SPTF Annual Meeting 2015: Day Two Notes
Client Outcomes Measurement Workshop: Health outcomes
This workshop discussed a set of health indicators developed by Freedom from Hunger. FFH
shared their experience developing and using these indicators with network members around
the world. Participants provided their own input and experiences with measuring and reporting
client health outcomes and discussed next steps for applying and refining health indicators.
Speaker: Bobbi Gray, Freedom from Hunger
Outcomes Workshop 4: Health Outcomes
Leader: Bobbi Gray, Freedom from Hunger
Theories of Change: Improved Health
 Freedom From Hunger has been doing microfinance+ health to improve households for
about 15 years. Over time, have moved from simple health programs to providing health
services, linkage to health providers, health savings and health insurance.
 FFH had been doing various evaluations and randomized control trials. Decided it wanted
to look at the indicators they were using. Asked, are there any indicators that are
particularly useful? What indicators could we use that people would be able to measure
over time? If MFIs were already using a PPI, could they add a few indicators to measure
health?
 To do this, took 30-40 plus indicators and examined them to say, which would be good
indicators?
Theory of Change: Different pathways to improved health outcome
 Financial service providers  increased income, balancing income with expenses
(consumption smoothing)  seek prompt medical care, seek preventive health care,
coping with health risks
 Health providers  client health education, medical services  improved health
knowledge, seeking prompt medical care, seeking preventive care
 Integrating health and microfinance  direct provision and linkages between sectors 
cross-sectoral efficiency gains in provision of financial and health services to poor
population  improved health knowledge, seek prompt medical treatment, seek
preventive health care, coping with health shocks
Theories for lack of change in health outcomes:
 Bobbi asked the group to think about the following questions:
o Why don’t people’s health outcomes change?
o What are reasons people don’t change behavior?
o What are reasons why people don’t seek prompt medical treatment?
o What are reasons why people don’t seek preventive care?
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Carmen Velasco, SPTF: It seems so obvious that if you taught them something, they would
share behavior. But I learned it has to come from them. It has to be a felt need. They might
not feel it’s needed. They might have other needs, live for today.
Ines Arevalo, AKAM: It’s a cultural thing. In China, there were things they were doing for
centuries. It’s not going to change overnight. When it comes to behavior change, the
message needs to be enforced from different agents.
Glenn Andre, AFD: There’s a huge lack of confidence in the different structures. They don’t
think to go to the doctor because they know the quality of the health care is not the best.
Carmen: It’s not just the fear of being ill, it’s also the fear of the cost of being ill. People
think, “If I’m sick, I’m just going to worry and it’s too expensive to get care, so it’s just best
not to know.”
Bobbi: Projects rarely ask beforehand, what are the things that could go wrong? Knowing
all these challenges, how could tracking changes in health outcomes be really challenging?
You have to think of what is in your control to measure, and think about all of these other
things in the background as you’re considering your indicators.
Choosing Health Indicators
 Feasibility – Did MFI collect the data and did it come from the survey?
 Usable – Do the indicators provide information that is valuable for MFIs?
 Relevant – Are they relevant for FSPs? Some indicators are more related to medical
treatment type issues. For FSPs that don’t have any health program, could be hard to
measure maternal health
 Generalizable – more applicable to general microfinance population. Trying to find
indicators that apply to men and women
 Reliability—can the outcomes be linked to the intervention?
 Consistent measurement over time. Whatever you are capturing provides a consistent
measure. For example, birth control use. Is that by choice or because people can’t afford
it?
Current pilot partners (sample sizes vary because FFH integrated data collection into their
existing surveys, collections.)
 ADRA (Peru)
 CARD (Philippines)
 ESAF (India)
 Equitas (India)
Survey Adaptations. Designed it for India and then decided what questions need to be adapted
for Peru and Philippines.
 Poverty measurement – Use of country-specific PPIs
 Food security and nutrition – Added a focus on food items in India to reflect stronger focus
on nutrition
 Preventive health care – Varies the most for each country. In India, asked about
institutional birth. In Peru, asked about annual exams and pap tests. In Philippines, asked
about annual exams
 Curative Health Care – Same question in every country: forgoing medical treatment and
purchase of medicines due to cost
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Water and Sanitation – In India, asked about open defecation; in Peru, asked about water
sources and treatment; in Philippines, asked about treatment of water
Attitudes – Only measured in Peru and Philippines, access levels of confidence related to
ability to cover future medical costs and seek adequate medical care
Example of Equitas in India
 Pilot-tested with cross-section of clients in 4th or 5th loan cycle.
 Fewer than 20% said they defecated in the open, which is lower than the national average.
 Identified indicators associated with poverty. How many health indicators are correlated to
their poverty level? Theory: as people are less poor, they’ll have positive increase in health
outcomes.
 Two indicators (Water treatment and children under 5 receiving vitamin A) were the only
ones that improved with improvement in poverty level. Everything else had a different
driver behind it (causes other than poverty decrease)
 Danger in tracking indicators: in this particular region, poorer people treated water
because they didn’t have access to clean water. In ESAF, wealthier people treated water
because they had money to do so. It’s important to ask these questions and understand
the context.
Lessons learned
 Standardization of indicators across all MFIs may be difficult. Maybe the themes will be
more useful than the actual indicators. Providing MFIs with a menu to choose from will be
more useful than saying “Use this one.”
 Proceed with caution in the interpretation of results.
 Baseline values will be important to establish.
 Baseline values with high levels of may not be useful to track performance (values that
start high will not show much change)
 The value of statistical analysis (ex: correlations between indicators of interest with
poverty) can help refine our “Theory of Change,” as well as determine which indicators
may be the most useful to help us understand changes in client outcomes.
 Who to track and for how long? This is a very important question to answer, as it influences
which indicators will be the most useful.
 This process requires patience. There’s not a silver bullet for improving poverty.
Final list of HOPI indicator – categories
 Food security (Do you have enough food and the type of food you want?)
 Water and sanitation (Main source of drinking water, do you treat water, if yes, how so?)
 Preventive healthcare (Have you visited doctor for preventive health service? Have you
used a strategy to save money specifically for health?)
 Curative health care (Have you delayed medical treatment because of cost?)
 Attitudes (Confidence that you can afford appropriate medical care when needed)
 Domestic violence (Fear of spouse, is husband ever justified in hitting wife?)
 Mental health (Hopeful for future, satisfied with life)
 Maternal and child health (How old is youngest child, did you receive antenatal care with
pregnancy of youngest child? How many times?)
 Some indicators were not tested in the original HOPI survey, such as domestic violence
indicator on whether you were afraid of your husband/partner.
Audience comment: It’s very important to get the buy-in of the practitioner to use the
indicators. Here, none of the indicators help them introduce a financial product. Can we think
of adding questions, like “Do you have a toilet at home? If no, would you be interested in a loan
product.” That could help generate buy-in. Comments:
 Bobbi: You could do your baseline with incoming clients and decide to add several
indicators that you could narrow down over time. The issue might be better for a market
research department than a monitoring department.
 Carmen: It’s important to not project. If you add the health component to your
microfinance clients, what’s going to happen? Is it worth it? Everyone is doing huge efforts
to include health, but what is their motivation? Is it for the public image of the institution,
or is it because I want to prove that X and Y indicators have improved in my clients? I don’t
want to be too rigorous in attribution. If, after 5 years, the same people that came into the
program have changed their health condition and behavior, those are the kinds of
outcomes I want to see. I won’t say it’s necessarily because of my institution.
 Ines: We may or may not want to enter discussion of attribution. You may want to say we
can talk about contribution with a different tool or different intervention. It all depends on
what you want to look at.
Case of CARD in Philippines
 They’ve been providing credit plus education (health, business, financial education). In
2006, worked to go deeper in health and decided to provide a health loan to pay
premium for national health insurance (PhilHealth). They have a network of loan
providers that provide discounted health services and have created a micro-franchise
pharmacy type structure.
 Had client satisfaction survey about to happen when FFH asked them to test indicators.
Included the indicators in their survey.
 How would you look at these results from the perspective of the MFI?
o More than 30% of respondents were food insecure, which is scary. Are these
people able to repay a loan? Are we making things worse?
 Food security is very sensitive – fluctuates a lot and have to be careful
about interpretation. But statistically, the more food secure you are, the
less poor you are.
 Food security tends to be an issue in the bottom 75% of income. In
ADRA case, clients were above poverty line but many were still food
insecure.
 CARD had more clients enroll in PhilHealth than people in the informal sector enrolled,
which shows that they are reaching the clients they want. Part of their education talks
about PhilHealth, and they help their clients fill out the paperwork.
 Bobbi: Anything missing from list of indicators?
o Didn’t include sanitation in all countries because thought health was more
relevant.
o In CARD, 10% delayed medical treatment due to cost. In ADRA, more than 60%
delayed, despite a free public health system in Peru. Is it because they want to
go to private health care? Make sure to understand the country context.