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The Role of Microfinance-Based Self-Help Groups in Improving Health Behaviours and Outcomes of the Poor in India Somen Saha Subm

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The Role of Microfinance-Based Self-Help Groups in Improving Health Behaviours and Outcomes of the Poor in India Somen Saha Subm The Role of Microfinance-based Self-Help Groups in Improving Health Behaviours and Outcomes of the Poor in India Somen Saha Submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy November 2016 The Nossal Institute for Global Health Melbourne School of Population and Global Health The University of Melbourne Declaration This is to certify that: i. the thesis comprises only my original work towards the Ph.D. except where indicated in the Preface, ii. due acknowledgement has been made in the text to all other material used, iii. the thesis is fewer than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices. Somen Saha ii Abstract Introduction: Despite an intense national discussion in India during 2010 – 2012, progress towards universal health coverage (UHC) has stalled. Coverage of the entire population is still a challenge, especially effective coverage of the poor. Through the mechanism of microfinance-based self-help groups (SHGs), poor women and their families are provided not only with access to finance in a way that is understood to improve livelihoods, but also in many cases with a range of basic health services. With 93 million people organised nationally, SHGs provide an established organised network that can potentially be used to extend health coverage. Through a combination of quantitative and qualitative research approaches, this thesis aims to explore the potential for existing microfinance networks, using SHGs with attached health programs, to contribute to improved health coverage for the poor. Methods: A mixed-methods approach was used to address the study aim. A review of published evidence on the role of microfinance programs in improving health outcomes was conducted. This was followed by analysis of a national survey dataset to assess the impact of the presence of an SHG at village level on key health indicators at the individual level. Finally, a mixed methods study to assess the effect of combining a health program with microfinance-based SHGs was undertaken. This mixed methods study comprised two rounds of surveys to collect pre-test and post-test data with matched comparison groups and subsequent qualitative investigation to better understand the interconnections between SHGs, health programs and health. Results: The presence of SHGs was associated with significantly higher odds of women delivering their babies in an institution, feeding colostrum to their newborns, having knowledge of modern family planning methods and using family planning products and services. Additionally, the inclusion of a health program within microfinance-based SHGs was associated with further improvements in health behaviours, including facility-based deliveries, feeding newborns colostrum and having a toilet at home. However, the SHG health program led to no significant reduction in diarrhoea among children and no effect in reducing household money spent on health care. Conclusion: Capitalising on SHGs with health programs to improve the health of poor women and their families is an avenue worth investigating further. These established organised networks of SHGs provide an administrative apparatus to more effectively reach iii poor women and their families with essential health programs. Public health planners could leverage SHGs to increase the proportion of the population enjoying health coverage and make progress in relation to financial coverage and utilisation of existing publically- financed health protection schemes, although a lot more work is needed to optimise these possibilities. iv Preface This research was supported by a Research Higher Degree grant from the University of Melbourne, Australia, and a Wellcome Trust Capacity Strengthening Strategic Award to the Public Health Foundation of India and a consortium of UK Universities. I did part of the primary data collection, particularly a baseline survey prior to commencement of my PhD at the University of Melbourne. This data was analysed and compared with a follow- up survey data, as detailed in the thesis, during my PhD candidature period. The baseline data collection process was approved by the institutional ethics committee of the Public Health Foundation of India, and the Nossal Institute for Global Health Human Ethics Advisory Group at the University of Melbourne approved the full study design. The following publications emerged out of this thesis: 1. Saha, S. (2016). Microfinance-based self-help groups: Outcomes from rural India. BMJ Outcomes (Accepted for publication). 2. Saha, S., Kermode, M., Annear, P.L. (2015). Effect of combining a health program with a microfinance-based self-help group on health behaviors and outcomes. Public Health, 129(11): 1510-1518. 3. Saha, S. and Annear, P.L. (2014). Overcoming access barriers to health services through membership-based microfinance organizations: A review of evidence from South-Asia. WHO South-East Asia Journal of Public Health, 3(2): 125-134. 4. Saha, S. (2014). ‘More health for the money’: An analytical framework for access to health care through microfinance and savings groups. Community Development Journal, 49(4):618-630. 5. Saha, S. and Rao, DSK. (2014). Integrated Health and Microfinance, Volume II: The Way Forward. Microcredit Summit Campaign and Freedom From Hunger (Also covered in a blog post at CFI-ACCION: http://cfi-blog.org/2014/08/04/integrating- health-and-microfinance-in-india/). 6. Saha, S., Annear, P.L., Pathak, S. (2013). The effect of self-help groups on access to maternal health services: evidence from rural India. International Journal for Equity in Health, 28;12(1):36. 7. Saha, S. and Annear, P.L. (2012). More than money: Self-help groups and maternal health. Health Policy & Health Finance Knowledge Hub Issue Briefs, No. 6. December 2012. v Acknowledgements Many people supported me during the process of my enrolment and helped me in writing this thesis. I wish to thank them for their support. At the onset, I wish to thank Professor Graham Brown, the founding Director of the Nossal Institute for Global Health, for his confidence and support in selecting me for this Ph.D. position. He was a constant source of support until his retirement in 2014. Also the academic committee of the Public Health Foundation of India and Dr Dileep Mavalankar, Director, Indian Institute of Public Health, Gandhinagar, granted a study leave to pursue the Ph.D. program and I am grateful to them. Associate Professors Peter Annear and Michelle Kermode, my supervisors at the Nossal Institute for Global Health, spent countless hours in advising me about the concept, research questions, methods and findings. Their insightful questions on my initial drafts challenged my own thinking and helped improve my reporting skills tremendously. Dr Shakil Ahmed also advised me on different aspects of this thesis. Colleagues at the Nossal Institute for Global Health and the Statistical Consulting Centre of the University had at different points of time helped me with my statistical queries. Without a scholarship from the University of Melbourne I would have had trouble to support my tuition fees and living in Melbourne. My sincere thanks to the Wellcome Trust Capacity Strengthening Award to the Public Health Foundation of India for funding my field study. Dr James Hargreaves, Senior Lecturer at the London School of Hygiene and Tropical Medicine, provided useful advice in designing my field work. Thanks are also due to Ms Mirai Chatterjee from Self Employed Women’s Association, Gujarat and Dr LM Manjunath from Shri Kshetra Dharmasthala Rural Development Project, Karnataka, for allowing me to do my field work with members from their program areas. A special note of thanks to the anonymous reviewers of the journals that published my work and also the journals that did not accepted my initial draft. Their valuable comments helped tremendously in identifying weaknesses and thereby improving my thesis. Without their very high quality review comments I would not have been able to raise the standard of my work to the current level. vi My family, specially my parents, my wife and my little daughter, spent countless days and hurdles without me for an extended period. This work is dedicated to them for providing me with the opportunity to enter the path of higher learning. Somen Saha vii Table of Contents DECLARATION.......................................................................................................................................II ABSTRACT .............................................................................................................................................III PREFACE ................................................................................................................................................ V ACKNOWLEDGEMENTS .................................................................................................................... VI ABBREVIATIONS ................................................................................................................................. XI 1. INTRODUCTION .......................................................................................................................... 14 1.1 INDIA’S COMMITMENT TO UHC ................................................................................................. 15 1.2 THE IDEA OF UNIVERSALISM IN INDIA ........................................................................................ 17 1.3 HEALTH POLICIES IN INDIA .......................................................................................................
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