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Health, Microfinance and Microenterprise Development (HAMED) Working Group Annual Meeting Review 2011

Sulava Gautam-Adhikary Bobbi Gray, Freedom from Hunger Ann Gordon, MEDA

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Going Beyond Single Solutions Single solutions have inadequate power to combat poverty.1 In recent years, there has been a growing acknowledgement that solutions such as microfinance alone are insufficient for pulling households out of poverty and that the poor need multiple interventions to better meet their needs. The Health, Microfinance and Microenterprise Development (HAMED) working group of the SEEP Network formed as a means to address the issues, challenges, and successes arising from integrating economic strengthening activities, such as microfinance and microenterprise development, with health. The goal of HAMED is to connect microfinance and microenterprise development practitioners with public health professionals and policy makers in order to document, demonstrate, and disseminate a growing body of best practices regarding the integration of health with economic strengthening (ES)2 programs. Prior to 2011, HAMED members built a body of knowledge that looked at best practices among practitioners who served HIV/AIDS-impacted communities with economic strengthening activities. Toward the end of 2010, HAMED members and members of the Poverty Outreach Working Group (POWG) at SEEP met to discuss the opportunities regarding integrated services for the poor and in particular, the ultra-poor. From this discussion HAMED decided to expand its mandate, go beyond its HIV/AIDS focus, and look at the integration of all health approaches with ES programs. This brief aims to summarize the HAMED learning products developed during the 2011 calendar year as a means to set the stage for documenting what we know to date and to identify the gaps in our knowledge and experience with integrated services. Building a Body of Knowledge and Experience In 2011, HAMED had three main objectives: 1. To develop a catalog of organizations providing health integrated services. One of the HAMED member-organizationsFreedom from Hungerhad already begun to build a catalog of organizations providing health and microfinance integration and HAMED members added to this database. However, very little evidence was available for health and microenterprise development and a specific effort was made to identify organizations providing these integrated services. 2. To begin building a body of knowledge of organizations providing health and ES services. To this end, three case studies were developed: 1) Trickle Up-India, 2) Living Goods/BRAC, and 3) The Livelihoods and Food Security Technical Assistance (LIFT) program of FHI 360 and Save the Children.
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Sachs, Jeffery. 2005. The End of Poverty. New York: Penguin Press. 2005. From this point on, we will use the term economic strengthening (ES) as the term that encompasses both microfinance and microenterprise development. We will use the individual terms of microfinance and microenterprise development only when there is an important distinction between these two strategies. Microfinance (MF) encompasses all financial services, such as loans, savings, microinsurance, etc. Microenterprise development (MED) encompasses strategies aimed to develop micro-enterprises of the poor and support value chain development and market facilitation. While these two strategies are in support of improving the economic security of poor households, practitioners of these approaches often provide one or the other and thus, the distinction between the two often becomes necessary.

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3. To build HAMED membership and represent HAMED-member work at an international conference. This document provides a summary of the findings from the catalog activity, the case studies, and captures the key lessons learned thus far. The first section of this document briefly outlines what we know from the organizations documented in the catalog; the second section summarizes the cases studies while the final section details the discussion between the working group and conference participants on the case studies and individual organization experiences as a whole. This discussion also identifies specific topics for the HAMED working group to concentrate on and develop in the coming year. Section 1: What do we know about organizations providing health and ES integration? Almost 100 Microfinance Organizations Providing Health Protection Services As of November 2011, ninety-five microfinance organizations had been identified as providing health services. Almost half of those identified were located in Asia and almost a quarter each in Africa and Latin America (Table 1). Table 1: Geographic Distribution of Microfinance Organizations Providing Health Protection Services Asia Latin America Africa Caribbean MENA European Union /Former Soviet Republics 43.16% 27.37% 23.16% 3.16% 2.11% 1.05%

Fifteen different health services were being provided across these ninety-five organizations (Table 2); the majority of organizations were providing health education and provision for linkages to health services.

Table 2: Health Protection Services Provided by MFIs

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Group Health Education Direct Delivery of Health Services Micro Insurance Referrals to Health Care Facilities Contracts with Individual Public/Private Providers Health Promotion Events (linked to insurance or health services) Others - Access to Affordable Medicines Health Loans at Level of Individual or Household Individual Education/Counseling Mobile Services for Remote Locations Others - support for community water & sanitation MF/MED products for HIV/AIDS affected populations Community Pharmacies or Dispensaries Microenterprise in Health Products Health Vouchers Health Savings Trained Community Health Workers Other - Access to Health Products

86% 33% 27% 26% 20% 13% 11% 11% 9% 8% 7% 7% 6% 6% 5% 5% 4% 2%

There is a knowledge gap in shared experiences among MED and Health Integration By the end of 2011, more than fifty organizations were identified as providing MED and health integrated programs. Examples in this category include 1) providers working with ultra-poor programs where qualifying ultra-poor community members are coached on a new economic activity, such as raising chickens, and linked to health providers and/or health education; 2) social franchises for the poor that include eyeglass sales and health products sales (medicines, insecticide-treated mosquito nets, oral rehydration sales, etc.); 3) organizations working with vulnerable populations, such as HIV/AIDS-impacted communities or disabled persons, whereby
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clients or patients are either linked to ES services or provided these services directly. The three cases studies mentioned earlier were written to represent these three broad categories of providers. These three broad categories may not actually represent all MED and health integrated programs; however, they were quickly identified as being a common approach and therefore a good starting place for the HAMED working group members to begin building a body of knowledge. Section 2: Case Study Summaries Trickle Up-India Janet Heisey, Director of the Asia Program, Chris Prottas, Program Associate for Asia and Central America, and Nilanjan Chaudhuri and Abhishek, Program Associates, of Trickle Up developed a case study looking at the health component of their Ultra-Poor Program in India. Janet also presented the case study at the HAMED annual meeting on October 31, 2011. Summary: Trickle Up, a livelihoods development organization based in the United States, works with local partners in Jharkhand, Orissa and West Bengal, India, to provide services and meet the needs of the ultra-poor. They also have livelihood development programs in Mali, Burkina Faso and Guatemala. Trickle Up targets the ultra-poor--a segment of the population that is not typically reached by economic strengthening programs-- and identifies them as such by using participatory rural appraisal tools. Once identified as being ultra-poor, the women participants are connected to support systems including a livelihoods coach, a health worker, and a savings group consisting of ten to fifteen Trickle Up ultra-poor program participants. With the livelihood coachs assistance, the women plan and implement a series of livelihood activities over a three-year period. This program is implemented by local partner organizations which help identify the best market opportunities to support livelihood growth, prioritize health issues, and leverage a network of government contacts. With the objective of augmenting human capital and preventing depletion of productive resources and capital, Trickle Up works to address the challenges of poor health and lack of access to affordable health care services through a combination of education and frequent contact with the health worker who works to link the participant to local health care facilities and to support the client in seeking appropriate health services. The key to success of these interventions are the two assigned coaches, the field and health worker, who will work together to mentor the women participants throughout the process. They work in concert to bring about improved health, well-being, and greater economic stability of the participants. Results: Trickle Up found that while the Indian government provides access to a multi-tiered healthcare system and covers certain healthcare resources, access to those services by ultrapoor families is extremely low. Several barriers identified that prevent Trickle Ups participants from accessing such services include a lack of awareness and self-confidence and a sense of exclusion that inhibit participants from engaging public health resources.
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In terms of economic strengthening, Trickle Ups livelihood development and self-help groups were found to directly benefit participant health. Profits from livelihood activities and loans from the self-help groups were often the means participants had to invest in health care or better hygiene practices. Self-help groups also provided social capital that was critical to participants availing local public health resources and advocating for improved services. While the long-term effects of the programs have not yet be assessed, preliminary analysis of midterm results suggested that Trickle Up health workers have positively affected behaviors associated with health outcomes. The individual health benefits also included increased utilization of public health services, improvements in hygiene, and utilization of government programs. More generally, focus group participants claimed that the frequency of illness in their households has been reduced, which they attribute to preventative health behavior. Challenges: Trickle Ups health component depends directly on the quality of its health workers, who have generally been junior staff members. Given that low quality government health resources, including staff and medicine shortages, are a persistent problem, having junior staff trying to advocate for improvements for their ultra-poor clients has been challenging. While more highly-qualified staff may improve government health provision at the margin, the inconsistent quality of the public resources and the participant perception of exclusion and neglect by staff are realities. In addition, while a number of low-cost health behaviors can be adopted by the participant, participants cannot always follow all the practices such as buying medicine due to lack of money. Looking ahead: Trickle Up is using several new strategies to improve the program and conditions of the ultra-poor population. They include: Hiring health workers with higher academic qualifications, Exploring the possibility of expanding its awareness and education work to incorporate additional diseases prevalent among the ultra-poor, Continuing to advance health awareness and linking participants with the government health care systems in order to catalyze the adoption of positive health and hygiene behaviors and preventative measures. The Livelihoods and Food Security Technical Assistance Program (LIFT) Benjamin Rinehart, Technical Advisor, Food Security and Livelihoods, from FHI 360 collaborated with Gareth Evans, Senior Specialist, Lisa Parrott, and Marie Eve Hammink from Save the Children to develop a case study on LIFT, which is a technical assistance and support project for food security and livelihoods funded by USAID. The FHI 360 and Save the Children team conducted research and documented experiences from Ethiopia regarding the linkage of livelihood strengthening and clinical HIV services. Summary: The case study on LIFT aimed to identify promising practices in HIV/AIDS clinics linking patients to local ES services and to highlight challenges and impacts of the linkages. Save the Children US (SC), a core LIFT technical assistance partner, conducted a background review
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of available literature, identified through USAID, key informants and online research, and engaged in field level discussions with three of SCs programs in Ethiopia to analyze the state of ES referral systems in the context of HIV programs. ES linkages are fundamental to build a sustainable response for people living with HIV/AIDS (PLHIV) who have lost their employment or who have very limited assets to cope with the cost of ART treatment over the long term. ES is most effective if the livelihoods support is correctly matched to the household needs and delivered in a context of social support designed to avoid stigma. Promising practices are emerging around using a community-based or case manager approach to coordinate the referrals to and from livelihoods and ES service providers, but very few sustainable models are in place, particularly in terms of linkages with clinical services. Existing systems tend to be adhoc and lack feedback mechanisms to ensure effective service delivery. Even fewer examples of measurable ES results for PLHIV exist. Challenges: Some of the challenges in implementing effective ES referral systems include: Lack of a clear, coordinating focal point for managing referrals at the facility level. Healthcare and traditional HIV service providers have limited understanding of strategies to build the assets and resiliency of households affected by HIV. Health care providers have heavy workloads, limited time, and also limited knowledge/skills in identifying livelihood status of most vulnerable families. There are few tested and accepted tools to evaluate client livelihoods needs and abilities. Often clients who need ES are the most vulnerable segments of the population because they have already exhausted limited income earning opportunities, or lost employment. In addition, they may bear a large debt burden which requires repayment. Demand for ES services exceeds the available resources, especially in countries with limited public resources and constraints to job creation due to structural poverty. ES service providers for HIV affected households are often weak, lacking systems and capacity to provide appropriate interventions and track livelihoods improvements. Limited engagement of local government systems and private sector partnerships to deliver services. It is difficult to systematically determine when to offer ES referrals: some PLHIV are clinically weak and yet successful livelihoods attainment requires time for referral and starting of new activities. Historical approach of providing free services and small grants for economic strengthening has created a culture of expectancy amongst HIV-affected households. Looking ahead: What is needed is a more sustainable, long-term approach to help build the assets and cash flow of economically vulnerable households affected by HIV. Health care workers lack the expertise and resources to directly link families to ES service providers, but there are promising approaches using community coordinating mechanisms. These coordinating systems rely on an ability to do a rapid assessment to determine if PLHIV qualify for referrals and strengthening of the coordinating mechanisms. In addition, ES service providers need both incentives to reach this population with services, as well as improvements in service delivery and better systems and tools for tracking outcomes and impact.
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Living Goods/BRAC Uganda Edmond Baganizi, a physician and public health student from Johns Hopkins Bloomberg School of Public Health worked with Ann Gordon from MEDA to develop the case study on Living Goods, which is an organization based in Uganda that partnered with BRAC to develop a social franchising program that focused on delivering important health products and medicines in rural areas of Uganda. Summary: The purpose of the Living Goods/BRAC case study in Uganda was to increase understanding of the intersection between market development and health. Utilizing an Avonlike micro-franchise network, Living Goods/BRAC Uganda trained women community health promoters to educate mothers in their communities about health, how to go door-to-door selling low-cost, high-impact health products, and how to make referrals to clinics. The program strategically bypassed multiple retailing chains thus allowing Living Goods/BRAC to leverage the buying power of the community to provide affordable health services and products to the poor. With a combination of best practices in microfinance, franchising, and public health, Living Goods/BRAC not only ensured a decent second source of income for the women, but they also ensured the provision of affordable services and products such as vitamins, de-worming tablets, oral rehydration salts, mosquito nets, condoms and solar lanterns to poor Ugandan communities. The door-to-door delivery model which facilitates face-to-face individual health education saves customers on high transport costs for obtaining important health products. The program promotes ownership and women entrepreneurship through provision of basic business training for all agents, business exposure, on job coaching and provision of affordable financing. As of 2009, Living Goods/BRAC had successfully scaled up its model across Uganda in partnership with BRAC tripling from 200 to over 700 communities and established its directly managed branches. Additionally, successful testing of new products including fortified foods, generic malaria medications and solar lanterns were also conducted. The income earned by community health promoters has been sustained at $332USD on average per year. And in 2011, for the first time, three of the Living Goods directly-operated local branches achieved financial sustainability. An impact evaluation will be completed by the end of 2012. Challenges: While the model in addressing pertinent health problems and in improving the wealth of target communities by Living Goods/BRAC has registered laudable results, several challenges continue to persist. For example, the recruitment and retaining of talented local management has been problematic. There has also been an issue with balancing the competing objectives of health outcomes and financial sustainability. Thus, there is always a question of how to improve sales and profitability while maintaining the communitys health outcomes. When new products or ideas emerge, the program continues to struggle with testing these new ideas cheaply without disrupting the core business. The decision to bypass the multiple retail chain may also be a concern with respect to effectively engaging current value chain players and the consequences of circumventing theses current market actors in the private sector. Lastly, while working with multiple partners has provided strength and allows ease of scaling
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the impact, there are challenges associated with integrating each participating organizations approach and philosophy. Ensuring ample communication between all partners has also proven to be a difficult task. Looking ahead: There are four key lessons learned from the initial study: 1. The achievement of financial sustainability of the program provides a great example that the poor can and will pay for quality and convenience. 2. To make a program successful and sustainable, governments play a critical role. 3. Selecting and training talented community health promoters is a key success factor. 4. There is an advantage in maintaining a focus on opportunities with the greatest level of impact. Section 3: Discussion and Lessons Learned With the three case studies in mind, the 18 participants in the annual HAMED meeting deliberated on the case studies in greater detail by breaking into smaller groups and focusing on the similarities and differences among the case studies, common benefits and challenges, and the overall lessons learned. Participating organizations were invited to share their own organizational experiences, perspectives and questions in integrating health and ES activities. Similarities and Differences Upon reviewing the case studies, HAMED identified seven similarities between the programs. They included: The programs were designed to engage local organizations in order to reach target audiences. All programs integrated training services as a key tool for success. The programs demonstrated a final goal of increasing the livelihoods of the target populations. The case studies highlighted the importance of government engagement for ensuring sustainability of the program. For example, government services, such as public health services were an integral part of the approaches. The importance of incentive structures for all stakeholder involvement was a common thread among the three programs. The provision of affordable services (health or ES) was also an important component. From the case studies and experiences in the group, it was acknowledged that no single solution works for all populations, therefore a comprehensive approach is necessary to strategically increase livelihoods. There were three differences between the programs that were highlighted: The first difference dealt with the idea about community versus individual reinforcement. For example, in the Trickle Up program, women were placed in
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groups with other women from the community which created a niche for communities to come together and support one anothers livelihood. The Living Goods/BRAC program on the other hand, focused on a single community health promoter who worked to improve the livelihood of her family, ultimately improving the livelihood of the community. The group also determined that while Trickle Up and Living Goods/BRAC were aimed at providing direct services, the LIFT program was focused more on the provision of technical assistance to the various actors and stakeholders (for example, between the clinics and the ES providers in order to facilitate their working together). The final difference was the demographics of the target populations. While Trickle Up focused on the ultra-poor, the LIFT program targeted people living with HIV/AIDS. The Living Goods/BRAC program however, did not specify a target population except with the end-goal of increasing poor womens access to sustainable business models that would initially function as a secondary income generating activity and eventually a single, profitable business.

Common Benefits and Challenges HAMED also assessed and discussed the common benefits and challenges among the case studies: A vital benefit to the success of all three programs was the strong commitment to increasing livelihoods which was demonstrated at all levels. Both sectors, economic strengthening and health, mutually benefited from the integration. The varied and often low capacity of local providers at all levels was identified as a common thread. This includes the health workers as well as the local ESproviders. Another common challenge was how to effectively market the services for the end market to encourage take-up and use of the products and services being provided by the health and ES providers. Education, considered generally, is important for both creating demand for the services as well as appropriate and effective use of those services. Financial sustainability is important, either through the generation of direct income or cross-subsidization of funds, for the long-term provision of the program. The group raised the question of whether it was important to consider profitability when implementing these programs and considered this an important area for further reflection. A key challenge is the fact that government initiatives, while positive, can often skew the market. Government services may not be uniform and may trump any effort to develop long-term markets for certain products and services, such as the sale of insecticide-treated mosquito nets and other health products and services.

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The use of coaches, whether they be health workers, credit officers, or livelihoods coaches, was a demonstrated need and benefit of the success of these programs. The LIFT case study demonstrated how a communityorganizer that focused on linking HIV-impacted patients and clients to local ES programs was necessary to ensure that referrals were made meaningful ES services; Trickle Up highlighted the combination of the health workers and livelihoods coach as the mechanism for ensuring comprehensive needs of the client was addressed. When health services are combined with microfinance, the credit officer often plays the role of ensuring clients are receiving and using both financial and health protection services. However, coaching also brings challenges and raises the question of whether this approach is sustainable for the long term for some programs. Freedom from Hunger shared the conceptual framework for considering the trade-offs between programs that have a unified model of delivery (one person within the same organization provides both services, for example, a credit officer providing financial services and health education to credit and savings groups), a parallel model (two people within the same organization provide different services, for example the health worker and the livelihoods coach at Trickle Up), and a linked model (two different organizations provide services to the same person with the intent of these services being integrated for the client, for example, the HIV clinics linking their clients to local ES services). Finally, a challenge which must be addressed across all programs is that groups which graduate from entry and basic services will eventually need business skills to continue the improvement of their livelihoods.

Key Lessons Learned and Gaps Some general lessons learned and gaps in industry knowledge were identified by the HAMED group: The case studies clearly demonstrated that the health sector can itself be a source of income, as is the case for Living Goods, and provide a livelihood for poor populations. It would be good to explore the models that integrate social or health insurance into ES programs. A gap which must be addressed is the models of health product retailing. Living Goods as an organization is a strong example of how health products can be made available for low cost to rural communities that lack access to these products; however, sustainable health product availability and affordability is a common problem in many countries and how can this model be expanded among ES providers? This is an area which warrants further research and review. Scaling programs was identified as another challenge and there is interest in exploring the cost differentials of doing similar programs in other parts of the world. Another business-in-a-box which requires further review is the possible application of
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veterinary care models to human care. Successful veterinary models from Uganda and Kenya were cited as places to initially start this research. Another key gap is the lack of evidence and proof of practice regarding the intersection of health and microenterprise development. The group determined that meeting once a year to discuss the successes and benefits of such programs is not sufficient, but rather meetings should occur multiple times to continue the conversation and engagement.

Looking Ahead for HAMED Based on the above discussion, the working group determined six key areas of focus for HAMEDs learning agenda in 2012. The focus areas are as follows: 1. The creation of incentive structures is important and coupled with that, the impact of such structures must also be addressed. Incentive structures are vital for all stakeholders involved in a livelihood program. At the local level, incentives are critical to engage and attract talented field, health, and/or community workers to provide services, products, information, or referrals. The community must also have an incentive to engage in these livelihood activities. Local and national governments must also have an incentive to offer both political and financial support and resources. 2. The working group decided that the issues of coaching required further review by HAMED. While this is the best practice for the provision of services, encouraging products and sales, as well as providing diagnostics, if a the selected coach does not have experience in a particular livelihood, be it health or economic strengthening, how valuable is the coach? How much knowledge and experience is necessary for coaching to be effective yet scalable? Can clients eventually become coaches? Are there models or examples of this? 3. Another key focus area is how programs demonstrate going to scale from a pilot program. 4. The working group also determined that HAMED should conduct more research on the idea of integrating health insurance into saving groups, microfinance institutions, and other ES activities. 5. While the initial discussion on differences between the case studies had focused on the variation in the groups targeted (for example, the ultra-poor in Trickle-Ups case study and the HIV-impacted in LIFT), the working group determined that there may be value in observing similarities in specific vulnerable populations across regions to define the lessons learned across these solutions. For example, explore the lessons of working with the ultra-poor, HIV-impacted communities, disabled populations---which all may be reason for their ultra-poor status and the cause of their vulnerabilities, but services to these populations are often designed with a particular strategy in mind but may face similar challenges or operate under similar program designs. 6. Finally, the group discussed keen interest in actively engaging public health actors in the HAMED working group to continue to identify common challenges, benefits, and
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effective strategies to working between the two sectors of health and economic strengthening.

Acknowledgements The HAMED facilitators, Bobbi Gray of Freedom from Hunger and Ann Gordon of MEDA, would specifically like to thank the active engagement of Janet Heisey of Trickle Up, Gareth Evans of Save the Children, Benjamin Rinehart of FHI 360, Edmond Baganizi, and Sulava Gautam-Adhikary for their active support and engagement in the HAMED working group this past year. In addition, wed like to thank Lisa Parrott and Marie Eve Hammink for their support and development of the LIFT case study; Chris Prottas, Nilanjan Chaudhuri and Abhishek for their support on the Trickle Up Case study; and the Living Goods staff membersChuck Slaughter and Chris Murphywho made themselves available for interviews to assist in the development of the Living Goods case study. We would also like to the HAMED member-organizations that contributed to the discussion highlighted in this paper: the SEEP network staff, Freedom from Hunger, Trickle Up, FHI 360, Save the Children, ProDesarollo, Mercy Corps Indonesia, Cardno Emerging Markets, AMPATH, Pakistan Microfinance Network, ACCESS, and Sa-Dhan.

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