited from increased knowledge from education targeted at infant feeding and treatment of child diarrhea (India), malaria and hIV & AIDS prevention (Benin), and health financial planning (Philippines and Bolivia). Unified model of Credit with Education, delivering dialogue-based education on preventing and managing one or more of the following: malaria, dengue fever, childhood illnesses, and hIV & AIDS to MFI clients during credit meetings • (PADME in Bénin, CrECEr in Bolivia, rCPB in Burkina Faso, CArD in Philippines, Star Microfin Service Society, Pioneer trad and People’s Multipurpose Development in South India, Cashpor in North India, Democratic republic of Congo Training on health financing and utilizing health services • Bolivia, Burkina Faso, India, and Philippines

Small Enterprise Foundation with the rural
AIDS and Development Action research (rADAr) Program at the School of Public health, university of the Witwatersrand found their hIV prevention program led to a 60% increase in client testing , 20% reduction in unprotected sex, and a 50% decrease in intimate partner violence.

Star Microfin Service Society (SMSS) India
Star Microfin Service Society (SMSS) is a sustainable MFI operating in two districts of Andhra Pradesh, South India and serving 35,000 clients, most of whom are very poor. In 2007, SMSS implemented a pilot project on integration of health education with microfinance, with technical support from Freedom From hunger (FFh) and Microcredit Summit Campaign (MCS). Forty field workers facilitated lessons to more than 6,000 clients on hIV & AIDS Prevention and Management, Integrated Management of Childhood Illnesses, and Women’s health. Evaluation studies by external evaluators have shown significant improvement in the knowledge levels of clients on these health topics.

Credit with Education Program of CARD MRI – Philippines
In 2000, CArD partnered with FFh on integrating health and business education with their microfinance operation with a pilot program in Quezon. The pilot delivered three health modules on breastfeeding, infant and child feeding, and women’s health to 1,000 clients. Clients and field staff were first apprehensive to increase their weekly meetings, but after seeing the health benefits and decreasing the lessons from 30-minutes to 15-minutes , they were more enthusiastic. The program has since expanded to include modules on Ah1N, Dengue, and Leptospirosis prevention. With ongoing FFh support, CArD next introduced the Microfinance and health Protection Program (MAhP) to offer loans for medical assistance/care to clients and their families. By securing good partner network with health care providers in the communities where their microfinance program is operating, CArD secured consultation discounts and established clinics in places with limited health care. See Health Financing and Insurance.

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health education is now mainstreamed into SMSS microfinance operations. More than 50 field workers are now trained to facilitate health lessons, which now include Infant and Child Feeding, healthy habits, and Malaria. More than 8,000 clients are being covered. health loans are also provided.

Sinapi Aba Trust (SAT) - Ghana
Sinapi Aba trust (SAt) formed an alliance with Planned Parenthood Association of Ghana (PPAG) with the goal of improving the well-being of SAt clients through quality health services related to hIV & AIDS, together with microfinance services. Specific objectives of the partnership included: intensifying education and awareness efforts for SAt clients; offering voluntary counseling and testing for hIV & AIDS; educating clients on stigmatization and discrimination against people living with hIV & AIDS; providing care and support for hIV & AIDS-affected people; and playing a leading role in advocacy to support people living with hIV & AIDS. Partnership activities: a three-day capacity-building workshop on hIV education and prevention for clients of both partners; voluntary counseling and testing in four SAt branches; ongoing support for infected persons, referrals to clinics for treatment; and creation of a support group for hIV-positive clients. Some 564 clients at four program locations participated in the workshop; 150 clients participated in voluntary hIV testing; and fifteen people were registered for follow-up support and care, such as counseling, transportation allowance, and nutritional support. Challenges 1. Providing one set of services leads to the provision of other services. Awareness raising and testing services often lead to the need for other services. For example, when SAt and PPAG learned that some clients tested positive for hIV, they wanted to offer medication and support services. Thus, a partnership formed with a limited scope may find itself wanting to offer or make linkages to further services. Sinapi Aba and PPAG have worked

together to ensure that follow-up services such as health referrals and support groups are available, but these options will not always be possible. 2. one-off programming and funding limits opportunities for expansion. Although the partnership has been successful and Sinapi Aba would like to continue to offer hIV & AIDS prevention training, its efforts to reach more communities are constrained by inadequate funding. Lessons learned 1. Participatory planning leads to stronger results. The SAt-PPAG alliance ran smoothly because both partners were actively involved from the outset of the program. The two organizations held consultations, roundtable discussions, and gathered input from the other partner when drafting and finalizing the memorandum of understanding (Mou) and the work plans of the partnership. 2. Anonymity concerns related to hIV are more easily addressed with a partner organization. Guaranteed privacy meant that MFI clients were willing to come forward for testing and treatment. If SAt had offered the training itself, it is unlikely that clients would have been willing to be tested, for fear that a positive result might result in them being turned away for future loans.

Microcredit Summit and UCLA Cost-benefit Analysis of Integrating Health Education
Issue: Cost-benefit analysis is needed to provide success indicators to support the delicate balance between outreach to the most under-served populations and funding interests. Recurrent theme against integrated services: Where is the quantifiable proof that integrations provide benefit to the clients, the MFIs, and the health organization? Cost for integrating health education: uS$1.59 per client Integration Challenges: • Varying perceptions over how integration fits into an organization’s sustainability scheme • requires operational changes that can decrease

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field productivity, demand greater client commitment, and increase expenses. • Difficult to measure the long-term benefit integrated activities generate without costly long-term controlled studies. Key Lesson: time and data are needed to provide a strong and convincing cost benefit analysis of integrated services.

Key Issues and Topics to Address over the Cost-Benefit Analysis of Integrating Services
• Evaluation of the initial investments, ongoing costs, long-term sustainability by MFIs • Donor strategies and funding to cover initial investments. • how to make the initial contacts between MFIs and health sector? -Educate and assist programs in the health sector to link to MFIs -Provide training on income generating activities and the development of financial products for health sector • Source of “roadblocks to integration: funding, linkages, and/or incentives to integrate

Health Financing and Insurance Health Financing and Insurance Programs Available
• Individual health loans for major medical expenses (Bolivia, Burkina Faso, India) • Collective health loans for primary/diagnostic services (Bolivia) • health savings accounts (Burkina Faso) • Community-health solidarity funds for small-scale village health projects (Burkina Faso) • Partner-agent health microinsurance with government health program (Philippines) • Loans to make health insurance premiums more affordable, reliable (Philippines, Kenya) • Exploration of prepaid health program (Benin, Burkina Faso, Philippines) & AIDS that were left out by MFIs as they were considered the “non-entrepreneurial poor”. These families were questioned on their level of happiness/ contentment. Most said that they were less than 25% happy as they had lost everything including their homes and children. When questioned on their ability to take loans, invest in small economic activities (SEAs) and pay them back in a month’s time, most cried, saying that they were too traumatized to do any activity and were only waiting to die. however, there were a few who began asking questions. tidy worked to identify their talents and invest in SEAs to enable income through buying and selling fish and banana’s, keeping small tables, preparing and selling bean cakes etc. Guidance was provided to form groups and take initial loans of $10 each to be paid back on a weekly basis. After two months, most of the clients with hIV were earning more income than their families and were reunited with their children. After a few months, evaluation found that some clients used their loans for consumption rather than investment. tidy established a format to engage them

Tidy Center’s HIV & AIDS Financing in the Democratic Republic of Congo (DRC)
In 2003, tidy Center established Advisory Centres for Better Living (ACBL) to provide a package of services) including access to microfinance services to recover and reintegrate families affected by hIV

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to invest loans in SEAs and demonstrate tangibly their enhanced living conditions before receiving their second loans. The hIV-positive group who were not willing to take loans observed the progress being made by those who received the services from the ACBL centers and joined the program in the third month. Around 500 hIV clients recovered and reintegrated with their families. There were some who improved their health and also some who became trainers to carry on the message. The registration fee of $1, was paid by everyone that requested any form of service from the ACBL centers. The $1 covered the first interview to identify talents/ strengths and the costs for orientation towards the most appropriate and feasible SEA (based on market surveys and the talents/strengths/likes of the client/ hIV-positive person). The $1 also covered most of the small business management, new technologies and marketing training as it was carried out within the ACBL. however, those who requested longer term training, such as sewing and motor mechanics were covered by the project, and were limited to the duration of the project. The loans were provided at an interest rate of 1% per week, and the loans were paid back in four to eight weeks. The salaries of the staff of

the ACBL centers were paid from the interest earned and from the registration fees. The total number of families reached by the program was around 5,000. In addition to the “Pre-engagement for impact-goals” format, tidy also developed a matrix to measure the enhancement/change of assets and livelihood security to monitor their transcendence of becoming ’not poor’ by ranking them at the start as either: a) Very Poor (VP), b) Not So Poor (NSP), or c) Non Poor (NP). The format for the DrC was based on one developed in Cote d’Ivoire and was published by the Microcredit Summit in 1999 and updated in June 2000. The results of the impact measurement in Cote d’Ivoire revealed that access to small loans to develop SEAs was able to enhance assets by 500%. It is now recommended that facilitation sessions be carried out to establish Committees for Better Living (CBL) with emerging leaders in any area where there is lack of access to resources for enhancing livelihoods (including access to health services), before establishing centers, as some areas may need Value Chain Associations and Producer organizations, some ACBL centers and others Production and Service centers.

Kenyan HealthStore Model
Providing the Poorest of the Poor with Better Access to medication, vaccinations and primary and secondary care healthStore trains microfinance clients to become franchise owners. Depending on their training and government regulations, they go on to open a pharmacy or clinic. They are given a loan to establish the clinic and begin business. They sell medicine and provide health information to their community members. The loan is repaid to healthStore out of their profits. Competition with other local businesses is rare since the healthStore operates in remote, rural locations that lack these services. Government facilities, when available, often operate at reduced hours with low inventory. The greatest challenge is the training and retention of skilled health care workers in the clinics. Providing incentives to bring trained, urban staff to rural areas is at a cost to the MFI, and training locals is also costly.

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Linkages/Access to Health Care Providers and Health Products Linkages to health care providers
Bolivia: Mobile doctors providing health education, preventive and diagnostic services in rural areas and referrals to MFI-approved private and public providers for secondary care Philippines: Preferred-provider network offering discounted primary care to rural MFI clients India: Extension of tuberculosis screening and treatment in coordination with government program

Access to health products
India: Community-based sales of over-the-counter drugs and health products Benin: Links to local retailers of specific health products such as insecticide-treated nets, family planning products, oral rehydration salts, and safe water systems Philippines: Exploration of linkage to franchise distributors of affordable drugs

Continuing this Discussion at the November 2010 SEEP Annual Conference November 1-5, Sheraton National Hotel, Arlington, VA
Freedom From hunger will facilitate a discussion on integrating services during the hAMED Working Group Meeting on Monday, November 1, from 2:00 – 4:00pm at the Sheraton National hotel in Arlington, VA. Freedom From hunger and Microcredit Summit will be hosting a workshop during the SEEP Annual Conference entitled “Microfinance as a Platform for health Protection: Does It Cost too Much?” on Thursday, November 4, from 11:00am – 12:30pm at the Sheraton National hotel in Arlington, VA.

Related HAMED Activities
hAMED is also accepting proposals for a new Case Study Series: Climbing the Ladder to Integrated Programming. This innovative series introduces key hIV & AIDS and MED-integrated programs and tracks their progress and development as they aim to achieve sustainability and success in raising livelihood security in the communities served, thereby “climbing the ladder” from challenge paper to emerging initiative to promising practice to best practice. The proposed themes are: micro-insurance, savingsled approaches, food security, and the use of cash transfer/social protection interventions. Ideas for case studies can be submitted to hAMED’s lead facilitator Kristen Eckert at kristen_eckert131@yahoo.com.

Timeline of Next Steps
• hAMED request for Case Study Proposals through october 29 • Freedom From hunger facilitated discussion on integration with hAMED and The SEEP Network Poverty outreach Working Group at the SEEP Annual Conference. • Freedom From hunger and Microcredit Summit workshop on the cost of integrating microfinance and health protection during the SEEP Annual Conference (see above). • Integration dialogue to continue on new hAMED Ning Platform • The SEEP Guidelines to be updated and expanded in 2011 to address additional integration services in a collaborative, cross-sector integration tool kit.

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Additional Resources
The follow resources are available for download on the Microlinks BEtA site: http://microlinks.kdid.org/ groups/speakers-corner/speakers-corner-40-why-integrate-microfinance-health-services/recommended-res Web/Video Resources • Video Presentation: Johnson & Johnson Microcredit Presentation • report: Financing healthier Lives • Video: healthy Microfinance: Innovations in health and Microfinance Services Resource Documents & Presentations Microfinance and health Protection (MAhP) overview [English] The Business Case for Adding health Protection to Microfinance health & Microfinance: Leveraging the Strengths of two Sectors to Alleviate Poverty Microcredit Summit Campaign Consulting report SEEP hIV/AIDS & Microenterprise Development (hAMED) Workgroup Brochure Linking Microfinance and health Working Paper Market research for Microfinance and health Protection: A technical Guide for MFIs health Loans: A technical Guide health Savings: A technical Note Developing Linkages with health Providers: A technical Guide for MFIs Sheila Leatherman and Christopher Dunford. Linking health of Microfinance to reduce Poverty. Bulletin of the World health organization, 2010; 88:470-471. Freedom from Hunger Powerpoint Presentation Microfinance and health Protection (MAhP): Summary of Findings and Lessons Learned The following resources are available for download on the hAMED Scribd platform: http://www.scribd.com/ Seephamed • The SEEP Network Guidelines for Microenterprise Development in hIV & AIDS-Impacted Communities • hAMED Promising Practices Case Study: Intervention with Microfinance for AIDS and Gender Equity (IMAGE) – South Africa • hAMED Promising Practices Case Study: Kibara Mission hospital hIV Project – tanzania • hAMED Challenge Paper: Improving Access to Formal Microfinance Institutions for hIV & AIDS Affected Vulnerable households in Kenya • hAMED Partnership Planning Conference Synthesis

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