MICROFINANCING OF PRIVATE MIDWIFERY

PRACTICES TO MEET MILLENNIUM DEVELOPMENT

GOALS

Rebekah Craig

Presented to: Secretary of Public Health for Tibet Autonomous Region on behalf of Touching

Hearts in Tibet INGO; 2008 Jul 4; Lhasa, TAR, China.

MEETING MILLENNIUM DEVELOPMENT GOALS

In 2000, world leaders at the United Nations Millennium Summit set forth eight

Millennium Development Goals (MDGs) to be achieved globally by 2015. The goals target

poverty, hunger, disease, empowerment for women and environmental sustainability. Three of

the goals have related public health aims to reduce child mortality (under age five), reduce

maternal mortality and reduce the spread of infectious diseases, particularly HIV/AIDS and

malaria.1 Several international coalitions and initiatives have taken on the challenge of fulfilling

one or more of these goals. The global safe motherhood movement, now in its 20th

year, is one

such initiative. Of the fifth MDG, Dr. Lynn Freedman, a leader in one safe motherhood

implementation program aptly stated, “Maternal mortality reduction is a global responsibility

that is codified in international law and endorsed repeatedly in policy statements.”2

Participants in the safe motherhood movement have identified three crucial elements in

the battle against maternal mortality: “family planning, skilled care for all deliveries, and access

to emergency obstetric care for all women with life-threatening complications.”2 The movement

aims to ensure that all births take place with skilled birth attendants and that obstetric

complications are treated in basic or comprehensive emergency care facilities. Further, Kruk et.

al. reported in a review of current literature: “Recent empiric research shows that skilled birth

attendants and emergency obstetric care (i.e. a set of interventions to treat direct obstetric

complications, from oxytocin for post-partum haemorrhage to vacuum extraction and Caesarean

section) are two of the most potent weapons in the battle against maternal mortality.”3 The safe

motherhood movement defines skilled birth attendant as a doctor, nurse or midwife.2 Evidence

reviewed in the Lancet Maternal Survival Series found that when available, midwives are

preferred to physicians as the primary providers of maternal care.4

Deployment and retention of physicians in impoverished and/or rural areas of LDCs is

difficult and costly. A study of obstetric care providers in Mozambique illustrated the problem

well. Seven years after deployment of non-physician surgical technicians and physicians to a

rural area, the retention rate for technicians was 88% as compared to 0% for physicians. In those

rural areas, surgical technicians performed over 90% of all major obstetric surgeries.2 Such

experiences suggest the deployment of mid-level medical personnel rather than physicians to

rural areas. Use of midwives as the main providers, as suggested by the Lancet Series, may

promote efficiency by expanding coverage and lowering costs. Studies demonstrate that in less

developed countries, use of physicians as birth attendants does not produce great gains in

effectiveness since the equipment and facilities needed for surgical and other advanced

interventions are often not available.4 Additionally, obstetric complications requiring surgical

intervention are rare, even in LDCs, with the most common life-threatening complications being

hemorrhage, eclampsia, infection, post-abortion complications and underlying illness.3

Contributors to the Lancet Maternal Survival Series promote as a “best-bet strategy” one of

“health center-intrapartum care” in which midwives are the primary care providers with other

attendants assisting them during procedures.4 Three other studies affirm that historically, in

Western countries, dramatic reduction in maternal mortality was achieved by providing

combined access to midwives and emergency obstetric care.3

THE CHANGING ROLE OF MIDWIVES

Midwives will play a critical role in reducing maternal mortality and achieving the

Millennium Development Goals. Midwives may enter the profession through different routes.

Some countries have direct entry training programs, while others provide midwifery training as

an addendum to nursing studies. The International Confederation of Midwives (ICM) defines a

midwife as:

…a person who, having been regularly admitted to a midwifery educational

program, duly recognized in the country in which it is located, has successfully

completed the prescribed course of studies in midwifery and has acquired the

requisite qualifications to be registered and/or legally licensed to practice

midwifery.5

Midwives and other skilled birth attendants should demonstrate competency in management of

“normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the

identification, management, and referral of complications in women and newborns” as agreed

upon by the World Health Organization, the International Confederation of Midwives and the

International Federation of Gynecology and Obstetrics.2

Recent decades, however, have seen an expansion of the role of midwives in less

developed countries beyond those traditional services. Most midwives now provide a broad

range of reproductive health services including counseling and provision of contraceptives,

diagnosis and treatment of sexually transmitted infections (STIs), post-abortion care, and basic

reproductive health education. Frequently, private practice midwives also provide other primary

care services, such as well-child visits, infectious disease management and acute care for trauma

patients. In a study of four geographically and socially dissimilar LCDs, USAID found that the

range of services provided by private practice midwives included family planning, care to

children less than five years old, childhood immunizations, voluntary counseling, diagnosis and

treatment of STIs, malaria and diarrheal diseases, DOTS (directly observed treatment short

course) for tuberculosis, manual vacuum aspiration, post-abortion care, and prevention of

mother-to-child transmission of STIs. With this expansion, USAID reports that private practice

midwives in many less developed countries may be the “frontline providers of care that impact

MDGs four through six: reduction of the mortality rate of children under 5 years old; reduction

of the maternal mortality ratio; and combating HIV/AIDS, malaria, and other diseases.”6

TARGETED INVESTMENTS FOR CLOSE-TO-CLIENT SYSTEMS

The United Nations Population Fund states that, “In all countries that have achieved

dramatic improvements in maternal mortality, professionally trained midwives have been a key

to success.”7 Given their pivotal role in meeting the MDGs, providing pregnant women access

to their services is essential. The ICM recommends a minimum of one midwife per 5,000

persons for adequate access to perinatal care alone.7 If midwives are to provide an expanded

level of service, more practitioners would be necessary to adequately serve the population.

However, a dire shortage of midwives exists in developing nations. In an analysis of

Demographic and Health Surveys (DHS) conducted in 42 developing countries, Kruk et. al.

found the mean utilization of skilled birth attendants was 53%, far short of the World Health

Organization’s goal of 100%.3 According to World Health Organization (WHO) estimates,

700,000 additional midwives would be required to produce an acceptable change in maternal

mortality rates.8 The challenge then, is how to meet this need.

In their 2005 statement, The Paris Declaration on Aid Effectiveness, nearly 200 countries

and organizations called for results-based, cost-effective development strategies.9 Needs

assessments conducted by Paxton et. al. using the UN process indicators for monitoring obstetric

care concurred. While they found “per population, most countries have enough comprehensive

facilities for emergency obstetric care but very few basic facilities,” their findings also

emphasized, “geographic distribution of facilities for emergency obstetric care is a challenge,

especially in rural areas,” and “quality of care… needs to be improved at all levels.”2 The WHO

Commission on Macroeconomics and Health examined the evidence concerning expansion of

health services and scaling up of health spending in developing nations. Most of their

recommendations do not call for great technical expertise or hospital-based interventions.

Instead, they recommend provision of health services through a “close-to-client system” – a

collection of small health facilities widely distributed throughout rural, poor underserved areas

that incorporate community-level oversight, action and accountability.10

The Kruk et. al. DHS analysis demonstrated that as governments invested more in health,

utilization of skilled birth attendants increased. A 3.7% increase in utilization for a 10% increase

in government spending was found (total health expenditures held constant, p-value = 0.048). 3

There may be as many explanations for this finding as there were means of governmental

investment in health. Governments may have lowered or abolished user fees removing some

obstructions to care, invested in training and deploying additional providers, or offered subsidies

that allowed providers to procure supplies and pharmaceuticals at lower costs. Most likely,

governments implemented a mixed strategy of these and other options. This finding implies that

increased funding for skilled birth attendants will increase utilization by potential clients. It

follows then, that increases in health spending by other investors may also produce increases in

attended births and subsequent reductions in maternal mortality, particularly if investments are

targeted to needy areas.

The Lancet Maternal Survival Series contributors suggested three considerations to guide

intervention planning and investment: “the location of women when they deliver, who is

attending them, and how quickly they can be transported to referral-level care.”4 Leaders in

global safe motherhood initiatives pose more exacting questions:

To develop and then plan for implementation of this strategy or any other

evidence-based one, the following questions are crucial for every district: where

do women give birth and under what circumstances (i.e., what proportion receives

skilled care)? Where is basic and comprehensive emergency obstetric care now

available and which signal functions are missing? What is the profile of human

resources—both clinicians and managers—that is now available compared with

what is needed? What is the present pattern of and capacity for referral (i.e.,

emergency transport, patterns of bypassing, etc)? Who is and who is not accessing

care—i.e., what is the equity profile? What are the demand-side barriers to use

and what is their relative importance?2

The authors also assert that:

Geographical targeting can be beneficial in extending access to services in the

poorest areas first. Such services include access to skilled delivery care, basic

emergency obstetric care, and transport or transport subsidies to get to hospitals.

This idea receives extensive support in published work, which reports that

geographic targeting, especially if focused on fairly small areas (e.g., district, sub-

district), is a cheap and effective way of reaching the poorest groups.2

THE PRIVATE SECTOR AND MICROFINANCE

Recent evidence demonstrates that the private sector provides 44 to 60 percent of all

health care services in Cambodia, India, Vietnam, and Uganda. Additional findings from DHS

and World Bank surveys indicate that in many developing nations, up to 60 to 80 percent of all

health services may be supplied by the private sector.6 Having noted this contribution, many

developing nations desire to invest in expansion and quality improvements of the private sector.

Although there may be several viable financing schemes for effective development of private

provider practices, including franchising and accreditation schemes, microfinance may also be

considered as a means to improve access to and increase the quality and viability of private

midwifery practices.

Microfinance institutions (MFIs), which gained notoriety through Grameen Bank’s

programs in Bangladesh, offer small loans to people in extreme poverty for entrepreneurial

projects that will generate income. Loans may be as small as $30 USD or up to several thousand

dollars. Across all sectors, most loans are less than $200 USD. Collateral requirements are

generally avoided by organizing borrowers into lending groups for accountability and/or co-

signing of loans. Often, a few members of a group are given initial loans. After repayment,

other members of the group are eligible to borrow from the repaid funds. Thus, group

accountability along with frequent required meetings for loan repayment contributes to

remarkably low default rates, generally below 5%. Loan terms are typically 6 to 12 months

although they may last up to three years, and interest rates vary from zero to about 35 percent.

MFIs typically offer business and other life-skills training for borrowers.11

The Microcredit Summit reported that microcredit is being offered by over 3,000

institutions to more than 113 million clients.12

Grameen Bank alone has served over 6.6 million

clients since 1976, 96% of whom were women.11

Microcredit is well established as a means of

helping alleviate poverty. Some evidence now suggests that microfinance programs may yield

positive health returns as well. Studies show improvements in child education and nutrition

status and women’s health and social status, particularly decreases in gender violence, among

microfinance households.12

Several studies suggest that health education could be successfully

integrated with business training programs since the borrower groups provide an avenue for

effective outreach and the health of borrowers is essential to loan repayment.13

Pronyk et. al.

reported that, “Quasi-experimental studies [of integrated microfinance-health programs] suggest

such models can lead to higher immunization rates, the adoption of healthy breastfeeding

practice, and better management of childhood diarrhea.12

Such a choice represents two different models of MFIs: a minimalist model in which only

financial services are provided and an integrated approach of combining financial services with

other services.14

Proponents of a minimalist approach argue that diversification of services

through non-financial program additions threatens MFI sustainability. Proponents of an

integrated approach retort that ignoring the health status of borrowers undermines sustainability

by endangering borrowers’ ability to meet loan obligations due to illness. Grameen Bank, for

example, reported that, “among its clients, illness and related expenditures are the leading cause

for micro-business failures and loan default.”14

The negative effects of borrower health

included: “delayed loan repayment, inability to repay loans resulting in default, poor attendance

at MFI group meetings, decrease in client business performance due to neglect and redirection of

capital and undermining MFI client group solidarity.”14

The Microcredit Summit Campaign described three delivery systems – linked, parallel

and unified – by which MFIs might integrate health services. Linked systems couple the services

of “two or more independent organizations operating in the same area”. Parallel delivery occurs

when there are “two or more programs of the same organization operating in the same area”.

Unified service delivery occurs when one organization utilizes their staff to provide financial and

health services to participants in one lending program.14

These approaches, however, neglect to

consider microfinancing of private health care providers. Investment in these needed practices

could provide much broader improvements in the health status of entire communities, not just

small borrower groups.

A DEARTH OF PUBLISHED CASES

Given the importance of skilled birth attendants, particularly midwives, in reducing

maternal mortality, meeting multiple Millennium Development Goals and providing a range of

reproductive and other health care services, and the impact of private sector providers in less

developed countries, it seems intuitive that many of the more than 3,000 microfinance

institutions would design programs aimed at increasing the number, quality and scope of such

practices. To evaluate the existence and outcomes of such programs, I performed a review of the

published literature using PubMed and Google databases. Search terms included combinations

of: “midwife/midwives/midwifery”, “private providers/practice/sector”, “skilled birth attendant”,

“developed/developing country/nation”, “microfinance/microcredit”, and “financing”. While a

significant body of literature was found addressing microfinance and health, midwifery

professional associations, clinical best practices and outcomes, reproductive health and safe

motherhood initiatives, only six documents addressed financing of midwifery practices – four

program reports and two peer-reviewed journal articles.6,15-19

The remainder of this paper

includes a discussion of that literature and policy recommendations.

BANKING ON HEALTH: WHERE’S THE BANK?

In 2005, Banking on Health, a program of the USAID, conducted a survey of private

practice midwives in the Phillipines. Over 500 midwives from nearly all regions of the country

were surveyed. Over 65% of midwives reported that lack of funds was the primary hindrance to

practice growth and 73% desired to borrow funds at that time. Loans were desired for a variety

of uses: procurement of contraceptives for resale (80%), purchase of supplies (44%), equipment

(42%), other products (39%), for investment in a facility (32%), property (14%) or for labor

expenses (7%). Only 53% of the midwives had collateral available. Most had poor business

skills – less than half knew how to keep financial records and most did not know how to obtain a

loan. Of all suitable lenders in the Philippines, only 9% had ever extended a loan to midwifery

practices. Over 78% were interested in doing so, but cited lack of funding and lack of midwife

business and clinical skills as obstacles.15

Pilipino midwives have borrowing potential similar to other microfinance clientele. They

are poor and lack essential business skills, but are already organized into optimal borrowing

groups via professional associations and have already displayed an entrepreneurial spirit by

launching into private practice. Considering the lasting impact they could have on their

communities and nation and the health improvements their practices could provide for other

borrowers, microfinance institutions would do well to respond to their present desire to borrow

money.

After reviewing several other program and global summit reports and journal articles, it

was apparent that only two countries, Indonesia and Uganda, are noted for employing

microcredit approaches to finance private practice midwives. In both instances, the USAID-

funded Summa Foundation provided microcredit and business training to midwives in an effort

to achieve the public health associated Millennium Development Goals.

THE INDONESIA MIDWIVES LOAN FUND

In 1991, the Government of Indonesia launched a program to train and deploy 60,000

new midwives to achieve complete coverage – at least one midwife in each village. After three

years of civil service midwives were expected to enter the private sector. In 1995, the Summa

Foundation helped establish a $1 million revolving loan fund to help midwives establish or

expand private practices. Loan applicants were selected based on membership in the national

midwifery association, two years minimum practice experience, general creditworthiness and

willingness to provide requested monthly reports. Attendance at borrower group and business

training meetings was required. Nearly all loan recipients borrowed the maximum of $2,200

USD (present dollar value) at 12.9% interest. A “group guarantee” method of accountability was

proposed but abandoned due to unwillingness, largely on the part of new, young village

midwives, to co-sign for loans. In lieu of this approach, 63% of borrowers were required to post

collateral. For property owners, their deed sufficed, but in an innovative and successful move,

the lending institution accepted midwives’ practice licenses as collateral. This proved an

effective motivation for timely loan repayment.16

Over a two year period ending in July 1999, the Indonesia fund disbursed loans to 575

midwives and maintained a default rate of 0.2%. From those repaid funds, an additional 674

loans were disbursed. Loan recipients saw an average of 207 new family planning clients, 77.5%

of whom had not previously accepted family planning services in the private or public sectors.

Over 11% of new clients had changed from public to private service provision. One shortcoming

of the program is that only 5.6% of borrowers were village midwives, significantly lower than

the projected 20%.16

Table 1 details the recent demographics of Indonesia. Utilization of skilled birth

attendants is still below the desired level of coverage and child mortality is quite high. Indonesia

has, however, achieved the ICM recommendation of one midwife per 5,000 population and now

has nearly universal antenatal coverage. Private practice midwives represent about 31 to 32

percent of all midwives in the country (~89,000).6

TABLE 1. INDONESIA DEMOGRAPHIC OVERVIEW*

Indonesia

Population (in millions) 222.7 (2005)

Percent of the population living on less than $1 a day 7.5 (2002)

Total Fertility Rate 2.3 (2004)

Contraceptive prevalence rate 60.3 (2003)

Percent of married woman with unmet need for family planning 8.6 (2002–03)

Percent antenatal coverage 97 (2003)

Percent of births attended by a skilled provider 66 (2002)

Less than 28 day mortality per 1,000 live births 18 (2000)

Less than 5 year mortality per 1,000 live births 38 (2004)

Maternal mortality ratio per 100,000 live births 230 (2000)

HIV/AIDS adult (15 to 49 year old) prevalence rate 0.1 (2003)

Doctors per 1,000 people 0.1 (2003)

Midwives per 1,000 people 0.2 (2003) *Adapted from White and Levin, Table 3.1, p. 8

The Summa Foundation’s program goals were to: “assist midwives in establishing or

expanding private practices, assist village midwives in establishing private practices, turnover or

revolve the Loan Fund, shift clients from public to private sector, increase number of new family

planning acceptors, sustain the value of the Loan Fund through continuous repayments, sustain

lending to midwives beyond the life of [USAID’s] involvement”. The loan fund achieved most

of those objectives. Noted design elements that contributed to program success were: “partner

expertise and responsibilities, borrower criteria, loan terms and conditions, promotion of Loan

Fund, coordination of partners and management of default”. However, constraining design

elements were: “borrower criteria, dissemination of policies and procedures, operating structure

and logistics of loan disbursements”.6

THE UGANDA PRIVATE PROVIDERS LOAN FUND

There are three published reports that describe aspects of the Uganda Private Providers

Loan Fund. In 2001, the Summa Foundation initiated the program with disbursement of 15 loans

to private practice midwives in Uganda. The program objectives were to strengthen the capacity

of private health providers and increase access to quality reproductive health services. In

addition to the lending criteria for the Indonesia microcredit program, further criteria applied.

Only midwives who owned their own private clinic were accepted, group guarantee was

required, they were willing to accept unannounced visits by program staff and were willing to

keep family planning products in constant supply. Loan terms were from 6 months to one year

with a 20% mandatory savings requirement. Mandatory business training was provided. Prior to

this training most midwives could not keep adequate service statistics or financial records or

separate monthly personal and business expenses.17

Initially, 15 midwives borrowed an average of $454 USD. Eleven of those borrowers

repaid their loans and took second loans averaging $742 USD. Of the first loan disbursements,

87% purchased pharmaceuticals, 47% invested in equipment and 40% in facility renovations.

The second disbursements were used for pharmaceuticals (91%), equipment purchases (55%)

and facility renovations (73%). Pharmaceutical sales represent a quick means of making profit

to repay the loan and most midwives took advantage of this market. Once comfortable with the

process, midwives were eager to borrow again for more costly facility renovations.18

During the second disbursement period in 2002, the applicant pool was expanded. While

midwives represented 44% of loan recipients, the pool included nurses (30.5%), clinical officers

(15.4%), and doctors (8.9%). Over 17% of borrowers practiced in rural areas. Average loan size

increased to $920 with a breakdown in usage similar to that of first round recipients.19

In addition to the microfinance intervention clinics, comparable non-intervention clinics

were selected for case-control analysis. Prior to and following the loan periods interviews were

conducted with several hundred clients at clinics in each category. During the first loan cycle, a

net positive impact of the intervention was demonstrated in four quality indicators: “perceived

availability of drugs, fair charges, cleanliness, and privacy”. Anecdotally, midwives reported

improvements such as lowering resale price of drugs because loan funds allowed them to make

bulk purchases at wholesale prices and building room dividers to provide client privacy and

better utilize clinic facilities.18

Analysis of client interviews from second loan cycle recipients revealed that perceived

availability of drugs and fair charges were the most important factors for client loyalty (reasons

for always choosing that clinic). Perceived range of services and essential equipment were not

predictors of client loyalty. Seiber and Robinson reported: “The strongest finding was that the

program improved sustainability at loan clinics through the enhanced and increased provision of

curative services, namely the consistent availability of drugs.”19

Intervention clinics saw and

average increase in patient load of 5 clients per week compared with comparison clinics. There

was no significant change in the number of preventative visits to loan clinics at follow-up.

However, in loan clinics, “respondents were four times as likely to cite drug availability in the

follow-up survey as the reason for their loan clinic choice,” indicating that private providers

represent an important source of supply for curative services.19

In contrast to Indonesia, the availability of vital reproductive health services in Uganda

needs significantly more investment. There are half as many midwives as recommended for the

population and private practice midwives represent only about 12 percent of all midwives in the

country (~5,000).6

TABLE 2. UGANDA DEMOGRAPHIC OVERVIEW*

Uganda

Population (in millions) 28.8 (2005)

Percent of the population living on less than $1 a day 84.9 (1999)

Total Fertility Rate 7.1 (2004)

Contraceptive prevalence rate 22.8 (2001)

Percent of married woman with unmet need for family planning 34.6 (2000–01)

Percent antenatal coverage 92 (2001)

Percent of births attended by a skilled provider 39 (2001)

Less than 28 day mortality per 1,000 live births 32 (2000)

Less than 5 year mortality per 1,000 live births 138 (2004)

Maternal mortality ratio per 100,000 live births 880 (2000)

HIV/AIDS adult (15 to 49 year old) prevalence rate 4.1 (2003)

Doctors per 1,000 people 0.1 (2004)

Midwives per 1,000 people 0.1 (2004) *Adapted from White and Levin, Table 3.1, p. 8

SUMMARY OF LITERATURE REVIEW

USAID’s assessment in the Philippines demonstrated that private practice midwives

obviously desire to borrow funds, but like many microcredit recipients have little or no collateral,

business skills and borrowing experience. Expectedly, traditional lenders are hesitant. However,

the midwives surveyed are organized into natural borrowing groups through professional

associations, have already displayed an entrepreneurial spirit by starting private practices, and

represent an ideal target group for microfinance institutions.

Due to the widespread lack of access to skilled birth attendants, Indonesia employed a

novel approach of extending microcredit loans to enable midwives to launch private practices.

The loan fund was successful in extending and recovering funds. One notable shortcoming was

the low level of village midwives accepted as loan recipients. Village midwives were perceived

as a greater risk because they have less opportunity to develop financially self-sustaining

practices.16

However, it is the geographic areas they serve that need the most intervention. This

outcome underscores a major criticism of microfinance schemes - that microfinance does not

reach the poorest of the poor who need it most. Donors and public health planners must devote

energy to designing viable financing schemes for such high-risk practices.

The Uganda experience demonstrated that microfinance can have a net positive effect on

strengthening capacity for private practice reproductive health providers. Once midwives

acquired business skills and borrowing experience they were eager to take bolder steps in

building capital for their practices (facility renovations, purchase of land, etc). It is evident from

this intervention that financing quality improvements can increase sustainability for private

midwifery practices. If the midwives can be further encouraged and enabled to invest in savings

accounts and acquire more skills in inventory management and pricing, perhaps the practices

could eventually turn enough profit to enable continual bulk wholesale purchasing of

pharmaceuticals - an important predictor of client loyalty and therefore of practice sustainability.

POLICY RECOMMENDATIONS

Microfinance institutions need only take a minimalist approach to financing private

practice midwives. Integration of health education is not necessary as they have already received

specialized training. MFIs that are concerned with threatening sustainability with non-financial

program additions could target midwives and other health sector providers and focus on financial

management and business skills training in borrower meetings. For start-up MFIs, lending to

private health providers may be a less risky early investment with long-term, broad-reaching,

quantifiable community benefits. It is my opinion that microfinancing of private health practices

should be a strongly recommended and promoted development strategy. Not only would

microfinance households garner the benefits of increased social and economic empowerment, but

because of the nature of their business, entire communities could experience great health

improvements which translate into community-wide economic gains.

A layering of microfinance approaches is recommended, tailored to a community’s

specific needs. The Indonesia program helped expand access to midwives by financing new

private practices while the Uganda program strengthened capacity and sustainability of existing

practices. Layering these two approaches could yield maximum progress toward meeting

Millennium Development Goals and securing overall private health sector sustainability.

Uganda, for instance, still needs to double access to skilled birth attendants. A bi-phasic

approach of initially financing new practices followed by capacity building, quality improvement

loans may help accomplish that goal.

Lastly, I recommend that once acceptable quality, financially self-sustaining practices are

established, local practitioners partner with local microfinance institutions to adopt a linked

delivery system for the integration of health education and curative services with microfinance

programs. Midwives are organized in regional, national and international organizations that

could easily partner at each of those levels with microfinance institutions. In doing so midwives

will, in turn, become investors - giving back to the lending institutions, participating in a broader

national and international health investments, and serving as inspirational role models of

successful entrepreneurship to their communities.

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