Integrating prevention of acute respiratory infections with micro-credit programme: experience of BRAC, Bangladesh

Effect of health intervention integration within women's self-help groups on collectivization and healthy practices around reproductive, maternal, neonatal and child health in rural India

BACKGROUND

This study evaluates an eight-session behavior change health intervention with women's self-help groups (SHGs) aimed to promote healthy maternal and newborn practices among the more socially and economically marginalized groups.

METHODS

Using a pre-post quasi-experimental design, a total of 545 SHGs were divided into two groups: a control group, which received the usual microcredit intervention; and an intervention group, which received additional participatory training around maternal, neonatal, and child health issues. Women members of SHGs who had a live birth in the 12 months preceding the survey were surveyed on demographics, practices around maternal, neonatal and child health (MNCH), and collectivization. Outcome effects were assessed using difference-in-difference (DID) methods.

RESULTS

Women from the SHGs with health intervention, relative to controls over time (time 1 to time 2), were more likely to: use contraceptive methods (DID: 9 percentage points [pp], p<0.001), have institutional delivery (DID: 9pp, p<0.05), practice skin-to-skin care (DID: 17pp, p<0.05), delay bathing for 3 or more days (DID: 19pp, p<0.001), initiate timely breastfeeding (DID: 21pp, p<0.001), exclusively breastfeed the child (DID: 27pp, p<0.001), and provide age-appropriate immunization (DID: 9pp, p<0.001). Additionally, women from the SHGs with health intervention when compared to the control group over time were more likely to report: collective efficacy (DID: 17pp, p<0.001), support through accompanying SHG members for antenatal care (DID: 8pp, p<0.05), receive a visit from SHG member within 2 days post-delivery (DID: 32pp, p<0.001), and receive reproductive, maternal, neonatal and child health information from an SHG member (DID: 45pp, p<0.001).

CONCLUSION

Findings demonstrate that structured participatory communication on MNCH with women's groups improve positive health practices. In addition, SHGs can reach a substantial proportion of women while providing an avenue for pregnant women and young mothers to be assisted by others in learning and practicing healthy behaviors, thus building social cohesion on health.

Determinants of childhood morbidity in Bangladesh: evidence from the Demographic and Health Survey 2011

OBJECTIVES

The present study aims to estimate the incidence of preventable infectious diseases or associated symptoms among young children in Bangladesh and also determine the factors affecting these conditions. The study hypothesised that various background characteristics of children as well as their parents influence the incidence of morbidity of children aged below 5 years.

SETTING

The study used data from the most recent nationally representative cross-sectional Bangladesh Demographic and Health Survey (BDHS) conducted in 2011.

PARTICIPANTS

A total of 7550 children aged below 5 years during the survey from mothers aged between 12 and 49 years are the participants of the study.

RESULTS

In general, younger children were more likely to suffer from multiple health conditions than their older counterparts. Children belonging to households classified as poor (OR=1.425, 95% CI (1.130 to 1.796)) or middle (OR=1.349, 95% CI (1.113 to 1.636)) faced greater risk of illness than those from well-off households. A combination of source and treatment practices of drinking water showed a significant impact on incidence of childhood morbidity. Children from households using untreated non-piped water were 85.8% (OR=1.860, 95% CI (1.269 to 2.728)) more likely to suffer from comorbidity than those who treat their piped drinking water. However, we observed that water treatment alone has no impact unless the water itself was sourced from a pipe.

CONCLUSIONS

Accelerated programmes promoting access to safe drinking water along with water treatment practices, and better household environment may prove effective in reducing the incidence of childhood morbidity in Bangladesh.

Where do the poorest go to seek outpatient care in Bangladesh: hospitals run by government or microfinance institutions?

Introduction

Health programs implemented by microfinance institutions (MFIs) aim to benefit the poor, but whether these services reach the poorest remains uncertain. This study intended to investigate the socioeconomic distribution of patients in hospitals operated by microfinance institutions (i.e. MFI hospitals) in Bangladesh and compare the differences with public hospitals to determine if the programs were consistent with their pro-poor mandate.

Methods

In this cross-sectional study, we used the convenience sampling method to conduct an interviewer-assisted questionnaire survey among 347 female outpatients, with 170 in public hospitals and 177 in MFI hospitals. Independent variables were patient characteristics categorized into predisposing factors (age, education, marital status, family size), enabling factors (microcredit membership, household income) and need factors (self-rated health, perceived needs for care). We employed Generalized Estimating Equations (GEE) to evaluate how these factors contributed to MFI hospital use.

Results

Use of MFI hospitals was associated with microcredit membership over 5 years (OR=2.9, p<.01), moderately poor household (OR=4.09, p<.001), non-poor household (OR=7.34, p<.01) and need for preventive care (OR=3.4, p<.01), compared with public hospitals. Combining membership and income, we found microcredit members had a higher tendency towards utilization but membership effect pertained to the non- and moderately-poor. Compared with the group who were non-members and the poorest, microcredit members who were non-poor had the highest likelihood (OR=7.46, p<.001) to visit MFI hospitals, followed by members with moderate income (OR=6.91, p<.001) and then non-members in non-poor households (OR=4.48, p<.01). Those who were members but the poorest had a negative association (OR=0.42), though not significant. Despite a higher utilization of preventive services in MFI hospitals, expenditure there was significantly higher.

Conclusion

Inequity was more pronounced in MFI hospitals than public ones. MFI hospitals appeared to miss their target population. We suggest that MFIs reorganize health programs toward primary health care to make care equitable and universally accessible. This study holds practical implications for governments, development agencies and microfinance practitioners working at the grassroots level.

Overcoming access barriers to health services through membership-based microfinance organizations: a review of evidence from South Asia

It is a challenge for the poor to overcome the barriers to accessing health services. Membership-based microfinance with associated health programmes can improve health outcomes for the poor. This study reviewed the evidence published between 1993 and 2013 on the role of membership-based microfinance with associated health programmes in improving health outcomes for the poor in South Asia. A total of 661 papers were identified and 26 selected for inclusion, based on the relevance and rigour of the research methods. Of these 26, five were evidence reviews. Of the remaining 21 papers, 12 were from India, seven from Bangladesh, and one each from Sri Lanka and Indonesia. Three papers addressed more than one theme. Five key themes emerged from the review: (i) the impact of microfinance programmes on the social and economic situation of the poor; (ii) the impact of microfinance programmes on community health; (iii) the impact of integrated microfinance health programmes on raising client awareness; (iv) the impact of integrated microfinance health programmes on financing health care; and (v) the impact of integrated microfinance health programmes on affordable health-care products and services. The review provides new evidence on the pathways through which microfinance helps to improve population health and value for money for such programmes. Among countries with large populations in the informal sector, there is a strong case for policy-makers to support these groups in providing access to life-saving health care among the poor.

The effect of Self-Help Groups on access to maternal health services: evidence from rural India

Introduction

The main challenge for achieving universal health coverage in India is ensuring effective coverage of poor and vulnerable communities in the face of high levels of income and gender inequity in access to health care. Drawing on the social capital generated through women’s participation in community organizations like SHGs can influence health outcomes. To date, evidence about the impact of SHGs on health outcomes has been derived from pilot-level interventions, some using randomised controlled trials and other rigorous methods. While the evidence from these studies is convincing, our study is the first to analyse the impact of SHGs at national level.

Methods

We analyzed the entire dataset from the third national District Level Household Survey from 601 districts in India to assess the impact of the presence of SHGs on maternal health service uptake. The primary predictor variable was presence of a SHG in the village. The outcome variables were: institutional delivery; feeding new-borns colostrum; knowledge about family planning methods; and ever used family planning. We controlled for respondent education, wealth, heard or seen health messages, availability of health facilities and the existence of a village health and sanitation committee.

Results

Stepwise logistic regression shows respondents from villages with a SHG were 19 per cent (OR: 1.19, CI: 1.13-1.24) more likely to have delivered in an institution, 8 per cent (OR: 1.08, CI: 1.05-1.14) more likely to have fed newborns colostrum, have knowledge (OR: 1.48, CI 1.39 – 1.57) and utilized (OR: 1.19, CI 1.11 – 1.27) family planning products and services. These results are significant after controlling for individual and village-level heterogeneities and are consistent with existing literature that the social capital generated through women’s participation in SHGs influences health outcome.

Conclusion

The study concludes that the presence of SHGs in a village is associated with higher knowledge of family planning and maternal health service uptake in rural India. To achieve the goal of improving public health nationally, there is a need to understand more fully the benefits of systematic collaboration between the public health community and these grassroots organizations.

Microfinance investments in quality at private clinics in Uganda: a case-control study

Background

Small private-sector health care providers can play an important role in meeting the developing country health care needs, but a lack of credit can prove major constraint to small-provider expansion. This study examines the potential of small, microfinance loans to strengthen the private health sector and improve access to quality preventive and curative health services in Uganda.

Methods

This study estimates logistic regressions using 2,387 client exit interviews to assess the impact of microfinance loans on perceived quality and the viability and sustainability of small, private clinics.

Results

The study finds perceived quality improved with loan recipients' clients being more likely to choose clinics on the basis of drug availability, fair charges, cleanliness, and confidentiality. In addition, the assessment found evidence of increased client flows, but the changes produced mixed results for sustainability with respondents being only half as likely to "always" visit a particular clinic.

Conclusion

The results indicate that the microfinance program improved perceived quality at loan recipient clinics, especially as reliable drug outlets.

Self-help: What future role in health care for low and middle-income countries?

In the debate on 'Third options' for health care delivery in low- and middle-income countries it is proposed that self-help should play a larger role. Self-help is expected to contribute towards improving population health outcomes and reducing government health care expenditure. We review scope and limitations of self-help groups in Europe and South Asia and assess their potential role in health care within the context of health sector reform.

Self-help groups are voluntary unions of peers, formed for mutual assistance in accomplishing a health-related purpose. In Europe, self-help groups developed out of dissatisfaction with a de-personalised health care system. They successfully complement existing social and health services but cannot be instrumentalized to improve health outcomes while reducing health expenditure.

In South Asia, with its hierarchical society, instrumental approaches towards self-help prevail in Non-governmental Organizations and government. The utility of this approach is limited as self-help groups are unlikely to be sustainable and effective when steered from outside. Self-help groups are typical for individualistic societies with developed health care systems – they are less suitable for hierarchical societies with unmet demand for regulated health care. We conclude that self-help groups can help to achieve some degree of synergy between health care providers and users but cannot be prescribed to partially replace government health services in low-income countries, thereby reducing health care expenditure and ensuring equity in health care.