integrating health with...

Integrating Health with Microfinance: Community Health Workers in Action

Authors

Dr. D.S.K. Rao, Sandhya Suresh, and Sabina Rogers

May 2015

“With the rise in lifestyle disease in our society, it is high time

we start working together, and the best model is the

community-based model where we train the community

women to deliver health education or awareness and they

are also equipped to do the health monitoring.”

— K. Paul Thomas, Founder and Chairman, ESAF Group

About the authors Dr. D.S.K. Rao is the regional director of the Microcredit Summit Campaign for the Asia-Pacific region and is based out of Hyderabad, India. He can be reached at: [email protected]. Ms. Sandhya Suresh is the senior manager for social performance management for ESAF. Ms. Sabina Rogers is communications and relationship manager for the Microcredit Summit Campaign. She can be reached at: [email protected].

The Microcredit Summit Campaign 1101 15th Street, NW, Suite 1200 Washington DC 20005 USA E-mail: [email protected] Website: www.microcreditsummit.org Telephone: +1 (202) 637-9600

ESAF Society Viswas Bhavan, Kundukulam Road, Mannuthy P.O Thrissur, Kerala 680651 India E-mail: [email protected] Website: www.esafindia.org Telephone: +91 04872373813 Copyright 2015 © Microcredit Summit Campaign All rights reserved Photos courtesy of the Microcredit Summit Campaign Cover photo: An Arogya Mithra trained by ESAF Microfinance in India measures blood pressure for ESAF clients and community members at a health screening camp organized by ESAF.


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CONTENTS

EXECUTIVE SUMMARY ................................................................................................................................................... 1

1.0 INTRODUCTION: ...................................................................................................................................................... 2

1.1. Relevance of the project .................................................................................................................................... 2

1.2 Pilot project in Palakkad district in Kerala state .................................................................................................. 3

1.3 ESAF’s strength in implementing the Arogya Mithra project .............................................................................. 4

1.4 Project objectives ................................................................................................................................................ 4

2.0 IMPLEMENTATION OF THE PROJECT ....................................................................................................................... 5

2.1 Selection of project area ..................................................................................................................................... 5

2.2 Selection of Arogya Mithras ................................................................................................................................ 5

2.3 Freedom from Hunger education module, “Healthy Habits for Life” ................................................................. 6

2.4 Delivery of health sessions .................................................................................................................................. 6

2.5 Regular review meetings and refresher trainings ............................................................................................... 7

2.6 Training of Arogya Mithras to measure blood pressure and blood sugar ........................................................... 7

2.7 Certificates, ID card, and family health cards ...................................................................................................... 7

2.8 Publicity for Arogya Mithra services ................................................................................................................... 8

2.9 Cost of implementation to ESAF ......................................................................................................................... 8

2.10 Challenges of sustainability and scale-up .......................................................................................................... 9

3.0 SELF-TRANSFORMATION THROUGH TRANSFORMING LIVES .................................................................................. 9

A former nurse finds satisfaction and income in community service ..................................................................... 10

Arogya Mithra training spurs further career opportunities .................................................................................... 10

4.0 STUDYING THE CHANGES IN AWARENESS AND PRACTICES .................................................................................. 11

4.1 Methodology ..................................................................................................................................................... 11

4.2 Findings of the baseline and end line studies ................................................................................................... 12

4.2.1 Check-ups for blood pressure and blood sugar: ........................................................................................ 12

Table-1: Frequency of check-ups (all participants) ......................................................................................... 12

4.2.2 Mode of transportation, time taken, and cost incurred: ........................................................................... 12

Table-2: Mode of transportation .................................................................................................................... 13

4.2.3 Healthy eating habits: ................................................................................................................................ 13

Table-3: Healthy eating habits ........................................................................................................................ 13

4.2.4 Awareness about diabetes and hypertension: .......................................................................................... 14

Table-4: Awareness about diabetes and hypertension .................................................................................. 14

4.2.5 Awareness about unhealthy habits leading to hypertension and diabetes: ............................................. 14

Table-5: Awareness about unhealthy habits leading to high BP and diabetes .............................................. 14

4.2.6 Awareness about the importance of medical check-ups: .......................................................................... 14

Table-6: Awareness about the importance of medical check-ups ................................................................. 14

Table-7: Medical check-ups during the previous year .................................................................................... 15

4.3 Qualitative surveys ............................................................................................................................................ 15

4.3.1 Interview with K. Paul Thomas, Founder and Chairman, ESAF Group ....................................................... 15

4.3.2 Interview with Jacob Samuel, Co-founder and Advisor-Social Performance Management, ESAF ............ 17

4.3.4 Focus group discussions ............................................................................................................................. 18

5.0 CONCLUSIONS ........................................................................................................................................................ 18

ACKNOWLEDGEMENTS ................................................................................................................................................ 20


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EXECUTIVE SUMMARY

ESAF Microfinance implemented a

pilot project on community health

workers (Arogya Mithras) in five

branches of Palakkad district of Kerala state with funding support from Johnson & Johnson. Under this

project, ESAF selected 12 women from among their clients and trained them to deliver education

promoting healthy habits to prevent non-communicable diseases (NCDs) such as hypertension, diabetes,

and cancer. The Arogya Mithras were also trained to measure blood pressure (BP) and blood sugar and

record them. After undergoing the training, the Arogya Mithras facilitated health lessons to 1782 SHG

members and have 1851 clients (in January 2015) whose BP and blood sugar readings they monitor.

Arogya Mithras, on average, have a very modest income of Rs. Rs. 660 per month.

Implementation of this pilot project had many challenges. The drop-out of selected and trained Arogya

Mithras because they could not be away from home resulted in cost and time overruns for ESAF. Most

of the clients, being wage earners, were available only in the late hours for education sessions. Training

the Arogya Mithras to measure blood pressure using a stethoscope took longer than expected. The

retail cost of procuring testing strips and needles for blood sugar measurement was much higher,

leaving very little profit margins. In spite of challenges, ESAF persisted with the project and in the

process had many insights in promoting the practice of community health workers.

Health education has enhanced awareness about unhealthy habits that lead to hypertension and

diabetes and foods to be avoided for preventing these diseases. Health risks of hypertension and

An Arogya Mithra tests for blood sugar levels at an ESAF health screening camp.

Arogya Mithra Marykutty says about the program, “This idea is so

innovative that I am happy to be doing real community service yet

earn some money for myself and my family.”


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diabetes and the importance of having a yearly medical check-up are also well understood by

participants. Increased awareness has brought about welcome changes in practices. Participants to the

project are now getting their blood pressure and diabetes checked at least once a year. Monthly check-

ups have become popular with those who are diagnosed to be suffering from these diseases

Average net income of Arogya Mithras is very modest and not sustainable. ESAF is keen for the

sustainability of the Arogya Mithras and are exploring ways for enhancing their income. ESAF is engaging

them for measuring BP and blood sugar in the NCD screening camps they conduct. ESAF is also exploring

the possibility of making it mandatory for all clients to undergo test for BP, blood sugar, and hemoglobin

with each loan cycle1. And engage Arogya Mithras for this work and pay for their services. Such a step, if

implemented, would open the doors for engaging Arogya Mithras in all the branches of the organization.

MFIs have the capacity for promoting community health workers. However, MFIs have to work hard to

ensure their sustainability. If MFIs have a strong commitment to make positive changes in the health

seeking behaviors of their clients and their families, working through community health workers is an

interesting possibility.

1.0 INTRODUCTION:

1.1. Relevance of the project

The world health statistics 2012 report, released by the World

Health Organization (WHO), focuses on the increasing burden

of non-communicable diseases (NCDs) across the world. While

most of the developed countries witnessed rise in NCDs at a

time when the communicable diseases had reached

significantly lower levels, India is witnessing the “double

burden” with high rates of NCD morbidity and mortality at a

time when the communicable diseases have yet not been

controlled. Substantial variations exist between different

regions, but risk levels are rising across the country, most

notably in demographically and economically more advanced

states of India, like Kerala State.

NCDs are chronic diseases, requiring prolonged treatments,

with significant financial implications for poor households. The National Sample Survey Organization

(NSSO) of India found in its survey that among those who did not seek health care for a medical illness in

the past 15 days, nearly 30 percent rural and 20 percent urban respondents cited financial reasons. In

1 The first loan cycle is for one year, and from the second cycle onwards, it is 2 years.

A client of ESAF Microfinance


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the case of NCD treatment, the figures are likely to be still higher because of the much higher cost

involved in their diagnosis and treatment.

Delaying treatment of NCDs is very unfortunate and inefficient because it leads to higher cost. When

treated late, treatment costs are higher and effectiveness of treatment is lower. As the prevalence of

NCDs rises, there will be greater demand for NCD-related health care services, including diagnosis and

treatment. In India where the ratio of health workers per 10,000 population is less than 0.5, the human

resource challenge for effectively addressing NCDs is immense (Indian Journal of Community Medicine,

2011). What makes the situation further grim is the inequitable distribution of physicians and other

paramedical workforce in urban and rural areas. However, some innovative models for service delivery

from India have shown that the para-health care workers can be used effectively for NCD risk

assessment and management.

1.2 Pilot project in Palakkad district in Kerala state

Kerala has achieved the status of a developed country in terms of human development indices.

However, performance of the state in respect of diabetes and cardio vascular diseases is abysmal.

Findings of the study by the Achutha Menon Centre for Health Science Studies, published in January

2010, show that 16.2 percent adult population in the state is afflicted with diabetes. Hypertension was a

whopping 32.7 percent. The study also found 30.8 percent of the study population (which included

7,449 individuals between 15 and 64 years of age, with 51 percent being women) to be overweight.

Abdominal obesity was 39.4 percent. Cholesterol levels above 200 mg/dL were found in 56.8 percent of

the population. Also, Kerala has the largest proportion of elderly people, which is growing at an alarming

rate. With millions of young men migrating for work in the Middle East, the elderly, left alone in their

homes, are badly in need of home-based medical care and services.

Developing models that deliver as much care as possible close to a patient’s home is therefore critical.

From a more positive standpoint, health care in the home environment is more comfortable for

patients, offers less risk of infection and lends itself to the promotion of ongoing strategies to improve

patients’ quality of life.

Having understood the need to address the fast growing malady of non-communicable diseases (NCDs)

in Kerala, ESAF found it necessary to pilot an innovative project aimed at training some of their active

clients as community health workers (Arogya Mithras). It was envisaged to deploy these Arogya Mithras

for facilitating health education sessions to self-help group (SHG) members on prevention of

hypertension, diabetes, and cancer by cultivating healthy habits. Considering the demand that exists in

rural Kerala for door-step service to regularly monitor blood pressure (BP) and blood sugar, it was also

envisaged to deploy the Arogya Mithras to charge a nominal fee for this service.

Palakkad district was chosen for the pilot as the expertise and support of the staff of ESAF Hospital

located in Palakkad could be sought from time to time. Also, focus group discussions (FGDs) with the


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clients in Palakkad district had revealed the huge demand for such services. FGDs also revealed that

some of the microfinance clients were interested to be health entrepreneurs themselves.

1.3 ESAF’s strength in implementing the Arogya Mithra project

ESAF Microfinance, having its presence in seven states of India and reaching out to over 700,000 low-

income families with financial services, has been actively engaged in offering credit-plus services to

facilitate the overall growth and development of poor families. Direct health is the most important

health plus services being offered by ESAF.

ESAF has been making conscious efforts to improve the awareness levels of its clients on matters related

to their health so that they do not lose their hard-earned money on medical expenses and also do not

lose their wages due to a day lost to ill-health. ESAF has supported 10,000 families to construct toilets

and also enabled water connections at their door step so that better health and hygiene is ensured.

ESAF also delivered lessons on reproductive and child health, prevention and management of HIV/AIDS,

WASH (water, sanitation, and hygiene) to 35,626 women clients in 2014.

ESAF also has the experience of running a hospital and a clinic in Palakkad district.

1.4 Project objectives

ESAF partnered with Microcredit Summit Campaign and

Freedom from Hunger during 2011-13 to deliver health

education to their clients in the backward districts of

Maharashtra, Madhya Pradesh, and Chhattisgarh states. In

this phase, they delivered modules on maternal and child

health. Encouraged by the results of this health education

project, as evidenced by positive outcomes both in terms of

knowledge and awareness, as well as behavior and practices,

ESAF decided to diversify the health services by creating a

cadre of health entrepreneurs (Arogya Mithras) from among

SHG members and leaders.

It was envisaged that Arogya Mithras would facilitate health

education modules on healthy habits to be practiced for the

prevention of NCDs, particularly hypertension and diabetes.

In addition, the Arogya Mithras would monitor the blood

pressure and blood sugar of community members and,

wherever necessary, make referrals to appropriate health

care providers. They would collect a small fee for their

services to earn a modest income.

An Arogya Mithra trained by ESAF


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The primary objectives of the project were:

1. To train SHG members as health entrepreneurs (Arogya Mithras) for facilitating health lessons

on healthy habits for the prevention of NCDs to their fellow members and also non-clients of the

community.

2. To train the Arogya Mithras to provide home-based monitoring and referral services for

prevention, diagnosis, and management of these diseases.

3. To increase opportunities for income generation for SHG members through their health-related

services to their own community.

The potential outcomes of this delivery model included:

Enhanced knowledge and awareness for the village community about prevention of NCDs, such

as hypertension and diabetes.

Adoption of practices that help prevent hypertension and diabetes.

Identification of high risk persons and patients of hypertension and diabetes and refer them to

suitable health care services.

2.0 IMPLEMENTATION OF THE PROJECT

2.1 Selection of project area

ESAF Microfinance selected five branches (Kozhinampara, Koduvayur, Chittur, Pudunagaram, and

Palakkad) in Palakkad district for implementation. The selection of branches was based on the following

criteria:

Branch is at least five years old, so that a good relationship with community members has

already been established by ESAF staff.

Clients show enthusiasm to participate in education.

A few enthusiastic members who are willing to become Arogya Mithras.

Branches where community needs for home-based health monitoring is high.

Microfinance staff shows enthusiasm to support the project.

All the selected branches are in a cluster and almost equidistant from each other.

2.2 Selection of Arogya Mithras

Arogya Mithras were chosen from out of active women clients of ESAF who were school educated (at

least completed 10th class). Preference was given to those who had the support of their family.

Accordingly, an advertisement on a printed pamphlet mentioning the project details and the essential

and desirable qualifications was sent across the selected branches. An interview panel comprising of the

director of social initiatives, the senior manager for social performance management (SPM), and the


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nursing superintendent of ESAF Hospital was formed; they selected 20 women after interviewing 50,

which was an average of three to four Arogya Mithras per branch.

2.3 Freedom from Hunger education module, “Healthy Habits for Life”

The facilitator guide developed by Freedom from Hunger, “Healthy Habits for Life,” like all of their other

health education modules, is well scripted, explaining every action to be made and every word to be

spoken by the facilitators. The module was translated into Malayalam, the local language. It is

thoroughly self-explanatory and easy to follow. The translated module was given to the Arogya Mithras

well in advance so that they could come prepared for the training.

The facilitator guide on Healthy Habits for Life included five lessons viz.

1. Diabetes and 6 healthy habits

2. Cancer, High Blood Pressure, and 6 Healthy Habits

3. Healthy Eating

4. Being Active

5. Five yearly check-ups

Each of the above lessons takes about 30 minutes to facilitate. Dr. DSK Rao, regional director of the

Microcredit Summit Campaign, was the resource person for the first training program, along with Mr.

Jacob Samuel (director of social initiatives for ESAF) and Ms. Sandhya Suresh (senior manager for SPM

for ESAF). In addition to the Arogya Mithras, the training was also participated by the managers of the

five selected branches. The idea was to expose them to the contents of the module and the training

methodology.

Though ESAF selected 20 Arogya Mithras after a careful selection process, many of them dropped out

after the initial training. Most of them dropped out because they felt they could not cope with the field

work involved in delivering the lessons and the health services. ESAF had to make fresh recruitments

and conduct fresh trainings on health education for the new recruits.

2.4 Delivery of health sessions

Ultimately, 12 Arogya Mithras settled down with the work and started delivering health sessions. The

coordinator employed by ESAF for the project worked closely with the Arogya Mithras. He introduced

them and their work to SHG members. Altogether, the 12 Arogya Mithras covered 1782 clients with the

five lessons over a period of six months.

The Arogya Mithras sometimes used the credit group meeting platform for delivering the sessions.

However, most of the members work as agriculture labors and, therefore, available in the evening or on

weekends. Accordingly, Arogya Mithras had to convene meetings separately in the evenings for

delivering the lessons.


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2.5 Regular review meetings and refresher trainings

As the Arogya Mithras were scattered across five branches, it was found necessary to understand the

basic challenges they faced. Monthly meetings participated by Arogya Mithras and the coordinator were

held regularly at ESAF Hospital in Palakkad. These meetings were chaired by either ESAF’s senior

manager for SPM or the director of social initiatives. These meetings also provided Arogya Mithras an

opportunity to interact with the medical officers of ESAF Hospital and get their doubts clarified.

2.6 Training of Arogya Mithras to measure blood pressure and blood sugar

After health education sessions were completed, the second phase of training was conducted; this

included training the Arogya Mithras on measuring blood sugar and blood pressure accurately. A

medical kit comprising of BP apparatus (non-digital) and Johnson & Johnson’s Accu-Chek to measure

blood sugar was provided to each of the 12 Arogya Mithras. The nursing superintendent of ESAF

Hospital trained them on using these gadgets.

Arogya Mithras had to clear a rigid test before they were allowed to practice BP and blood sugar

measurement in the field. Blood sugar check was easy to master, but it took quite some time and repeat

training to learn accurate measurement of blood pressure using a stethoscope; they required several

coaching sessions in groups and one-on-one learn the correct technique.

2.7 Certificates, ID card, and family health cards

Each of the 12 Arogya Mithras passed the rigid test and earned the certificate issued by ESAF, which was

presented in a formal function organized by ESAF and inaugurated by the District Medical Officer (DMO)

An Arogya Mithra measures blood pressure at an ESAF health screening camp.


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of Palakkad District. ESAF also issued them a medical kit, which contained a BP apparatus, thermometer,

glucometer, needles, and strips; Arogya Mithras were also given family health cards (cards given to

individuals who joined the scheme, which are used to record the readings). The family members of the

Arogya Mithras also attended the function and collected the medical kit along with the Arogya Mithras.

It was a deliberate step to ensure support of the family members to Arogya Mithras in discharging their

duties. The DMO congratulated the Arogya Mithras and stated that this initiative would go a long way in

the prevention and proper management of chronic diseases like cancer, high BP, diabetes, etc.

2.8 Publicity for Arogya Mithra services

Leaflets mentioning the names and the telephone numbers of Arogya Mithras and the services offered

by them were distributed to all the credit groups of ESAF. The project coordinator and the loan officers

of ESAF introduced the Arogya Mithras to the group members. With such publicity, SHG members

started calling the Arogya Mithras seeking their services, and gradually, the clientele of Arogya Mithras

picked up.

Each Arogya Mithra started her services by visiting her neighborhood groups and enquiring about the

general health status of the family members. They also spent time counseling the family members on

healthy habits, foods to be eaten frequently, and foods that are affordable.

Community members were cautious initially. They wanted to be sure about the training Arogya Mithras

underwent. They used to also check the ID card, which the Arogya Mithras carried with them. ESAF’s

long standing presence in the community gave the much needed credibility to Arogya Mithras. Very

soon, even patients from neighboring villages started calling the Arogya Mithras.

As the Arogya Mithras settled down with their work, clients started demanding more services such as

measurement of cholesterol, anemia, etc. There was also demand for medicines like paracetamol, oral

rehydration solution (ORS) packets, etc. However, ESAF, as a policy, does not allow their partners or

staff to provide services in which they are not trained. ESAF does not let their staff misuse the status

given to them. In future, ESAF will have a discussion with their clients, and if the demand for diverse

health-related services is established, they may design suitable products for the same. All together, the

AMs could enroll 1821 clients as well as non-clients for their services.

2.9 Cost of implementation to ESAF

The outputs of the project are 12 Arogya Mithras trained to deliver health lessons, having adopted adult

learning principles, and to measure blood pressure and blood sugar accurately; 1782 SHG members

learned five health lessons related to healthy habits to be maintained to prevent NCDs; and 1821 clients

(and constantly increasing) received regular monitoring services for blood pressure and blood sugar.

ESAF incurred an expenditure of Rs. 710,807 in implementing the project. This covered the training of

Arogya Mithras; a stipend paid to them during the project period; the purchase of health kits; and


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monitoring, supervision, and evaluation of the project. There was a cost overrun of Rs. 229,807 more

than the estimated budget; this owed mainly to the additional trainings required in measuring blood

pressure readings accurately using a stethoscope and because many of the initially recruited Arogya

Mithras dropped out. Instead of the one training proposed in the budget, ESAF had to conduct four

rounds of trainings, including one by the medical officer of ESAF hospital who clarified many doubts

expressed by the Arogya Mithras.

Monitoring costs were also high because of scattered location of the implementing branches.

2.10 Challenges of sustainability and scale-up

The drop-out of Arogya Mithras was a challenge ESAF had to contend with. Drop-outs led to repeated

trainings, which in turn resulted in higher cost of the project and delayed implementation. Arogya

Mithras mainly cited their inability to spare time from their household chores as their reason for r

dropping out of the project.

ESAF’s strategy of paying a stipend of Rs. 1000 to each Arogya Mithra for the initial six months of the

project helped. It took care of their transportation cost when the income was low. By the time the

project ended, however, the Arogya Mithras’ income increased sufficiently to meet their transport cost.

Though Arogya Mithras charged Rs. 40 per sugar test, the net income was only Rs. 12 (the cost of 25

needles and testing strips comes to Rs. 700, making it Rs. 28 per test). The Arogya Mithras did not have

the resources to purchase the needles and strips in bulk at cheaper cost.

Those whose BP and blood sugar readings are normal are not eager to go for repeat checks, and hence

the Arogya Mithras have to spread out to new geographic areas to find clients, which increased the

transport cost. Some enterprising Arogya Mithras have started tapping officials in schools, government

offices, banks, etc.

3.0 SELF-TRANSFORMATION THROUGH TRANSFORMING LIVES

All the Arogya Mithras were only housewives and

had no income of their own before taking up this

assignment. The income they were earning and the

community service they were rendering as Arogya

Mithras was extremely gratifying to them and gave

them a sense of dignity. They felt privileged when

even people from neighboring villages started

seeking their services. Handling the measuring instruments—particularly measuring BP using a

stethoscope—made them feel very proud.

Sajitha, one of the Arogya Mithras says, “I

never thought I will be able to check BP

using the same machine used by a doctor. It

makes me feel so proud with the

stethoscope around my neck!”


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Arogya Mithras feel thoroughly happy when the patients whom they refer to hospitals on account of

severe variations in their BP and sugar levels, come back and express their gratitude for the timely

referral.

Saradha, an Arogya Mithra, belongs to a community engaged in making a local fried delicacy called

“murruku.” Members of this community sit for more than five to six hours at a stretch to prepare this

snack. They sit for even longer duration when they have to meet large orders. Many of them contract

blood pressure and diabetes due to their sedentary work combined with high consumption of salt,

sugar, and oil. They found the tips that Saradha gave on the importance of reducing consumption of salt,

sugar, and oil as well as physical exercise very useful. Many of them have started practicing what they

learnt from Saradha.

A former nurse finds satisfaction and income

in community service

Marykutty is 50 years old and has been an active client of

ESAF Microfinance for the past 10 years. On average, she

earns net income of about Rs. 2000 per month. Marykutty

trained as a nurse, but family conditions caused her to

leave that profession long ago. With the Arogya Mithra

training, she is determined to continue her services,

though not in a hospital or a clinic but as a health

entrepreneur. She gladly says, “This idea is so innovative

that I am happy to be doing real community service yet

earn some money for myself and my family.”

Marykutty enjoys the support of her family members in

the delivery of her services. As most of her clients are in

the interior parts of the village, her son or husband drops

her on their motorbike. She goes to sites where men and

women work as daily labourers; these are the people who

have never gone for a BP or sugar check-up as they never

get time and also do not want to spend money and time in

transportation. So, Marykutty meets them during tea and

lunch breaks and checks up their BP/blood sugar. The

work supervisor pays her upfront for all those who get

their check-ups and deducts the amount from their wages

later.

In addition, Marykutty has regular calls from bed-ridden

patients who are not able to go for a health check-up. As

she is a trained nurse, she also provides first-aid, dressing

for bedsores, etc., and earns additional income from such

geriatric patients.

Arogya Mithra training spurs further career

opportunities

Sabira Faizal comes from a traditional Muslim family

where women’s mobility is mostly restricted, but Sabira is

determined to make a difference in her own life and her

community. Having heard about the Arogya Mithra

project, she approached ESAF and requested to be

inducted as a health entrepreneur. Because Sabira was

already employed as an ASHA (Accredited Social Health

Activist) worker under the National Rural Health Mission

(NRHM), a project of the Government of India, she enjoys

good rapport with the community.

Sabira was good at facilitating the health lessons and also

learned to measure BP and blood sugar quickly. She

preferred to go to her Muslim neighborhood where she

believes women do not have adequate awareness on the

prevention of NCDs. Sabira also offers pain and palliative

care to several patients who are terminally ill. Seeing good

opportunities in this field, she is undergoing a three-

month course on geriatric care, paying the tuition fees out

of her meager resources.

Sabira has two girl children whom she wants to educate in

a way that they would use their education for the benefit

of the society. Her husband, who is an auto driver, is very

happy when Sabira is respected by the community

members for what she is doing. “My husband drops me in

his auto to the places where I want to go for health

education—free of cost!” smiles Sabira while saying this.


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4.0 STUDYING THE CHANGES IN AWARENESS AND PRACTICES

The baseline survey was done in January 2014 by the Institute for Financial Management (IFMR). The

objective of the baseline study was to examine the demographics, current health status, health

awareness, and health practices of SHG members prior to the intervention. The end line was conducted

by an independent consultant engaged by the Microcredit Summit Campaign. The baseline and end line

were done to study the changes that have come as a result of a health service specifically targeting

blood pressure and diabetes within the framework of a community health worker model and through

the delivery channel of a microfinance institution (ESAF) in Palakkad district of Kerala state.

The end line study was conducted in December 2014, after a gap of 11 months of the baseline study.

The end line study had the objective of knowing the changes in terms of knowledge and awareness as

well as habits and practices of the community after the intervention, i.e., the health education and

access created at door step for monitoring blood pressure and blood sugar.

4.1 Methodology

The baseline study was conducted across four ESAF branches of Chitoor, Kozhinjampara, Koduvayur, and

Pudunagaram in Palakkad district of Kerala. Stratified random sampling methodology was adopted in

which initially 90 SHGs were selected across the above branches. Four to six members from each SHG

supported by the selected branches were picked at random for administering the questionnaire.

The baseline questionnaire included the following sections:

a) Household information,

b) Income information,

c) Health seeking behavior,

d) Diet and lifestyle, and

e) Health awareness.

The survey assessed demographic characteristics, heath practices, and perception of risk factors of high

blood pressure and blood sugar levels, health awareness, etc. Portions of the survey included

information for all household members, which increased the sample size to 1,419 individuals for select

information categories (though the sample size was only 490).

The questionnaire was common for both the baseline and end line studies. In addition, the end line

attempted to understand the community’s response to the services being offered by the Arogya

Mithras. Satisfaction levels of the community to the services provided by Arogya Mithras was also

studied through qualitative studies.

Out of the baseline sample of 490 SHG members, only 263 received health education because three of

the groups had Arogya Mithras who dropped out after the baseline and the villages covered by them


12

had to be excluded for the project. These three were replaced with villages in the vicinity of the newly

recruited Arogya Mithras. The end line study selected randomly 100 members from out of 263, who had

participated in the baseline survey and also had received health education.

4.2 Findings of the baseline and end line studies

4.2.1 Check-ups for blood pressure and blood sugar:

The baseline study revealed that 69 percent and 76 percent of the sample never had their blood

pressure or blood sugar (glucose) levels, respectively, checked. More than half of the sample over the

age of 55 years had never got their BP and blood sugar checked. Amazing transformation is noticed in

the end line survey: 100 percent of the sample had their check-up of blood glucose and blood pressure

in the last year (table-1).

Table-1: Frequency of check-ups (all participants)

Frequency of check-up Blood Pressure Blood Glucose

Baseline End line Baseline End line

Never checked 69% 0% 76% 0%

Irregular check-ups 9% 0% 7% 0%

Once in 12 months 5% 76% 3% 76%

Once in 6 months 10% 3% 8% 3%

Once a month 7% 21% 6% 21%

Among those who are diagnosed to be suffering from hypertension and diabetes (a subset of table-1),

the frequency of check-ups was much better. The baseline revealed 46 percent of those who were

suffering from blood pressure and 49 percent of those suffering from diabetes, respectively, had their

check-up once a month; 11 percent and 14 percent of the diagnosed, respectively, had their check-up

once in six months. The behavior of those diagnosed with hypertension and diabetes as reflected in the

end line survey is much different from the total population: 100 percent of the diagnosed have monthly

check-ups as opposed to 21 percent of the total population.

The baseline study revealed that only 27 percent went to public hospitals for their check-up while the

end line study showed that 69 percent went to public hospitals. Apart from availing the services of

Arogya Mithras, people are getting their BP and blood sugar checked whenever they get a chance to

visit the public hospital, which can be attributed to their appreciation of the message for regular check-

ups.

4.2.2 Mode of transportation, time taken, and cost incurred:

The baseline showed persons availing mostly public transport (57 percent) for going for a check-up,

followed by 31 percent who go “by foot” (meaning they did not take public or private transportation). In

comparison, the end line survey revealed that 100 percent went “by foot”; many of the participants


13

availed door step service being offered by the Arogya Mithras. This is also reflected in the cost for

transportation and testing with 100 percent of the end line sample spending Rs. 0-50 for the cost of the

test and transport for BP/ blood sugar, as compared to 34 percent in the baseline sample. This clearly

shows that with the introduction of Arogya Mithra services, many clients benefit by not spending on

transportation (table-2).

Table-2: Mode of transportation

Mode of transportation Baseline End line

By foot 31% 100%

Public transport 57% 0%

Private transport 12% 0%

4.2.3 Healthy eating habits:

The education module covered the foods to be eaten frequently, moderately, and rarely in order to

maintain good health. There was good awareness about the foods to be eaten frequently (particularly

about the importance of vegetables) and rarely even before introducing the health lessons. However,

more persons became aware of healthy eating habits after the lessons (table-3).

Table-3: Healthy eating habits

Food type Should be frequently eaten Should be rarely eaten


Vegetables 97% 100%

Whole grains 31% 47%

Maida 71% 83%

Deep fried snacks 54% 79%

Sweets 60% 89%

Red meat 69% 86%

As seen in table-3 above, respondents’ awareness about foods to be consumed rarely increased

significantly as compared to the baseline as did their awareness of needing to eat whole grains

frequently. However, their awareness of needing to consume vegetables frequently, there was only a

slight improvement in the knowledge levels because, even without education, they knew they were

good for health.


14

4.2.4 Awareness about diabetes and hypertension:

Table-4 below shows that awareness about the risks associated with high blood pressure and blood

sugar has slightly improved with education.

Table-4: Awareness about diabetes and hypertension

Question Percent who knew the correct answer

Baseline End line

Risk of stroke is high for patients of high BP 51% 62%

Risk of kidney problems is high for patients of high BP 9% 20%

Risk of blindness is high for patients of diabetes 32% 53%

Risk of kidney problems is high for patients of diabetes 22% 34%

Risk of losing toes is high for patients of high diabetes 48% 57%

4.2.5 Awareness about unhealthy habits leading to hypertension and diabetes:

The studies revealed improvement in awareness about the unhealthy habits that lead to hypertension

(high blood pressure) and diabetes (high blood sugar). However, somehow the importance of being

active to prevent high BP and diabetes has not gone well (table-5).

Table-5: Awareness about unhealthy habits leading to high BP and diabetes

Unhealthy habit

Factor contributing to high blood pressure

Factor contributing to high blood sugar


Drinking too much colas, coffee, tea 39% 62% 53% 62%

Being inactive 14% 9% 9% 9%

Not keeping a healthy weight 10% 23% 11% 23%

Smoking or breathing in smoke 16% 20% 11% 20%

Alcohol use 14% 18% 17% 18%

4.2.6 Awareness about the importance of medical check-ups:

The health education stressed the importance of regular check-ups for prevention and early detection of

cancer, hypertension, and diabetes. Participants in the education module have appreciated this message

and also seem to have started practicing new behaviors to varying degrees (table-6 and -7).

Table-6: Awareness about the importance of medical check-ups

Which medical check-ups one should undergo at least once a year? Percent who knew the correct answer

Baseline End line

Blood test for diabetes 52% 85%

Blood pressure test 70% 85%

Pap test for cancer near womb 3% 4%

Breast exam for cancer 2% 5%


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Table-7: Medical check-ups during the previous year

Had a check-up the previous year for blood pressure and blood sugar Baseline End line

Blood test for diabetes 33% 85%

Blood pressure test 44% 85%

Pap test for cancer near womb 2% 4%

Breast exam for cancer 1% 5%

Participants were not aware of the importance of check-ups for breast and cervical cancer before

education. Unfortunately, the message about these check-ups has not been understood even after

education. During the health sessions for some reason, many women also felt that unless they have

some symptoms they will not voluntarily go for expensive check-ups such as a Pap test. However, in

respect of BP and blood sugar, they are more open to have frequent check-ups.

4.3 Qualitative surveys

In addition to quantitative baseline and end line surveys, qualitative studies were conducted, including

individual interviews and focus group discussions. Interviews of the key responsible persons were also

taken.

4.3.1 Interview with K. Paul Thomas, Founder and Chairman, ESAF Group

Q. Do you think initiatives like that of Community Health Worker/Entrepreneur have the potential and

scope for scaling up?

K. Paul Thomas: Yes, definitely. With the rise in lifestyle disease in our society, it is high time we start

working together, and the best model is the community-based model where we train the community

women to deliver health education or awareness and they are also equipped to do the health

monitoring. As such, door step services can reduce the transportation cost and there will be huge

demand for such services. Through focus group discussions, we came to know the willingness of clients

to pay for such services; that prompted us to implement the pilot project. This initiative was designed to

generate some income for the health entrepreneurs. If we go towards the northern part of India, we can

think of training Arogya Mithras on communicable diseases, women and child health also, so the scope

looks quite enormous.

Q. Do you think any MFI can start such an initiative, or should they have prior experience in health

education/health care, etc.?


16

KPT: I think any MFI can start such an initiative provided they

have the passion and commitment to see positive health

transformation in the lives of their clients. For implementing

such social sector projects, the MFI needs to plan carefully

and be willing to deploy dedicated staff. MFI should be able

to invest time, efforts, and resources. Close monitoring is of

course absolutely essential.

ESAF’s vision and mission very clearly stress holistic

transformation in the lives of its clients and we are convinced

this cannot be achieved unless the health issues are

addressed.

Q. What are your plans to replicate this model across all the

branches of ESAF?

KPT: Before the replication, we will have to study the success

and failures of this pilot. We are assessing the financial

sustainability of this project also because the Arogya Mithras are mostly women from low income

families and the moment they do not get enough patients to have a reasonable income for themselves,

they will be quite disappointed. Once we have been able to fix these issues, we can think of replicating

and scaling up. But, I can assure you that the model will definitely be replicated with much more

viability.

Q. Do you think Arogya Mithra model will always have to be subsidized, or can it become sustainable?

KPT: Sustainability is very important. We need to train the Arogya Mithras in diverse activities. For

example, they can be marketing agents to sell low cost sanitary napkins, nutritious weaning foods for

children, etc. We need to explore further.

We are discussing if we can have an integrated health model where we make it mandatory for every

woman who takes a loan from us to undergo hemoglobin, blood pressure, and blood sugar check-up.

But we need to work on the economics. ESAF conducts regularly NCD screening camps for their clients.

In such camps, we will engage the Arogya Mithras and pay for their services.

ESAF is keen to scale up the project in a way that the challenges met during the pilot project are

addressed. Replicating the model to 200 branches where ESAF is working will require dedicated staff to

select and train the Arogya Mithras and monitor their work. Sustainability of Arogya Mithras will also

depend on continuous work and regular income for them. ESAF is toying with the idea of a mandatory

medical check-up, for all their clients with each loan cycle and engage the Arogya Mithras for measuring

hemoglobin, blood pressure, and blood sugar. And, ESAF could pay the fees to Arogya Mithras. That will

Attendees at an ESAF health camp


17

generate continuous work. ESAF is engaged in analyzing the cost-benefit of such a large scale

intervention.

4.3.2 Interview with Jacob Samuel, Co-founder and Advisor-Social Performance Management,

ESAF

Q. Your role in the implementation of the Arogya Mithra project was quite crucial as you were involved in

the selection of the Arogya Mithras, their training, and overseeing the entire project. How do you rate

the success of this project?

Jacob Samuel: I would give it 8 marks out of 10. The community health worker project is a pilot and

ESAF’s maiden attempt in this direction. So, we gave our best to address all the emerging needs and

issues at the right time. We had to give inputs that were beyond the scope of the project proposal. For

example we had envisaged only one training for the Arogya Mithras, but we found that it was not

enough as many of them discontinued because they could not be away from domestic responsibilities.

So we had to conduct 3 rounds of trainings, including one refresher training where we had invited our

medical officer from ESAF Hospital. We had the support from ESAF Hospital as we used to conduct our

monthly reviews in the hospital and also our nursing

superintendent trained the Arogya Mithras in checking the

BP using the conventional BP apparatus. Here we had the

support from the staff of ESAF Hospital, SPM department,

ESAF Society to give their required expertise from time to

time. We could implement this project because of all these

support systems. Microfinance staff of ESAF alone could not

have implemented this project so successfully.

We know there are gaps in the implementation and that

without ESAF’s handholding the Arogya Mithras will not able

to function on their own fully. Probably we should have had

the sustainability plans by the time the project ended. But

even now we are utilizing the services of all the Arogya

Mithras in our NCD camps so that they get a reasonable

income out of it.

Q. If you replicate this model, what would you consider?

JS: The selection of Arogya Mithras is very important. Unless the women have support from their family

she will never be able to give her 100 percent. Also, if women have very small children at home without

any support system, then even if they wish, they are not in a position to continue. Any prior experience

of community work, especially if they are ASHA workers, will be an added advantage. A good linkage and

networking should be established with government health system/clubs/associations etc. so that the

Measuring blood pressure


18

services of Arogya Mithras are not confined only to microfinance clients and their families. Unless the

whole effort is worth a good return for them, they will not be motivated.

4.3.4 Focus group discussions

Focus group discussions were done with 3 groups of members, viz.

Those who underwent health education and enrolled themselves as clients for the health

monitoring services of Arogya Mithras.

Those who underwent education but did not join as clients for the health monitoring services of

Arogya Mithras.

Those who did not attend education but enrolled as clients of Arogya Mithras.

The focus group discussions brought out clearly that the members had a very clear understanding about

the foods to be eaten frequently and rarely to prevent hypertension and diabetes. They also had a good

understanding about the quantities of sugar, salt, and oil to be consumed. Naturally, such understanding

was not there among those who did not attend the education.

The education module stressed the need for five check-ups annually for every woman viz. general check-

up of eyes, ears, etc., as well as blood pressure, blood sugar, breast cancer, and cervical cancer. Those

who underwent education remembered clearly the five tests. Those who did not receive education,

understandably, did not know about these tests.

When enquired with the group that received education but had not become clients of Arogya Mithras,

their response was that they would rather avail free service at the Government Primary Health Centers

than availing fee based service offered by the Arogya Mithras.

5.0 CONCLUSIONS

5.1 Microfinance clients who are school-educated can successfully facilitate Freedom from Hunger

education modules, adopting adult learning principles. However, proper training is important.

5.2 Though work as community health workers (Arogya Mithras) is very demanding and gives a very

small and uncertain income, microfinance clients in the project area showed initially considerable

interest to take up this responsibility. However, there were many drop outs at the level of training and

later after they started practicing as Arogya Mithras. The low income and the family responsibilities,

which did not allow them to be away from home for long hours were responsible for the drop out. Only

those who have very strong commitment to the cause and support from their family members survived

in this job.

5.3 Those community women who have some experience of working in the health sector such as ASHA

(Accredited Social Health Activist) or Anganwadi workers (both are front-line health workers trained and


19

supported by the Government of India) have a better chance of success as Arogya Mithras as they have

already built a good rapport with the community. Such candidates have an added advantage of already

possessing certain skills and training needed by a community health worker.

5.4 Freedom from Hunger’s education module, “Healthy Habits for Life,” has yielded impressive results

in terms of change of behavior and practices. The baseline study revealed 69 percent and 76 percent of

the sample never had any check-up for BP and blood sugar, respectively, whereas the end line study

showed almost everybody having been tested within the last 12 months.

5.5 A high percentage of members knew even before the

baseline that frequent eating of sweets, red meat, deep fried

snacks, and food made of maida (finely milled refined and

bleached wheat flour) is bad for health. Education enhanced

their awareness of these facts. Similarly, there was a slight

improvement in knowing the health risks of high blood

pressure and blood sugar with education.

5.6 Awareness was very poor before the education module

about the importance of regular check-ups for breast and

cervical cancer and about the importance of being active and

doing physical exercise. However, even after education, there

is very little improvement in the appreciation levels on these

two issues.

5.7 If the tests reveal they do not have high blood pressure or

blood sugar, this experience shows that poor people (in this

case in rural areas, but also applicable in other settings) do

not want to spend on repeating the tests at regular intervals.

5.8 Arogya Mithra clients are also demanding additional services from Arogya Mithras such as

measurement of cholesterol, hemoglobin etc. There was also demand for medicines like paracetamol,

oral rehydration solution (ORS) packets, etc. ESAF will have a discussion with their clients, and if the

demand for diverse health related services is established, they may design suitable products for the

same.

5.9 ESAF will continue to support the Arogya Mithras even after the completion of the pilot project.

ESAF is exploring more income earning opportunities for the Arogya Mithras. ESAF’s support till the

income of Arogya Mithras enhances and stabilizes is very crucial.

5.10 ESAF is also contemplating to introduce Arogya Mithra concept to other operational areas in Kerala

state where there is better scope for their sustainability. ESAF is also considering deploying Arogya

Mithra services in poor and backward states such as Chattisgarh, which has very poor record of women

A health screening camp patient


20

and child health. However, it is imperative that ESAF subsidizes the Arogya Mithras for considerably long

periods.

ACKNOWLEDGEMENTS

The authors are grateful to Johnson & Johnson for their grant support to implement and evaluate this

project.

The authors would like to thank Freedom from Hunger for the technical assistance in implementing this

project. In particular, they would like to thank Dr. Gabriela Salvador and Dr. Soumitra Dutta for their

valuable comments and guidance in implementing and finalizing this report.

The authors would like to thank Mr. Paul Thomas, CEO of ESAF, for his commitment and keen interest in

implementing this project. His encouragement and constant guidance inspired the Arogya Mithras very

much.

The authors would like to thank Mr. Jacob Samuel, director of programs at ESAF, who ensured smooth

implementation of the project by interacting regularly with the staff of ESAF hospital, branches, and the

Arogya Mithras.

The authors are grateful to Ms. Sirisha Papineni, senior research associate at IFMR, and Dr. Jasmine

Lydia for the high quality baseline and end line surveys they conducted.

The Microcredit Summit Campaign (the “Campaign”), a project of RESULTS Educational Fund, is the largest global network of institutions and individuals involved in microfinance and is committed to 2 important goals: 1) reaching 175 million of the world’s poorest families with microfinance and 2) helping 100 million families lift themselves out of severe poverty. The Campaign convenes a broad array of actors involved with microfinance to promote best practices in the field, to stimulate the exchange of knowledge and to work towards alleviating world poverty through microfinance. Since 2002, the Campaign has partnered with microfinance service providers to mitigate the risk of health challenges to both clients and institutions through its Financing Healthier Lives project. www.microcreditsummit.org www.100millionideas.org

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