Academic journal article Bulletin of the World Health Organization

Assessing the Incremental Effects of Combining Economic and Health Interventions: The IMAGE Study in South Africa/Evaluation Des Effets Supplementaires Produits Par la Combinaison D'interventions Economiques et Sanitaires: Etude De l'Intervention IMAGE En Afrique Du Sud./Evaluacion De Los Efectos Incrementales De la Combinacion De Intervenciones Economicas Y Sanitarias: Estudio De IMAGE En Sudafrica

Academic journal article Bulletin of the World Health Organization

Assessing the Incremental Effects of Combining Economic and Health Interventions: The IMAGE Study in South Africa/Evaluation Des Effets Supplementaires Produits Par la Combinaison D'interventions Economiques et Sanitaires: Etude De l'Intervention IMAGE En Afrique Du Sud./Evaluacion De Los Efectos Incrementales De la Combinacion De Intervenciones Economicas Y Sanitarias: Estudio De IMAGE En Sudafrica

Article excerpt

Introduction

The United Nations Millennium Development Goals have articulated a global agenda that explicitly recognizes the importance of addressing the intersections between poverty, gender inequalities and health. (1) Microfinance programmes expand access to credit and savings services. Globally they reach over 100 million poor clients, most of them women. (2) In addition to the economic benefits of microfinance, there is some evidence to suggest that it may be an effective vehicle for empowering women. Acquiring new business skills may enhance their self-esteem, self-confidence, conflict-resolution ability and household decision-making power and expand their social networks. (3-5) Reductions in child mortality and improvements in nutrition, immunization coverage and contraceptive use have also been demonstrated, (3,6-8) which has sparked interest in the potential of microfinance to bring about improvements in connection with other health-related issues, such as HIV/AIDS and gender-based violence. (9-12)

Both HIV/AIDS and intimate partner violence (IPV) are major public health challenges in sub-Saharan Africa. In South Africa alone, 29.1% of women visiting public antenatal clinics in 2006 were HIV-positive, (13) and national prevalence surveys suggest that women and girls make up 55% of the HIV-infected population. (14) In addition, 1 in 4 South African women reports having experienced IPV, (15) which has been identified as an independent risk factor for HIV infection. (16)

We conducted the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study, a cluster randomized trial, to evaluate the effect of a combined microfinance and training intervention on poverty, gender inequalities, IPV and HIV/AIDS. Carried out in rural South Africa, IMAGE combined group-based microfinance with a 12-month gender and HIV training curriculum. Women received the training at loan meetings held every two weeks. After 2 years, IMAGE participants showed improvements in economic well-being and multiple dimensions of empowerment. (17) Furthermore, levels of physical and sexual IPV were 55% lower among IMAGE participants compared with controls, (18) and young programme participants reported higher levels of HIV-related communication and HIV testing and greater condom use with non-spousal partners. (19)

These findings highlight the potential synergy that can be generated by integrating targeted public health interventions into development initiatives such as microfinance. By addressing the immediate economic priorities of participants, IMAGE was able to gain access to a particularly vulnerable target group and to maintain sustained contact for over 1 year--a critical opportunity rarely afforded to stand-alone health interventions.

Because the IMAGE study tested a combined microfinance--training model, the findings raise additional policy- and programme-related questions. For example, how much of the observed effect is attributable to the microfinance component of the intervention and how much to the training programme? In a donor climate where microfinance institutions are under growing pressure to recover their operational costs and achieve financial sustainability, what added value does health training contribute? Is it possible that the provision of microfinance services alone would produce a similar range of economic, social and health benefits?

To address these questions, we analysed data from villages participating in IMAGE, matched villages receiving microfinance alone and a control group. Our analysis compared indicators of economic well-being, empowerment, IPV and HIV-risk behaviour in these three groups after similar duration of exposure.

Methods

The study was conducted between June 2001 and March 2005 in rural Limpopo province, an area where, despite South Africa's status as a middle-income country, poverty remains widespread and more than 60% of adults are unemployed. …

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