POLICY PROPOSAL: INCREASING ACCESS TO MICROFINANCE FOR DISABLED WOMEN IN KENYA

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by Gabriella Fleischmann
Contributing Writer

A policy proposal directed towards Mrs. Phumzile Mlambo-Ngcuka, Executive Director of the United Nations Women Africa

Executive Summary

I propose that the UN Women Africa make a partnership with the Kenya Women Microfinance Bank (KWFT) to ensure that their services are extended to disabled women in Kenya. Targeted efforts need to be made to reach and educate disabled women about how to access and successfully use microfinance. Disabled women are particularly vulnerable, and have less economic security than non-disabled women. While there has been an emphasis on using microfinance as a tool to empower women, disabled people have been left out of the promise of microfinance to uplift disadvantaged groups. The UN Women Africa should partner with microfinance institutions that serve women, beginning with the KWFT as a flagship program, to implement the following policies: (i) incentivizing the KWFT to hire qualified disabled women as credit officers, (ii) ensuring that the KWFT provide disability-friendly materials and services, (iii) partnering with disabled women in the community to provide leadership training and to understand the needs of disabled women, and (iv) outreach to disabled women to help them understand how they can take advantage of microfinance.

Statement of Issue/Problem

Microfinance is a type of banking in which small amounts of money are made available, often in the form of low-interest loans, to poor people and businesses who usually would be denied credit. Microfinance has been identified as a possible mechanism for poverty alleviation in Kenya by allowing recipients to participate in the economy, smooth income and consumption shocks, and grow businesses (Kiiru, 2007). Making microfinance available for disadvantaged groups has increased the opportunities for disadvantaged people to participate in the economy (Ibid). Many MFIs have directed their efforts and services towards women in particular, including the Kenya Women’s Microfinance Bank (KWFT). However, disabled people are still largely excluded from microfinance, due largely to discrimination by MFIs or self-exclusion due to low self-esteem (Mersland and Martinelli, 2010). The heightened vulnerability of disabled women, and their continued exclusion from markets, has received very little attention from women’s organizations. Nowhere on the websites of UN Women Africa or the KWFT are disabled women acknowledged. Many microfinance institutions seek to empower women, but need to recognize that disabled women are further disadvantaged compared to non-disabled women. It will take a concerted effort to help integrate disabled women into the economy.

Microfinance institutions have made a pointed effort to extend their services to women for several reasons. Women often are excluded from market participation, and thus giving them credit through microlending gives them an opportunity to participate in the economy and in some cases “increases their bargaining power in the household” (Vonderlack and Schreiner, 2002). This is both beneficial from a social justice standpoint and an economic standpoint. Secondly, women are more likely to invest loans in household and family consumption, such as food, health and education, and have better rates of loan repayment (Sooryamoorthy, 2005; Brana, 2013).

While microfinance in Kenya has made efforts to include other disadvantaged groups that often are “excluded from the traditional banking system,” such as the poorest people and rural-dwellers, it has done little for disabled people (Brana, 2013; “The Link Between”). Labie et al. (2015) found that disabled people were more likely to be discriminated against by MFIs. Many may argue that disabled people are less capable than non-disabled people and thus are unable to pay back loans and are not worth the risk (Martinelli and Mersland, 2010). However, there is evidence that disabled people are able to leverage microfinance successfully, save regularly, and overcome obstacles to running their businesses in creative ways (Bwire, Mukasa and Mersland, 2009; Martinelli and Mersland, 2010; Lewis, 2004).

It is imperative that women’s organizations recognize the heightened discrimination and vulnerability that disabled women face. A United Nations document on the link between poverty, gender and disability proposes microfinance as a possible method of integrating disabled women into the economy. Bwire, Mukasa and Mersland (2009) found that influencing MFIs to work with disabled people required individualized partnership, and disabled people often were misinformed about MFIs. Thus, in order to successfully reach out to disabled women in Kenya, the United Nations Women Africa should partner with the KWFT to promote outreach and education as well as eliminate discriminatory practices. While limited access to microfinance for disabled women is an issue in Africa in general, partnering with the KWFT in Kenya can serve as a valuable flagship program.

Origin/History of the Problem and Current Context

Disabled women are multiply disadvantaged, experiencing discrimination for both their gender and disability. Compared with disabled men, they experience higher rates of unemployment and less access to services such as education and rehabilitation (Parnes et. al, 2009). Compared with non-disabled women, they are less likely to get married or receive inheritance (Ibid.). Disabled girls are the most likely to be abandoned by their families, the last to get family resources, and last to be employed (Lewis, 2004). However, both the United Nations Women Africa and the KWFT currently do not have an agenda for reaching and empowering disabled women.

Martinelli and Mersland (2010) define microfinance as “the supply of financial service to micro-enterprises and poor families” (218). This can take the form of microcredit (or small loans) as well as savings, insurance, and other services (Ibid.). Many MFIs are convinced of the potential of microfinance to empower women, rural-dwellers, and other disadvantaged groups, and have a socially benevolent mission. The KWFT website claims that the bank’s mission is the “empower” and “uphold the dignity” of women (“Kenya Women”). The Kenyan government has even acknowledged the potential of microfinance to uplift disadvantaged groups, first providing credit to a struggling agricultural sector, and then broadening to provide credit to “individuals involved in both small and micro- enterprises like handcrafts and home based business” (Kiiru (2007), 2). However, disabled people have largely been left out of microfinance, due both to self-exclusion (disabled people are less likely to seek microfinance services) and exclusion from communities and institutions (Martinelli and Mersland, 2010).

Lewis (2004) asserts that “[microfinance lenders] assume that, by virtue of their disability, women with disabilities are not appropriate for microcredit or business services, or that they are adequately and better served by rehabilitation programmes and charities” (31). Martinelli and Mersland (2010) further that many MFIs argue that lending to disabled people is too great a risk. Many of the women in Zambia and Zimbabwe whom Lewis (2004) studied reported being denied loans, oftentimes “explicitly on the basis of disability” (34). One woman reported being told that “[a disabled woman] is always a beggar” when she applied for a loan (33). While there has been less research in Kenya about disability-based discrimination in microfinance specifically, there is evidence of disability-based discrimination generally in society in Kenya. In a study of disabled people in Kenya, 86% reported unequal treatment, oftentimes even exploitation from family members, and “80% claimed having experienced segregation, isolation and lack of support for their needs on the grounds of disability” (Parnes et. al (2009), 1177-1178). Thus, it is likely that disability-based discrimination extends to microfinance in Kenya.

The primary stakeholders in expanding access to microfinance for disabled women are the MFIs that will expand their services and the disabled women who will be offered microfinance. Disabled women benefit by being included in the local economy and gaining access to markets. For MFIs, there may be costs associated with expanding their services to disabled women, including translating materials into braille, hiring interpreters, hiring more disabled women, and spending  time and resources finding potential clients whom may be less likely to come to the MFI themselves. Even though disabled women may represent an untapped potential market of capable entrepreneurs, MFIs may not see the benefits as being worth all of the associated costs.

Critique of Policy Options

There have been limited attempts to target disabled women through microfinance. There have been several attempts to use microfinance to target disabled people in general, but this has been largely unsuccessful or unsustainable. Alternate policy options include: partnering with non-profit organizations and disability-focused groups rather than MFIs, and using wage incentives and training to encourage credit officers not to discriminate on the basis of disability. However, both of these policy options are flawed.

Partnering with non-profit or disability-focused organizations makes sense in theory, as helping disabled women is explicitly in line with the goals of these organizations (rather than maximizing profits, the ultimate goal of most MFIs) and thus they may be more receptive or fully invested. Martinelli and Mersland (2010) claim that these attempts were unsuccessful, in fact, because they were carried out by non-profits and disability- focused groups rather than MFIs. These groups had limited understanding of microfinance and could not afford to provide more than one loan; oftentimes the first loan is not enough for an individual to see a marked change in her life (Ibid.). Martinelli and Mersland (2010) argue that the necessary conditions for a disabled person to successfully use microfinance are no different than those for a non-disabled person: a good MFI and sufficient willingness and capacity to repay on the recipient’s part. With full information and no discriminatory biases, a good MFI should be have no reason to turn away a disabled woman who is a good candidate for microfinance, and the disabled woman should not need anything from the MFI that a non-profit or disability-focused organization would provide. Thus, the emphasis should be on eliminating biases from the side of the MFI, and finding and attracting good candidates for microfinance amongst disabled women.

In a study of MFIs in Uganda, Labie et. al (2015) find that credit officers are the most likely staff members to agree that the MFI discriminates based on disability, controlling for belief about the credit risk of a disabled person. Given that credit officers grant loans at their own discretion, Labie et. al conclude that credit officers may be “a key channel through which discrimination may operate” (4). However, they note that even a socially benevolent MFI may not wish to use wages to incentivize credit officers not to discriminate, because the more that is spent on officers’ wages, the less that is available for loans to help the poor. “Aiming for optimal mission fulfillment may drive the MFI to tolerate some discrimination,” and so wage incentives for credit officers may not be an optimal solution (Ibid., 10). Martinelli and Mersland (2010) argue for better training of employees, but this is also costly and could result in continued discrimination for the same reason. Thus, it is likely that investing in employee training or incentivizing client officers not to discriminate through wages would not be cost-effective.

Policy Recommendation

The United Nations Women Africa should partner with the Kenya Women Microfinance Bank to help it extend its services to disabled women in Kenya. If the program is successful, the UN Women Africa should replicate the program with other MFIs, as the problem is widespread. The KWFT is appropriate for a flagship partnership because it is an MFI that has been successful in reducing gender-based discrimination in a country where disability-based discrimination is still a persistent problem (“Kenya Women”; Parnes et. al, 2009). The KWFT is the only bank in Africa specifically for women, and claims 800,000 clients (“Kenya Women”). The KWFT has the institutional knowledge, expertise, and security to implement a program to target disabled women. Furthermore, it understands the needs and special considerations of women that other MFIs may not be as sensitive to. Success can be measured by the number of disabled women who are granted microfinance relative to the current level, their ability to repay loans, and differences in these women’s livelihoods following receipt of microfinance.

Policies need to be in place to ensure that women are not discriminated against on the basis of their disability, and there needs to be better outreach to disabled women so that they know how to take advantage of microfinance. I propose: (i) incentivizing MFIs to hire qualified disabled women as credit officers, (ii) ensuring that MFIs provide disability-friendly materials and services, (iii) partnering with disabled women in the community for leadership training and to understand the needs of disabled women, and (iv) outreach to disabled women to help them understand how they can take advantage of microfinance.

It may be difficult for an MFI to incentivize its credit officers not to discriminate against disabled women if they are biased against disabled women. Thus, hiring qualified disabled women as credit officers may be the most effective method to eliminate discrimination. Most MFIs have less than one percent disabled clients, and many disabled people have reported being denied microfinance on the basis of disability (Martinelli and Mersland, 2010; Lewis, 2004). Ten percent of the world population is disabled, and they are disproportionately in developing countries (Labie et. al, 2015). One in five of those who live on less than one dollar a day are disabled, and Labie et. al (2015) claim that “the low incidence of disabilities among MFIs’ customers cannot be explained by higher credit risk only” (6). As mentioned previously, wage incentives or training for credit officers may not sufficiently eliminate discrimination. D’Espallier et. al (2009) found that female credit officers were more likely to grant loans to other females, and Labie et. al (2015) recommends the same model for overcoming discrimination on the basis of disability: hiring disabled credit officers. As disabled men may have biases against disabled women on the basis on gender, it is imperative to hire disabled women specifically.

However, this model is based on the assumption that MFIs are socially benevolent. Discrimination against disabled women may be happening because MFIs are profit-maximizing and believe that disabled women are too high risk. It is important that MFIs understand that disabled women represent an untapped market, not just a social responsibility. According to Martinelli and Mersland (2010), disabled people should be presented “as resourceful entrepreneurs” rather than as “needy” (240). Lewis (2004) studied disabled women in Zambia and Zimbabwe who were granted loans, and found that they were able to overcome additional difficulties imposed on them by their disabilities in order to repay their loans and grow their businesses. Some of these mechanisms included working from home, forming business collectives in order to pool resources and skills, and rely on family members or hired assistants for services such as transportation. Martinelli and Mersland (2010) found that, in a survey on 841 disabled Ugandan business owners, 74% saved regularly and had a month’s income worth of cash on hand, in contrast to the idea of disabled people as beggars. Profit-seeking MFIs need to be made aware of these facts in order to view disabled women as a potential source of income.

MFIs may unintentionally exclude disabled people by not providing information and services that are accessible to disabled people. Lewis (2004) argues that MFIs should reach out to women with disabilities, particularly leaders of organizations, both to understand their needs and to offer information and services. Simple disability-friendly interventions include making information available in braille and through interpreters, holding meetings in accessible locations with ramps or on first floors, or making low technology adaptations of materials (Ibid.).

MFIs need to make efforts to help disabled women overcome their own self-exclusion. While exogenous discrimination is a serious reason for exclusion of disabled people, many disabled people will not seek out microfinance services in the first place due to low self-esteem. They are often the last to receive services from an early age and “have little chance to develop the confidence and assertiveness required to succeed as a borrower and businesswoman” (Lewis (2004), 32). Thus, it is important to recognize that expanding microfinance services to disabled women may require demand-side interventions – such as making disabled women aware of microfinance opportunities and helping them most effectively leverage them – in addition to supply-side interventions.

Very few disabled women even apply for microfinance because they are unaware of the services or because they do not believe their applications will be accepted. Lewis (2004) advocates for partnerships between MFIs and disabled women in order to provide training, mentorship, and support for disabled women in leadership and capacity-building. By understanding the needs of disabled women and helping them attain positions within organizations, MFIs can better serve disabled women and provide them what they need to effectively use microfinance.

Conclusion

Disabled women are a part of two groups that are frequently discriminated against, but each group is served by different organizations and interests. Rather than being uplifted by microfinance with non-disabled women, they have remained untouched by it with disabled people in general. While women’s groups have acknowledged the multiple disadvantage of the poorest and rural-dwelling women, they have not extended the same understanding towards disabled women. As with other particularly disadvantaged women, special consideration needs to be made for disabled women to ensure that they are able to access services. Extending microfinance to disabled women may have immediate positive impacts by providing these women credit to grow their businesses, and it may also have long-term impacts on the social expectations of disabled women. MFIs are in a unique position to boost the confidence of disabled women: “being trusted by a credit company… can totally change a person’s self-respect. For many disabled persons this is of absolute importance” (Martinelli and Mersland 2010, 237). Implementing the proposed policies through a partnership with the KWFT will be an effective way to increase access to microfinance and uplift disabled women in Kenya.

 

References:

Brana, S. “Microcredit: an Answer to the Gender Problem in Funding?”Small Business Economics, vol. 40, no. 1, 2013, pp. 87–100.JSTOR, www.jstor.org/stable/23360591.

Bwire, Flavia Nakabuye, George Mukasa, and Roy Mersland. “Access to Mainstream Microfinance Services for Persons with Disabilities – Lessons Learned from Uganda.” Disability Studies Quarterly 29.1 (2009): n. pag. Web. 20 Apr. 2017.

d’Espallier, B., I. Guérin, and R. Mersland (2009), “Women and Repayment in Microfinance”, RUME Working paper 2009-2.

“Kenya Women Microfinance Bank – Our Story.” Kenya Women Microfinance Bank – Banking on Women. Kenya Women Microfinance Bank, 2017. Web. 31 May 2017.

Kiiru, Joy M. “Microfinance, entrepreneurship and rural development: Empirical evidence from Makueni district, Kenya.” Global Poverty Research Group (GPRG) Conference: Oxford University, UK March 18th. Vol. 2007. 2007.

Labie, Marc, Pierre-Guillaume Meon, Roy Mersland, and Ariane Szafarz. “Discrimination by Microcredit Officers: Theory and Evidence on Disability in Uganda.” The Quarterly Review of Economics and Finance 58 (2015): 44-55. Web. 20 Apr. 2017.

Lewis, Cindy. “Microfinance from the Point of View of Women with Disabilities: Lessons from Zambia and Zimbabwe.” Gender and Development 12.1 (2004): 28-39. Web. 20 Apr. 2017.

“The Link Between Poverty, Gender and Disabilities.” United Nations. Web. <http://www.un.org/disabilities/documents/workshops/link-poverty-gender-disability.pdf>.

Martinelli, E. “Microfinance for People with Disabilities.” Poverty and Disability. Ed. R. Mersland. London: Leonard Cheshire Disability, 2010. 215-59. Print.

Parnes, Penny, Debra Cameron, Nancy Christie, Lynn Cockburn, Goli Hashemi, and Karen Yoshida. “Disability in Low-income Countries: Issues and Implications.” Disability and Rehabilitation 31.14 (2009): 1170-180. Web.

Rebecca M. Vonderlack, and Mark Schreiner. “Women, Microfinance, and Savings: Lessons and Proposals.” Development in Practice, vol. 12, no. 5, 2002, pp. 602–612. JSTOR, www.jstor.org/stable/4029405.

Sooryamoorthy, R. “Microfinance and Women in Kerala: Is Marital Status a Determinant in Savings and Credit-Use?” Sociological Bulletin, vol. 54, no. 1, 2005, pp. 59–76. JSTOR, http://www.jstor.org/stable/23620585.

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UCSD’S WINTER QUARTERLY CONVERSATIONS IN GLOBAL HEALTH

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By: Meredith Anderson
Staff Writer

On Wednesday, February 15th the UCSD Students for Global Health, the Global Health Program, and Global Forum held the Winter Quarterly Conversations in Global Health. The event focused on the topic, “Food Insecurity – Local and Global Perspectives.” Nancy Postero, a professor in the Department of Anthropology and the Director of the Human Rights program at UCSD, moderated the event.

This Quarterly Conversations in Global Health featured three speakers, who each gave a brief presentation regarding food insecurity, followed by a question and answers session. The first speaker was Dr. Hanna Garth, the Assistant Professor of Anthropology at UCSD. Garth presented on what she calls the “Global Industrial Food Complex” and how globalization has led to an increase in food insecurity. Garth provided the example of the 2008 global food crisis, a time when food prices rapidly increased while supply decreased, leading to riots worldwide. She explained how the modernization of agricultural practices caused such instability.

“These changes had the immediate effect of increasing food production across the developing world,” Dr. Garth explained. “However, the increase in green yields did not necessarily lead to a reduction in hunger or malnutrition.”

Dr. Garth continued on to suggest that the cause of malnutrition may not be insufficient food supply, but rather the inequality of distribution. Additionally, the foods commonly overproduced are grains, which can increase caloric intake but may not contain sufficient micronutrients to eradicate malnutrition. She provided an example of the United States foreign policy that promoted price supports and export subsidies on agricultural goods. This policy led to the overproduction of cheap goods, specifically corn and soybeans, which were then dumped into the global market. At the same time, many developing countries were accepting loans from the International Monetary Fund and the World Bank, which came with strings attached. These conditions included adjustment programs, which require developing nations to partake in “free market” style practices. In relation to food security, these structural adjustment programs led to the privatization and deregulation of agricultural practices in developing countries. As a result, some firms were able to produce food cheaply. This, combined with the dumping of agricultural goods at low prices from developed nations, undermined the local farmers in developing countries. The long term effect is the modern dependence on industrialized nations for food products and weakened economies of developing nations.Dr. Garth concluded by stating that food insecurity and malnutrition will persist into the future, but she challenged the audience to use the lessons learned during the 2008 food crisis to prevent future food crises.

Kelcey Ellis, the Director of Programs for Feeding San Diego, spoke next. Feeding San Diego is a local nonprofit hunger-relief organization that distributes healthy food to San Diego residents. Ellis began her presentation by showing a video featuring the diverse array of San Diego residents who have relied on Feeding San Diego for assistance. Ellis continued on to promote Feeding San Diego’s various programs and encouraged the audience volunteer with the organization to support their efforts in building a hunger-free and healthy San Diego.

The final speaker at the Quarterly Conversations in Global Health was Dr. Pascale Joassart-Marcelli, a Professor of Geography at San Diego State University. Dr. Joassart-Marcelli focused her presentation on “food deserts.” The United States Department of Agriculture defines food deserts as, “parts of the country vapid of fresh fruit, vegetables, and other healthful whole foods, usually found in impoverished areas.” When mapping food deserts, organizations typically base the accessibility of healthy foods off of the number of grocery stores in an area. Dr. Joassart-Marcelli challenged this notion in her presentation by claiming that ethnic markets, while not considered when mapping food deserts, provide communities with an abundance of fresh, healthy foods.

Dr. Joassart-Marcelli provided information from the local “Food, Ethnicity, and Place Project” that she works on. Specifically, she explained how the community of City Heights in San Diego is considered a “food desert” because it only has one supermarket. However, City Heights is home to an abundance of ethnic markets that serve the local community, which includes a large number of refugees from various countries. The study found that these ethnic markets actually supply more fresh food than supermarkets. Additionally, these markets offer what Dr. Joassart-Marcelli called “culturally appropriate foods” and often at a better price than large grocery stores. Therefore, she concluded that City Heights should not be deemed a “food desert.” Dr. Joassart-Marcelli also stated that the labeling of areas as “food deserts” has become a form of “territorial stigmatization and racialization.” Moving forward, policies must be more accepting of food suppliers, such as ethnic markets, in order to get an accurate understanding of which regions truly are “food deserts.”

The event concluded with a brief question and answer session during which the speakers discussed topics such as the global impact of animal agriculture, access to “culturally appropriate” foods, and the importance of supporting local farmers and economies.

Photo by: Neha Viswanathan

THE WORKERS WHO CAN MAKE HEALTHCARE AFFORDABLE

By Staff Writer: Jennifer Grundman

Among the many causes often touted as contributing to the high costs of American health care are lack of access to primary care and overuse of emergency department services. These two tend to be connected: Consistent primary care encourages steady use of preventive measures against chronic conditions and decreases the frequency with which people visit emergency rooms — visits that are often much more expensive than visits to a primary care provider. Though the Affordable Care Act attempts to alleviate this problem by providing greater funding for primary care and incentives for medical students to specialize in it, the dearth of primary care doctors remains ominous.8 Yet all hope is not necessarily lost, and the United States might do well to look at examples set by several countries that rely on community health workers (CHWs) to improve primary care access for underserved and lower-income people.

Precisely defining CHWs can prove elusive, since they tend to vary widely in their level of formal medical education and in their specific duties.17  Broadly speaking, they are workers who receive circumscribed medical instruction and serve communities where access to health care facilities is limited.17 The roots of CHWs as a group can be traced back to two major beginnings: First to 19th-century Russia, as physician assistants called “Feldhsers,” who worked in rustic areas with sparse connections to major medical facilities, and then to early 20th-century China, where so-called “Barefoot Doctors,” after receiving a brief health-related education, administered essential medical aid to agricultural communities.16,17  Though the CHW movement suffered setbacks in the 1980s because of restrictions on public-sector financing and poor organization of CHW programs, since the 1990s, CHWs have become increasingly common in developing nations like Pakistan, India, and several African countries. 16

Their reemergence can be attributed to their demonstrated effectiveness in the countries they serve, especially in areas like maternal health, children’s health, and in connecting rural people to physicians. A 2013 study, for instance, reported that CHWs in low-and middle-income countries were useful in delivering preventive care for mothers and children, such as in helping lower rates of diarrhea in children. 9 As USAID’s Maternal and Child Survival Program reports, CHWs can be thanked for a 37 percent reduction in child mortality over the past two decades, along with a reduction of maternal mortality by 34 percent between 1990 and 2008.5 In addition, a study published in early 2017 found that CHWs, partnered with a team of physicians and psychiatrists in a community-based mental health program in India, were able to improve rural households’ knowledge of mental health disorders, ensuring that people would be more likely to consult a doctor. 19

Despite these examples of the success of CHW programs, on a global scale, it is difficult to determine just how many CHWs are currently active; the World Health Organization, for instance, as of 2014, lacked a data set specifically concerning them. 1 This scarcity is both emblematic of the struggle to grow CHWs as a global health force and representative of the problems governments face when trying to integrate them into more formal health care systems. Without worker data, CHW advocacy groups are bereft of valuable arguments in their favor, and governments have little information to go on when justifying their inclusion in health sectors. 1 Some projects, such as the One Million Community Health Workers Campaign, seek to rectify this by pushing for increased statistics and numbers of active CHWs, basing their advocacy off of successful case studies of CHWs in several developing countries. 14

One of the most lauded CHW programs is in Brazil, where CHWs have become institutionalized as a core part of the government’s Family Health Strategy, which is an integral component of the country’s Unified Health System. This program links Community Health Agents (who are essentially the same as CHWs), nurses, physicians, and medical specialists into one team that serves an area of a few thousand people, with each Agent on the team providing care for up to 150 families.22 Started in 1994 as the Family Health Program,15 the project, as of 2015, is a major part of primary care for 62 percent of the population, an increase of 58 percent from its reach in 1998. 13 Agents working for the program visit their assigned families monthly, checking if their clients have attended their health care appointments, if they are maintaining their medication schedules, and staying up-to-date regarding any other relevant health-related information. In addition, the Agents tend to make note of any troubling indicators, such as abuse or drug usage.13

Agents are fully integrated into the Brazilian health care system and are considered government workers.23 As a 2015 report by the World Health Organization explained, Brazil’s CHW program is financed through various sources, including taxes and employer health insurance purchases, and states and municipalities are required to pay up to 15 percent of their budgets on health care.7 The health care system in general is financed by both private and public sectors, with nearly the same percentage of inpatient care covered by each, though municipal governments are, as of 2013, responsible for around 84 percent of primary care. Significantly, the number of hospitals in Brazil has not increased; there has been a conscious push in the country to emphasize primary care and downplay the “hospital-centric, curative care model” by increasing the use of ambulatory services.6 Overall, there is evidence to suggest that Brazil has mostly been successful in its aims to provide universal health care and lessen inequities in the system. From 1988 to 2010, over a quarter of Brazil’s population obtained health coverage, with 75 percent of Brazilians receiving it through the Unified Health System.3 Furthermore, studies have shown that the Brazilian health system, with its focus on primary care, has reduced hospitalizations.6

But how might CHW programs work in developed countries? In fact, it is possible to look to the U.S. for an example of how such programs are being implemented; several states have growing forces of CHWs, who are widely seen as important to improving primary care access and rendering guidance in what is often a confounding medical system. 2,20 For instance, Texas, the first state to introduce a certificate program for CHWs, 18 had 1900 CHWs in 2012, a growth of nearly 200 percent over three years. 21 As a report on CHWs in Texas reveals, a sizable portion of Texan employers were interested in increasing their numbers of CHWs, and the use of them was effective in cutting down on hospitalizations, lowering the cost of care, and promoting better use of medical homes. Some of the best-valued functions of CHWs in Texas were also found to be providing education about health and services, along with increasing clients’ access to care.21

Texas uses a type of CHW called a promotor(a), a CHW who shares a culture or lives in a region with the particular community he or she serves. These types of CHWs have been found to be especially helpful in targeting Hispanic and rural communities and people who are otherwise hard to reach.4 To become a CHW in Texas, prospective workers must either complete a training program of 160 hours or show that they have completed 1000 hours of relevant work in the past six years. As of 2012, there were around 25 facilities — such as health centers and community colleges — that offered this type of training to prospective CHWs.21

The potential benefits of a comprehensive CHW program are hard to understate, yet these programs have difficulty finding stable financing in the U.S. In the same Texas report, it was noted that the Texas Tech University Health Sciences Center Navigator Program found that CHWs were useful in serving as links between health agencies and communities, helping to manage chronic diseases and to educate communities regarding health-related matters. Funding for CHW programs, though, tends to be unsteady, comes from both public and private sectors, and mostly arrives in the form of grants.21 Auspiciously, however, the Affordable Care Act created a provision that preventive services provided by non-licensed health workers (i.e., CHWs) under Medicaid can be reimbursed, increasing the potential for states to be able to effectively use and finance CHW programs.11

One of the most universally noted assets of CHW programs has been their general tendency to lower health care costs for consumers. In the Texas report, it was found that three organizations in the private sector — Christus Health, Baylor Health Care, and Gateway Community Health Center — all saw their CHW programs result in cost-reductions through lower hospital admissions and emergency department visits, higher rates of which are typically culprits in lamentations about steep health care bills.21 Increasing access to primary care, and reducing the number of emergency room visits, especially among lower-income populations who often use emergency rooms for preventive care (instead of trips to primary care doctors who refer them to specialists, in turn forcing them to pay copayments they cannot afford) could potentially cut down on the $30.8 billion spent per year, as of 2013, by the U.S in unnecessary emergency department visits.12 Some progress has been made in this area though the Affordable Care Act,10 but more will have to be done, especially in light of the law’s uncertain future. In addition, though there are numerous case-studies exemplifying the cost-effectiveness of CHW programs, among which are studies conducted in Denver, Baltimore, and among Hispanic adults, further research is needed to create a more comprehensive view on CHW programs’ potential cost savings.2

Organizations in the U.S. that have experience with active CHW forces already have some salient recommendations for other nascent CHW programs: Support the integration of CHWs into health teams composed of other health professionals (such as physicians), increase the variety of work CHWs can practice, ensure that CHWs can effectively serve as links between patients and other health care providers, create a clear system to financially back CHW services and keep them sustainable, and provide standardized training for CHWs.20 Whether more states choose to implement CHW programs — and whether those states will follow the recommendations of those who have already done so — remains to be seen, though the effectiveness of these workers in bringing affordable primary care to larger numbers of people is becoming more evident. And in a new era of greater uncertainty about American health care’s future, expansion of CHW programs might at least provide one way of improving the industry’s accessibility.

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Works Cited:

  1. A Commitment to Community Health Workers: Improving Data for Decision-Making. Rep. N.p., n.d. Web.
  2. Bovbjerg, Randall, Lauren Eyster, Barbara Ormond, Theresa Anderson, and Elizabeth Richardson. The Evolution, Expansion, and Effectiveness of Community Health Workers(2013): n. pag. The Urban Institute. Web.
  3. “Brazil’s March towards Universal Coverage.” WHO. World Health Organization, n.d. Web.
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