Adherence & Retention

Hi Kaitlyn,
Sounds like a fascinating project. Have you looked at BRAC's microfinance/health model? They have been delivering large-scale, highly successful microfinance that integrates CHW in rural Bangladesh for over 25 years, and recently began to work in Southern Sudan as well. I'd encourage you to read up on their experience and model and perhaps try to reach out to the local BRAC members that are in your area.
There are a few differences in your programs/aims, but I think that you could learn a lot from their experience--they've also worked to expand the program in new contexts, so have a lot of expertise on how to create flexible programs that allow you to learn and adjust as you go.

A few links that might be a good starting point:
BRAC's work in Sudan: http://www.brac.net/usa/bw_sudan.php
BRAC's microfinance model: http://www.brac.net/microfinance.htm
BRAC's essential health program: http://www.brac.net/essentialhealthcare.htm

Hope that helps!

Hi Kaitlyn,

I work indirectly for Partners In Health (PIH) and my day to day work revolves around an HIV project in Peru although I'm based in Boston. Within that HIV project, we have a microfinance project that we are piloting with a dozen or so HIV+ patients. Our site in Peru, Socios En Salud (SES), is fortunate to just act as the intermediary between TB and HIV patients and the existing medical infrastructure unlike most of PIH's other sites. Because of this, SES' team is largely comprised of nurses, health promoters, and community health workers. These individuals comprise our more clinical team which help stabilize patients via community based directly observed therapy and accompaniment. The clinical team in strong collaboration with our socioeconomic team composed largely of an economist and social worker work towards alleviating our patients' poverty, one mechanism for that is the microfinance project.

Our project in Peru is not linked with any external microfinance institution (MFI) so our expertise is largely internal and funding limited which also limits the scale of our project. Our participants were selected on standardized instruments that looked at any debt they had, motivation, previous business skills and/or training ...

Hi Kaitlyn,

I work indirectly for Partners In Health (PIH) and my day to day work revolves around an HIV project in Peru although I'm based in Boston. Within that HIV project, we have a microfinance project that we are piloting with a dozen or so HIV+ patients. Our site in Peru, Socios En Salud (SES), is fortunate to just act as the intermediary between TB and HIV patients and the existing medical infrastructure unlike most of PIH's other sites. Because of this, SES' team is largely comprised of nurses, health promoters, and community health workers. These individuals comprise our more clinical team which help stabilize patients via community based directly observed therapy and accompaniment. The clinical team in strong collaboration with our socioeconomic team composed largely of an economist and social worker work towards alleviating our patients' poverty, one mechanism for that is the microfinance project.

Our project in Peru is not linked with any external microfinance institution (MFI) so our expertise is largely internal and funding limited which also limits the scale of our project. Our participants were selected on standardized instruments that looked at any debt they had, motivation, previous business skills and/or training, business idea, and need for assistance. There was a selection period, training period (business and marketing skills), elaboration of business plan period, implementation of business plan (loan dispersal, no interest, accompaniment for purchase of business materials), and follow-up (food baskets for 4 months to ensure funds go toward businesses and not other expenditures, visits to business, group meetings, lots of documentation including of profits vs. losses, etc).

The main point to take from this is that the program despite its
small size is a very well structured program that revolves around a
multidisciplinary team. The project's ultimate success relies not only on the patient's initiative but also on constant monitoring and evaluation by both the clinical and economic team.

Based on this experience, community health workers can be engaged/facilitate microfinance but it requires training and probably limiting other responsibilities.

Considering these facts and your own desire for input I suggest much research and planning as you try to implement your own project. We have relied heavily on our research of other groups to ensure our project at least incorporates the major components that most MFIs would have.

If this all seems overwhelming then reaching out to a local and established MFI might be a better alternative to help guide you. Some initial observations of our own research is the need for greater dissemination of best practices for microfinance among populations already infected with HIV.

Other more focused suggestions include:

1. Besides looking at Grameen (http://www.grameen-info.org/) and Brac (as suggested by Maria: http://www.brac.net/), also look at Freedom from Hunger (http://www.freedomfromhunger.org/). Many different options for microfinance exist like group lending, individual lending, etc...

2. The biomedical literature regarding microfinance and health outcomes leaves a lot to be desired. So depending on what you mean by medicalmicrofinance, I suggest learning from such groups as the IMAGE project in South Africa (Pronyk and Hargreaves; http://www.ajph.org/cgi/content/abstract/97/10/1794) and a group in Haiti (Marie Deschamps). The IMAGE project does microfinance and health education with the hope of reducing gender violence and help prevent HIV. The Haiti group seems to offer microfinance to HIV positive individuals and HIV negative individuals with good repayment (pilot's initial findings: http://www.gbcimpact.org/documents/members/biomerieux/Biomerieux_Haiti_case%20study_English.pdf.

3. Link to IAS microfinance poster discussions along with links to abstracts and presentations. For our Peru group, you can email for the actual pdf of the poster.

4.Combining health education with microfinance is a preferred method by many groups.

5. Cash transfers might be another alternative for those people not
suitable for microfinance. Cash transfers were a topic of discussion at the recent IAS conference in Mexico City (Focus on cash transfers for social protection and the feasibility for large scale implementation Jacqueline Oduol, Kenya: PPT here: http://www.aids2008.org/Pag/ppt/MOSAT1104.ppt). There are also different types of cash transfer, conditional versus non-conditional cash. Opportunidades in Mexico would be a good example of a conditional cash transfer project should you decide to learn more about that option. More information about this last one here: http://www.fpa.org/topics_info2414/topics_info_show.htm?doc_id=522390.

Good luck.

Al

Hi Kaitlyn!
I worked in south eastern part of Sudan with MSF (Sobbat corridor area) in Malaka, Ulang, Adong and Nasir.
UNICEF used to support communities with drugs so they can sell them to generate money so they can start buying new drugs on their own etc..
If you are dealing with <18years old population, did you try with UNICEF?

Also I am curious to know if the population there is mobile or settled because this can be concern for fund donors, how to prove your intervention will work well etc...?


Good luck!
ziad

Thank you Maria. We are currently communicating with BRAC's team in South Sudan. I really appreciate your input and see the value in collaborating with BRAC.

Thank you Adolfo! Such great resources. I was already familiar with Freedom from Hunger's work and BRAC. I will keep you updated on our progress.

Hi Ziad!

We have approached UNICEF for help with projects focused on education, but not medical microfinance. I will be sure to meet with them once I arrive in Yei. The population in Yei is settled, but this does vary throughout the rest of the region and is a challenge we have encountered as we try to secure funding. Thanks for your thoughts!

Hi Kaitlin,

I hope you are well! I work with Partners In Health in Rwanda, and we are currently implementing a small microfinance initiative with members of HIV associations. The previous responses have already offered great resources . But I did want to offer a quick response to share a lesson from our experiences here.

Previously, the PIH microfinance program gave large loans to the HIV associations in Rwanda. Loans were given to the associations themselves (and were effectively under the control of the association's leadership committee) to implement large group enterprises. With this model, we found that it was difficult to ensure that benefits reached all members of the associations, and there was some incentive for association leaders to mismanage projects to give themselves greater control of the businesses. In addition, the projects themselves gave diffuse benefits, so there was not always strong incentive for members to be very invested as individuals.

In response to these challenges, in June 2008 we shifted to a model that gives far more control to each individual HIV association member. We are using a simple and fairly classic microfinance model in which we give small loans to individual HIV association members. Loans are ...

Hi Kaitlin,

I hope you are well! I work with Partners In Health in Rwanda, and we are currently implementing a small microfinance initiative with members of HIV associations. The previous responses have already offered great resources . But I did want to offer a quick response to share a lesson from our experiences here.

Previously, the PIH microfinance program gave large loans to the HIV associations in Rwanda. Loans were given to the associations themselves (and were effectively under the control of the association's leadership committee) to implement large group enterprises. With this model, we found that it was difficult to ensure that benefits reached all members of the associations, and there was some incentive for association leaders to mismanage projects to give themselves greater control of the businesses. In addition, the projects themselves gave diffuse benefits, so there was not always strong incentive for members to be very invested as individuals.

In response to these challenges, in June 2008 we shifted to a model that gives far more control to each individual HIV association member. We are using a simple and fairly classic microfinance model in which we give small loans to individual HIV association members. Loans are repaid in six equal monthly repayments, and a low interest rate of (5% - we are not trying to recover our management costs, recognizing that this is primarily a social service program and not a self-sustaining lending enterprise). We have a small team of loan officers that offers financial trainings and other support.

While we give the loans to individuals, loan recipients work in small groups with 4-6 members who are responsible for repaying together. So we actually do not track which individuals repay -- group members are responsible for gathering funds from each member and repaying collectively. This creates a group co-guarantee system, in which members' ongoing eligibility depends on repayment by all other members. This model aims to make use of "social collateral" as a means to avoid asking for any material collateral. So far, this system is working very well! Repayment has been 100% for the first two months.

I think the lesson we learned is that, in our program, it proved problematic to give loans to large groups, as the funds were controlled by a few leaders who did not always share benefits evenly. By giving loans to individuals or very small groups, you may find it's easier to ensure benefits reach those they are intended to reach, and to ensure that projects are managed well.

I hope that helps! You may not encounter similar challenges in lending to large groups of your community health workers, but this has been our experience.

Best of luck, and please feel free to be in touch if you have further questions about our experiences!

Regards,
Annie

hi kaitlyn
regarding your new programmee in yei sudan i will propose to you better the rwanda model which is putting the suppervision of payment to chws themself this is similar to what we have here in kenya pathfinder in collabboration with KREP BANK initiated the programme in 2004 and they left in 2006 in our region but because of members were taking the leading role repayment and sustainability was good up to now i have managed to borrow a loan three times and repaying but one has to start with a small amount as he grows with the ladder as you also have time for learning ones character and will to pay