Issue 18 July could improve the health of participating individuals through greater access to nutrition and primary care.

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1 THE NEED TO MEASURE MICROFINANCE Issue 18 July 2011 MADAKTARI AFRICA: PHYSICIANS TRAINING PHYSICIANS IN TANZANIA...2 PEDIATRIC GLOBAL HEALTH FELLOWSHIP Global Health ENCOURAGING ACTIVISM IN GLOBAL HEALTH THROUGH KNOWLEDGE, INNOVATION AND ENGAGEMENT The Need to Measure Microfinance link Center for Global Health faculty profile of John Brett, PhD, Associate Professor in the Department of Anthropology, University of Colorado Denver In the 1990 s microfinance, or the strategy of granting small loans to individuals below the defined poverty threshold, gained popularity among many international organizations seeking to improve the economic status of citizens in developing nations. In exchange for a small loan, often equivalent to under a $100 U.S. dollars, microfinance participants could create a business or entrepreneurial opportunity, from which they would repay the loan and generate sustainable income for themselves and their families. Hailed as a strategy to support and empower individuals, primarily women, early on it was assumed that microfinance would lead toward financial security and sustainability among many of the world most poor communities; and by extension, microfinance could improve the health of participating individuals through greater access to nutrition and primary care. Despite its popularity and twenty years of implementation, limited research has been conducted to show the strategy s efficacy in meeting the end goals of poverty reduction and health improvement. Moreover, emerging research findings illustrate a complicated picture of the impact of microfinance. University of Colorado Denver Associate Professor of Anthropology John Brett, PhD is among the researchers expanding the evidence base used to evaluate microfinance and measure its impact on health and nutrition.1 (Continued on page 4) The Center for Global Health has moved. Our new physical location on the Anschutz Medical Campus is: East Montview Boulevard, Suite 310. Come and visit us in the UPI Building on the North end of the Campus! 1

2 Madaktari Africa: Physicians Training Physicians in Tanzania An Interview with Kevin O Lillehei, MD, Professor and Ogsbury-Kindt Chair at the University of Colorado School of Medicine and Director, Neuro-Oncology Program at the University of Colorado Hospital. Dr. Lillehei (pronounced Lily-hi) is one of thousands of talented neurosurgeons in the United States. When he travels to Tanzania, however, his presence in the country brings the grand total of neurosurgeons up to about five. economically advanced city], they ve hardly got anything [in the way of medical care], so Why neurosurgery? It seems like they need neurosurgery like they need a hole in the head. He s working on increasing that number through the organization called Madaktari Africa. Madaktari is a Swahili word for doctor and Lillehei is working with Madaktari to implement a program where doctors teach doctors. The model works on the basis of doctors and other health professionals volunteering their time to train Tanzanian counterparts in techniques that may be new to local physicians and professionals. In the instance of neurosurgery, Dr. Lillehei and four or five other surgeons each rotate spending short stints in Tanzania offering training. Working with a carefully chosen surgeon in a stepwise training program that is somewhat like a residency, Lillehei and his colleagues impart vital new skills to the neurosurgeon in training in his own setting. This gives the surgeon the opportunity to continue serving his patient population, while still having the opportunity to work in a program of one-on-one teaching and mentoring. Of course, one limitation that the Madaktari crew confronts is that Tanzania is a resource-poor setting with very little medical infrastructure. Lillehei mentions, The question that is always asked, and we have to justify ourselves, is that we ve got a country that, outside Dar es Salaam [the most 2 As more and more people go over to Africa to volunteer and do their programs, the awareness of that (absence of infrastructure) becomes evident. We need to help them with their infrastructure, not just throw equipment at them. They ve got the equipment; we ve got to teach them how to use it and how to repair it, Kevin Lillehei, MD All joking aside, while neurosurgery might not appear to be an immediate need in such an undeveloped area of the world, the reality is that if steps are taken to make neurosurgery possible in one of the regional hospitals, it follows that the standard of care throughout the whole hospital will have been greatly elevated. Dr. Lillehei offers an example, To perform neurosurgery, you need an intensive care unit that can really function, and you re going to have to strive for that improvement, and that s not just to benefit neurosurgery, it is going to enhance the standard for everyone. But there are two sides to the coin. Although the hospitals undoubtedly lack essential equipment like ventilators and oxygen saturation monitors, when the hospital does receive donated equipment, often times the donations replace closed up in a shipping container located in a lot behind the hospital. In speaking specifically about ventilators at one of the regional hospitals, Dr. Lillehei comments, Nobody s unloaded them, nobody knows how to use them, and nobody wants to learn how to use them unless there is someone there who can actually teach them. So while there is a definite need for equipment to make the feat of neurosurgery possible, the equipment that is (Continued on page 3)

3 (Continued from page 2) donated is worthless without training the recipients to set up, use and repair it. This is why education is the root of Madaktari Africa s approach to building medical infrastructure. The idea is that utilizing experienced specialists to train Tanzanians has the efficacy of a bottom-up, or grass-roots approach that will eventually have a cascading effect in the community. This model could work for biomedical equipment specialists, or nurses, or community health workers. For Dr. Lillehei the teaching experience pertains to instructing new surgical procedures such as myelomeningocele closures for kids with spina bifida, which is still a prevalent issue in Tanzania. Another common procedure that Lillehei has trained on is the installation of shunts in pediatric patients with hydrocephalus. He finds this continuing education method fulfilling because it is not just placating a need for neurosurgeons and other specialists, he explains that, It s about leaving something behind when you go there. Every time you go, you teach a few new procedures, so that when you leave they can continue to do procedures to their level of comfort. Speaking of one of his trainees, Dr. Lillehei mentions, Now after three or four years of people coming and training him, we ve got a designated neurosurgeon, who will in turn, have the ability to educate other Tanzanian doctors who follow in time. Dr. Lillehei operating in the field in Africa. To learn more about Dr. Lillihei and his work go to: ucdenver.edu/academics/colleges/medicalschool/ departments/neurosurgery/faculty/clinicalfaculty/pages/ lillehei.aspx Learn more about the work at Madaktari Africa go to: Tanzania In Tanzania and other East Africa countries, there is a frightening lack of physicians and other healthcare workers. Which means healthcare in Africa is in real trouble. Tanzania has 5.2 healthcare workers for every 10,000 people. That's as scary as it sounds. That's the lowest number of physicians per persons in the world. And, the shortage of healthcare workers is getting worse. Currently, 25,000 healthcare workers are trying to serve a population of 40 million. The problem doesn't end there. 85% of Tanzanians live in rural areas with rugged roads and little to no transportation. So, a trip to a healthcare facility is difficult and often dangerous. But where there is a challenge, there is also opportunity. 3

4 The Need to Measure Microfinance (Continued from page 1) As a nutritional anthropologist, Brett s interest in microfinance first emerged during a research trip to Bolivia where he was to conduct research on diet and dietary change among local women. After spending several months interviewing women about the factors that they considered when making dietary decisions for their families, Brett noticed a common thread among the responses - microfinance. Dr. Brett conducting focus groups. It was through focus groups and interviews that he first began to learn more about the challenges of microfinance and the limited research conducted to date showing the efficacy of microfinance as a development strategy. Microfinance kept coming up, prompting me to ask why, states Brett. The answers were broadly disturbing in that they were frequently We sacrifice and eat less. Given the frequency of this response, Brett believed it was important to better understand the relationship between microfinance and food. Brett began to unravel the relationship by conducting in depth interviews with 28 women in El Alto, Bolivia, and participant observations with 50 women within their homes, places of business and microfinance organizations. For those interviewed, Brett began by asking Is there a relationship between household food security and microfinance participation? He followed up with details on the amount of money each interviewee borrowed, repayment costs, input costs, business enterprise, income from sales and the interviewee s experience as a microfinance entrepreneur. Brett s research revealed inconsistencies in the methods used by micro lending organizations to improve participant success, including training for participants to improve their businesses and access to a primary care clinic. With inconsistencies in process and strategy, Brett saw inconsistencies in outcomes. would seem likely that nutrition and access to health care would improve, says Brett. Since participation in a microfinance program provides an individual with the cash to create and sell goods, it presumably will lead toward profit generation and thus income. However the price of goods is independently set through the free market. If prices are depressed then the income generated by sales may not cover the cost of goods. Additionally, when limited income is generated, participants may have to choose between using income for loan repayment versus covering household needs, such as food consumption or access to primary care. If my initial findings and those of the current study are borne out, then [microfinance] is a mixed picture. Some clearly benefit but a Microfinance kept coming up, prompting me to ask why, states Brett. The answers were broadly disturbing in that they were frequently We sacrifice and eat less. substantial number (up to half) may in fact not receive benefit. Given the uncertainty about the success or outcomes of microfinance participation, Brett believes that additional research is necessary to better understand the actual, versus ideologically impact of microfinance programs. But Brett is not quick to degrade the development strategy; rather he focuses on its lack of scientific evaluation. John Brett, PhD There are multiple case examples where clearly households have benefited through participation, often immensely, comments Brett. The Internet and promotional materials are littered with these individual cases. But very little research that looks at the impact of microfinance at the population level has been done. But beyond the inconsistency in the operation of a lending program, Brett accounted for inconsistencies in impact due to independent factors such as the social, economic and political factors of participants households, communities and Bolivia as a nation. According to some analyses, these factors may have a very real impact on a program s success and on an individual s ability to gain value from participation. If net income rises and remains generally higher, then it It has relatively little to do with microfinance per se, which makes a lot of sense in many ways; but the way it has been developed globally since the early 1990 s and the fundamental failure to engage in the hard, controlled studies that will demonstrate impact on populations, is discouraging and irresponsible. In response to this concern researchers like Brett, and his colleagues at the Center for Global Health, may partner with industry and nongovernmental organizations to evaluate programs, identify problems, implement solutions and measure their impact. Hopefully, the outcome will be more than scientifically proven success, but a meaningful and measurable improvement in the health and financial security of individuals in developing countries like Bolivia. (Continued on page 5) 4

5 John Brett is an associate professor in the departments of anthropology and health and behavioral sciences at the University of Colorado Denver College of Liberal Arts and Sciences. He holds a PhD in anthropology from the University of California Berkeley and his research interests include evolutionary medicine, ethnobotany, medical anthropology, evaluation research and nutritional anthropology. To read more about Dr. Brett and his work go to: globalhealth.ucdenver.edu. 1Brett, J, We Sacrifice and Eat Less : The Structural Complexities of Microfinance Participation, Human Organization, Vol. 65, No. 1, 2006 Copyright 2006 by the Society for Applied Anthropology. Abstract: Having borrowed money from a microfinance organization to start a small business, many women in El Alto, Bolivia are unable to generate sufficient income to repay their loans and so must draw upon household resources. Working from the women s experience and words, this article explores the range of factors that condition and constrain their success as entrepreneurs. The central theme is that while providing the poor access to credit is currently very popular in development circles, the social and structural context within which some women operate so strongly constrains their productive activity that they realize a net income loss at the household level instead of the promised benefits of entrepreneurship. This paper explores the social and structural realities in which women seek out and accept debt beyond their capacity to repay from the proceeds of their business enterprise. By examining some of the hidden costs of microfinance participation, this paper argues for a shift from evaluation on outcomes at the institutional level to outcomes at the household level to identify the forces and factors that condition women s success as microentrepreneurs. While there has been much discussion on the benefits of microcredit lending and increasing critique of it on both ideological and substantive grounds, there have been few ethnographically informed studies on consequences to users. The Colorado School of Public Health Center for Global Health of the University of Colorado is accepting applications for a one year fellowship training program in Pediatric Global Health for July Applicants have completed an advanced degree in a global health related field (Master's or PhD degree) or a pediatric residency with evidence of research training and international experiences related to global health. Preference will be given to applicants with research training who have participated in successful research projects. The mission of this fellowship program is to provide the mentoring, training, course work, and experiences for fellows to eventually become independently funded global health investigators with the capacity to design, implement, and evaluate innovative global health programs in a collaborative manner. Pediatric Global Health Fellowship It is important for fellows to recognize that it will take at least 3 to 5 years after completing the fellowship to reach this goal. The fellowship will provide both the foundation and opportunity for a successful career in global health that may involve research, program development and implementation, and policy. The fellowship structure will be flexible based on the fellow's degree, training, and experiences. An additional year of fellowship training may be available but is not guaranteed. The key component for any fellow will be the selection of a mentor and a thematic area of maternal and child health. This decision will impact almost every component of the fellowship curriculum, which will include participation in research seminars, advanced course work in the School of Public Health, clinical care experiences (for clinicians), and international field work related to the thematic area of maternal and child health. To learn more about the Fellowship in Pediatric Global Health, please go to: 5 University of Colorado Denver Center for Global Health Mail Stop A090, E Montview Blvd, Suite 310 Aurora, CO