Integrating Health with Microfinance: Community Health Workers in Action

ESAF Microfinance implemented a
pilot project on community health
workers (Arogya Mithras) in five
branches of Palakkad district of Kerala state with funding support from Johnson & Johnson. Under this
project, ESAF selected 12 women from among their clients and trained them to deliver education
promoting healthy habits to prevent non-communicable diseases (NCDs) such as hypertension, diabetes,
and cancer. The Arogya Mithras were also trained to measure blood pressure (BP) and blood sugar and
record them. After undergoing the training, the Arogya Mithras facilitated health lessons to 1782 SHG
members and have 1851 clients (in January 2015) whose BP and blood sugar readings they monitor.
Arogya Mithras, on average, have a very modest income of Rs. Rs. 660 per month.
Implementation of this pilot project had many challenges. The drop-out of selected and trained Arogya
Mithras because they could not be away from home resulted in cost and time overruns for ESAF. Most
of the clients, being wage earners, were available only in the late hours for education sessions. Training
the Arogya Mithras to measure blood pressure using a stethoscope took longer than expected. The
retail cost of procuring testing strips and needles for blood sugar measurement was much higher,
leaving very little profit margins. In spite of challenges, ESAF persisted with the project and in the
process had many insights in promoting the practice of community health workers.
Health education has enhanced awareness about unhealthy habits that lead to hypertension and
diabetes and foods to be avoided for preventing these diseases. Health risks of hypertension and

An Arogya Mithra tests for blood sugar levels at an ESAF health screening camp.

Arogya Mithra Marykutty says about the program, “This idea is so
innovative that I am happy to be doing real community service yet
earn some money for myself and my family.”

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diabetes and the importance of having a yearly medical check-up are also well understood by
participants. Increased awareness has brought about welcome changes in practices. Participants to the

project are now getting their blood pressure and diabetes checked at least once a year. Monthly check-
ups have become popular with those who are diagnosed to be suffering from these diseases

Average net income of Arogya Mithras is very modest and not sustainable. ESAF is keen for the
sustainability of the Arogya Mithras and are exploring ways for enhancing their income. ESAF is engaging
them for measuring BP and blood sugar in the NCD screening camps they conduct. ESAF is also exploring
the possibility of making it mandatory for all clients to undergo test for BP, blood sugar, and hemoglobin
with each loan cycle1

. And engage Arogya Mithras for this work and pay for their services. Such a step, if
implemented, would open the doors for engaging Arogya Mithras in all the branches of the organization.
MFIs have the capacity for promoting community health workers. However, MFIs have to work hard to
ensure their sustainability. If MFIs have a strong commitment to make positive changes in the health
seeking behaviors of their clients and their families, working through community health workers is an
interesting possibility.
1.0 INTRODUCTION:
1.1. Relevance of the project
The world health statistics 2012 report, released by the World
Health Organization (WHO), focuses on the increasing burden
of non-communicable diseases (NCDs) across the world. While
most of the developed countries witnessed rise in NCDs at a
time when the communicable diseases had reached
significantly lower levels, India is witnessing the “double
burden” with high rates of NCD morbidity and mortality at a
time when the communicable diseases have yet not been
controlled. Substantial variations exist between different
regions, but risk levels are rising across the country, most
notably in demographically and economically more advanced
states of India, like Kerala State.
NCDs are chronic diseases, requiring prolonged treatments,
with significant financial implications for poor households. The National Sample Survey Organization
(NSSO) of India found in its survey that among those who did not seek health care for a medical illness in
the past 15 days, nearly 30 percent rural and 20 percent urban respondents cited financial reasons. In

1 The first loan cycle is for one year, and from the second cycle onwards, it is 2 years.

A client of ESAF Microfinance

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the case of NCD treatment, the figures are likely to be still higher because of the much higher cost
involved in their diagnosis and treatment.
Delaying treatment of NCDs is very unfortunate and inefficient because it leads to higher cost. When
treated late, treatment costs are higher and effectiveness of treatment is lower. As the prevalence of
NCDs rises, there will be greater demand for NCD-related health care services, including diagnosis and
treatment. In India where the ratio of health workers per 10,000 population is less than 0.5, the human
resource challenge for effectively addressing NCDs is immense (Indian Journal of Community Medicine,
2011). What makes the situation further grim is the inequitable distribution of physicians and other
paramedical workforce in urban and rural areas. However, some innovative models for service delivery
from India have shown that the para-health care workers can be used effectively for NCD risk
assessment and management.
1.2 Pilot project in Palakkad district in Kerala state
Kerala has achieved the status of a developed country in terms of human development indices.
However, performance of the state in respect of diabetes and cardio vascular diseases is abysmal.
Findings of the study by the Achutha Menon Centre for Health Science Studies, published in January
2010, show that 16.2 percent adult population in the state is afflicted with diabetes. Hypertension was a
whopping 32.7 percent. The study also found 30.8 percent of the study population (which included
7,449 individuals between 15 and 64 years of age, with 51 percent being women) to be overweight.
Abdominal obesity was 39.4 percent. Cholesterol levels above 200 mg/dL were found in 56.8 percent of
the population. Also, Kerala has the largest proportion of elderly people, which is growing at an alarming
rate. With millions of young men migrating for work in the Middle East, the elderly, left alone in their
homes, are badly in need of home-based medical care and services.
Developing models that deliver as much care as possible close to a patient’s home is therefore critical.
From a more positive standpoint, health care in the home environment is more comfortable for
patients, offers less risk of infection and lends itself to the promotion of ongoing strategies to improve
patients’ quality of life.
Having understood the need to address the fast growing malady of non-communicable diseases (NCDs)
in Kerala, ESAF found it necessary to pilot an innovative project aimed at training some of their active
clients as community health workers (Arogya Mithras). It was envisaged to deploy these Arogya Mithras
for facilitating health education sessions to self-help group (SHG) members on prevention of
hypertension, diabetes, and cancer by cultivating healthy habits. Considering the demand that exists in
rural Kerala for door-step service to regularly monitor blood pressure (BP) and blood sugar, it was also
envisaged to deploy the Arogya Mithras to charge a nominal fee for this service.
Palakkad district was chosen for the pilot as the expertise and support of the staff of ESAF Hospital
located in Palakkad could be sought from time to time. Also, focus group discussions (FGDs) with the

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clients in Palakkad district had revealed the huge demand for such services. FGDs also revealed that
some of the microfinance clients were interested to be health entrepreneurs themselves.
1.3 ESAF’s strength in implementing the Arogya Mithra project

ESAF Microfinance, having its presence in seven states of India and reaching out to over 700,000 low-
income families with financial services, has been actively engaged in offering credit-plus services to

facilitate the overall growth and development of poor families. Direct health is the most important
health plus services being offered by ESAF.
ESAF has been making conscious efforts to improve the awareness levels of its clients on matters related
to their health so that they do not lose their hard-earned money on medical expenses and also do not
lose their wages due to a day lost to ill-health. ESAF has supported 10,000 families to construct toilets
and also enabled water connections at their door step so that better health and hygiene is ensured.
ESAF also delivered lessons on reproductive and child health, prevention and management of HIV/AIDS,
WASH (water, sanitation, and hygiene) to 35,626 women clients in 2014.
ESAF also has the experience of running a hospital and a clinic in Palakkad district.
1.4 Project objectives
ESAF partnered with Microcredit Summit Campaign and
Freedom from Hunger during 2011-13 to deliver health
education to their clients in the backward districts of
Maharashtra, Madhya Pradesh, and Chhattisgarh states. In
this phase, they delivered modules on maternal and child
health. Encouraged by the results of this health education
project, as evidenced by positive outcomes both in terms of
knowledge and awareness, as well as behavior and practices,
ESAF decided to diversify the health services by creating a
cadre of health entrepreneurs (Arogya Mithras) from among
SHG members and leaders.
It was envisaged that Arogya Mithras would facilitate health
education modules on healthy habits to be practiced for the
prevention of NCDs, particularly hypertension and diabetes.
In addition, the Arogya Mithras would monitor the blood
pressure and blood sugar of community members and,
wherever necessary, make referrals to appropriate health
care providers. They would collect a small fee for their
services to earn a modest income.

An Arogya Mithra trained by ESAF

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The primary objectives of the project were:

  1. To train SHG members as health entrepreneurs (Arogya Mithras) for facilitating health lessons
    on healthy habits for the prevention of NCDs to their fellow members and also non-clients of the
    community.
  2. To train the Arogya Mithras to provide home-based monitoring and referral services for
    prevention, diagnosis, and management of these diseases.
  3. To increase opportunities for income generation for SHG members through their health-related
    services to their own community.
    The potential outcomes of this delivery model included:
     Enhanced knowledge and awareness for the village community about prevention of NCDs, such
    as hypertension and diabetes.
     Adoption of practices that help prevent hypertension and diabetes.
     Identification of high risk persons and patients of hypertension and diabetes and refer them to
    suitable health care services.
    2.0 IMPLEMENTATION OF THE PROJECT
    2.1 Selection of project area
    ESAF Microfinance selected five branches (Kozhinampara, Koduvayur, Chittur, Pudunagaram, and
    Palakkad) in Palakkad district for implementation. The selection of branches was based on the following
    criteria:
     Branch is at least five years old, so that a good relationship with community members has
    already been established by ESAF staff.
     Clients show enthusiasm to participate in education.
     A few enthusiastic members who are willing to become Arogya Mithras.
     Branches where community needs for home-based health monitoring is high.
     Microfinance staff shows enthusiasm to support the project.
     All the selected branches are in a cluster and almost equidistant from each other.
    2.2 Selection of Arogya Mithras
    Arogya Mithras were chosen from out of active women clients of ESAF who were school educated (at
    least completed 10th class). Preference was given to those who had the support of their family.
    Accordingly, an advertisement on a printed pamphlet mentioning the project details and the essential
    and desirable qualifications was sent across the selected branches. An interview panel comprising of the
    director of social initiatives, the senior manager for social performance management (SPM), and the

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nursing superintendent of ESAF Hospital was formed; they selected 20 women after interviewing 50,
which was an average of three to four Arogya Mithras per branch.
2.3 Freedom from Hunger education module, “Healthy Habits for Life”
The facilitator guide developed by Freedom from Hunger, “Healthy Habits for Life,” like all of their other
health education modules, is well scripted, explaining every action to be made and every word to be
spoken by the facilitators. The module was translated into Malayalam, the local language. It is
thoroughly self-explanatory and easy to follow. The translated module was given to the Arogya Mithras
well in advance so that they could come prepared for the training.
The facilitator guide on Healthy Habits for Life included five lessons viz.

  1. Diabetes and 6 healthy habits
  2. Cancer, High Blood Pressure, and 6 Healthy Habits
  3. Healthy Eating
  4. Being Active
  5. Five yearly check-ups
    Each of the above lessons takes about 30 minutes to facilitate. Dr. DSK Rao, regional director of the
    Microcredit Summit Campaign, was the resource person for the first training program, along with Mr.
    Jacob Samuel (director of social initiatives for ESAF) and Ms. Sandhya Suresh (senior manager for SPM
    for ESAF). In addition to the Arogya Mithras, the training was also participated by the managers of the
    five selected branches. The idea was to expose them to the contents of the module and the training
    methodology.
    Though ESAF selected 20 Arogya Mithras after a careful selection process, many of them dropped out
    after the initial training. Most of them dropped out because they felt they could not cope with the field
    work involved in delivering the lessons and the health services. ESAF had to make fresh recruitments
    and conduct fresh trainings on health education for the new recruits.
    2.4 Delivery of health sessions
    Ultimately, 12 Arogya Mithras settled down with the work and started delivering health sessions. The
    coordinator employed by ESAF for the project worked closely with the Arogya Mithras. He introduced
    them and their work to SHG members. Altogether, the 12 Arogya Mithras covered 1782 clients with the
    five lessons over a period of six months.
    The Arogya Mithras sometimes used the credit group meeting platform for delivering the sessions.
    However, most of the members work as agriculture labors and, therefore, available in the evening or on
    weekends. Accordingly, Arogya Mithras had to convene meetings separately in the evenings for
    delivering the lessons.

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2.5 Regular review meetings and refresher trainings
As the Arogya Mithras were scattered across five branches, it was found necessary to understand the
basic challenges they faced. Monthly meetings participated by Arogya Mithras and the coordinator were
held regularly at ESAF Hospital in Palakkad. These meetings were chaired by either ESAF’s senior
manager for SPM or the director of social initiatives. These meetings also provided Arogya Mithras an
opportunity to interact with the medical officers of ESAF Hospital and get their doubts clarified.
2.6 Training of Arogya Mithras to measure blood pressure and blood sugar
After health education sessions were completed, the second phase of training was conducted; this
included training the Arogya Mithras on measuring blood sugar and blood pressure accurately. A
medical kit comprising of BP apparatus (non-digital) and Johnson & Johnson’s Accu-Chek to measure
blood sugar was provided to each of the 12 Arogya Mithras. The nursing superintendent of ESAF
Hospital trained them on using these gadgets.
Arogya Mithras had to clear a rigid test before they were allowed to practice BP and blood sugar
measurement in the field. Blood sugar check was easy to master, but it took quite some time and repeat
training to learn accurate measurement of blood pressure using a stethoscope; they required several
coaching sessions in groups and one-on-one learn the correct technique.

2.7 Certificates, ID card, and family health cards
Each of the 12 Arogya Mithras passed the rigid test and earned the certificate issued by ESAF, which was
presented in a formal function organized by ESAF and inaugurated by the District Medical Officer (DMO)
An Arogya Mithra measures blood pressure at an ESAF health screening camp.

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of Palakkad District. ESAF also issued them a medical kit, which contained a BP apparatus, thermometer,
glucometer, needles, and strips; Arogya Mithras were also given family health cards (cards given to
individuals who joined the scheme, which are used to record the readings). The family members of the
Arogya Mithras also attended the function and collected the medical kit along with the Arogya Mithras.
It was a deliberate step to ensure support of the family members to Arogya Mithras in discharging their
duties. The DMO congratulated the Arogya Mithras and stated that this initiative would go a long way in
the prevention and proper management of chronic diseases like cancer, high BP, diabetes, etc.
2.8 Publicity for Arogya Mithra services
Leaflets mentioning the names and the telephone numbers of Arogya Mithras and the services offered
by them were distributed to all the credit groups of ESAF. The project coordinator and the loan officers
of ESAF introduced the Arogya Mithras to the group members. With such publicity, SHG members
started calling the Arogya Mithras seeking their services, and gradually, the clientele of Arogya Mithras
picked up.
Each Arogya Mithra started her services by visiting her neighborhood groups and enquiring about the
general health status of the family members. They also spent time counseling the family members on
healthy habits, foods to be eaten frequently, and foods that are affordable.
Community members were cautious initially. They wanted to be sure about the training Arogya Mithras
underwent. They used to also check the ID card, which the Arogya Mithras carried with them. ESAF’s
long standing presence in the community gave the much needed credibility to Arogya Mithras. Very
soon, even patients from neighboring villages started calling the Arogya Mithras.
As the Arogya Mithras settled down with their work, clients started demanding more services such as
measurement of cholesterol, anemia, etc. There was also demand for medicines like paracetamol, oral
rehydration solution (ORS) packets, etc. However, ESAF, as a policy, does not allow their partners or
staff to provide services in which they are not trained. ESAF does not let their staff misuse the status
given to them. In future, ESAF will have a discussion with their clients, and if the demand for diverse
health-related services is established, they may design suitable products for the same. All together, the
AMs could enroll 1821 clients as well as non-clients for their services.
2.9 Cost of implementation to ESAF
The outputs of the project are 12 Arogya Mithras trained to deliver health lessons, having adopted adult
learning principles, and to measure blood pressure and blood sugar accurately; 1782 SHG members
learned five health lessons related to healthy habits to be maintained to prevent NCDs; and 1821 clients
(and constantly increasing) received regular monitoring services for blood pressure and blood sugar.
ESAF incurred an expenditure of Rs. 710,807 in implementing the project. This covered the training of
Arogya Mithras; a stipend paid to them during the project period; the purchase of health kits; and

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monitoring, supervision, and evaluation of the project. There was a cost overrun of Rs. 229,807 more
than the estimated budget; this owed mainly to the additional trainings required in measuring blood
pressure readings accurately using a stethoscope and because many of the initially recruited Arogya
Mithras dropped out. Instead of the one training proposed in the budget, ESAF had to conduct four
rounds of trainings, including one by the medical officer of ESAF hospital who clarified many doubts
expressed by the Arogya Mithras.
Monitoring costs were also high because of scattered location of the implementing branches.
2.10 Challenges of sustainability and scale-up
The drop-out of Arogya Mithras was a challenge ESAF had to contend with. Drop-outs led to repeated
trainings, which in turn resulted in higher cost of the project and delayed implementation. Arogya
Mithras mainly cited their inability to spare time from their household chores as their reason for r
dropping out of the project.
ESAF’s strategy of paying a stipend of Rs. 1000 to each Arogya Mithra for the initial six months of the
project helped. It took care of their transportation cost when the income was low. By the time the
project ended, however, the Arogya Mithras’ income increased sufficiently to meet their transport cost.
Though Arogya Mithras charged Rs. 40 per sugar test, the net income was only Rs. 12 (the cost of 25
needles and testing strips comes to Rs. 700, making it Rs. 28 per test). The Arogya Mithras did not have
the resources to purchase the needles and strips in bulk at cheaper cost.
Those whose BP and blood sugar readings are normal are not eager to go for repeat checks, and hence
the Arogya Mithras have to spread out to new geographic areas to find clients, which increased the
transport cost. Some enterprising Arogya Mithras have started tapping officials in schools, government
offices, banks, etc.
3.0 SELF-TRANSFORMATION THROUGH TRANSFORMING LIVES
All the Arogya Mithras were only housewives and
had no income of their own before taking up this
assignment. The income they were earning and the
community service they were rendering as Arogya
Mithras was extremely gratifying to them and gave
them a sense of dignity. They felt privileged when
even people from neighboring villages started
seeking their services. Handling the measuring instruments—particularly measuring BP using a
stethoscope—made them feel very proud.

Sajitha, one of the Arogya Mithras says, “I
never thought I will be able to check BP
using the same machine used by a doctor. It
makes me feel so proud with the
stethoscope around my neck!”

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Arogya Mithras feel thoroughly happy when the patients whom they refer to hospitals on account of
severe variations in their BP and sugar levels, come back and express their gratitude for the timely
referral.
Saradha, an Arogya Mithra, belongs to a community engaged in making a local fried delicacy called
“murruku.” Members of this community sit for more than five to six hours at a stretch to prepare this
snack. They sit for even longer duration when they have to meet large orders. Many of them contract
blood pressure and diabetes due to their sedentary work combined with high consumption of salt,
sugar, and oil. They found the tips that Saradha gave on the importance of reducing consumption of salt,
sugar, and oil as well as physical exercise very useful. Many of them have started practicing what they
learnt from Saradha.
A former nurse finds satisfaction and income
in community service
Marykutty is 50 years old and has been an active client of
ESAF Microfinance for the past 10 years. On average, she
earns net income of about Rs. 2000 per month. Marykutty
trained as a nurse, but family conditions caused her to
leave that profession long ago. With the Arogya Mithra
training, she is determined to continue her services,
though not in a hospital or a clinic but as a health
entrepreneur. She gladly says, “This idea is so innovative
that I am happy to be doing real community service yet
earn some money for myself and my family.”
Marykutty enjoys the support of her family members in
the delivery of her services. As most of her clients are in
the interior parts of the village, her son or husband drops
her on their motorbike. She goes to sites where men and
women work as daily labourers; these are the people who
have never gone for a BP or sugar check-up as they never
get time and also do not want to spend money and time in
transportation. So, Marykutty meets them during tea and
lunch breaks and checks up their BP/blood sugar. The
work supervisor pays her upfront for all those who get
their check-ups and deducts the amount from their wages
later.
In addition, Marykutty has regular calls from bed-ridden
patients who are not able to go for a health check-up. As
she is a trained nurse, she also provides first-aid, dressing
for bedsores, etc., and earns additional income from such
geriatric patients.

Arogya Mithra training spurs further career
opportunities
Sabira Faizal comes from a traditional Muslim family
where women’s mobility is mostly restricted, but Sabira is
determined to make a difference in her own life and her
community. Having heard about the Arogya Mithra
project, she approached ESAF and requested to be
inducted as a health entrepreneur. Because Sabira was
already employed as an ASHA (Accredited Social Health
Activist) worker under the National Rural Health Mission
(NRHM), a project of the Government of India, she enjoys
good rapport with the community.
Sabira was good at facilitating the health lessons and also
learned to measure BP and blood sugar quickly. She
preferred to go to her Muslim neighborhood where she
believes women do not have adequate awareness on the
prevention of NCDs. Sabira also offers pain and palliative
care to several patients who are terminally ill. Seeing good

opportunities in this field, she is undergoing a three-
month course on geriatric care, paying the tuition fees out

of her meager resources.
Sabira has two girl children whom she wants to educate in
a way that they would use their education for the benefit
of the society. Her husband, who is an auto driver, is very
happy when Sabira is respected by the community
members for what she is doing. “My husband drops me in
his auto to the places where I want to go for health
education—free of cost!” smiles Sabira while saying this.

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4.0 STUDYING THE CHANGES IN AWARENESS AND PRACTICES
The baseline survey was done in January 2014 by the Institute for Financial Management (IFMR). The
objective of the baseline study was to examine the demographics, current health status, health
awareness, and health practices of SHG members prior to the intervention. The end line was conducted
by an independent consultant engaged by the Microcredit Summit Campaign. The baseline and end line
were done to study the changes that have come as a result of a health service specifically targeting
blood pressure and diabetes within the framework of a community health worker model and through
the delivery channel of a microfinance institution (ESAF) in Palakkad district of Kerala state.
The end line study was conducted in December 2014, after a gap of 11 months of the baseline study.
The end line study had the objective of knowing the changes in terms of knowledge and awareness as
well as habits and practices of the community after the intervention, i.e., the health education and
access created at door step for monitoring blood pressure and blood sugar.
4.1 Methodology
The baseline study was conducted across four ESAF branches of Chitoor, Kozhinjampara, Koduvayur, and
Pudunagaram in Palakkad district of Kerala. Stratified random sampling methodology was adopted in
which initially 90 SHGs were selected across the above branches. Four to six members from each SHG
supported by the selected branches were picked at random for administering the questionnaire.
The baseline questionnaire included the following sections:
a) Household information,
b) Income information,
c) Health seeking behavior,
d) Diet and lifestyle, and
e) Health awareness.
The survey assessed demographic characteristics, heath practices, and perception of risk factors of high
blood pressure and blood sugar levels, health awareness, etc. Portions of the survey included
information for all household members, which increased the sample size to 1,419 individuals for select
information categories (though the sample size was only 490).
The questionnaire was common for both the baseline and end line studies. In addition, the end line
attempted to understand the community’s response to the services being offered by the Arogya
Mithras. Satisfaction levels of the community to the services provided by Arogya Mithras was also
studied through qualitative studies.
Out of the baseline sample of 490 SHG members, only 263 received health education because three of
the groups had Arogya Mithras who dropped out after the baseline and the villages covered by them

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had to be excluded for the project. These three were replaced with villages in the vicinity of the newly
recruited Arogya Mithras. The end line study selected randomly 100 members from out of 263, who had
participated in the baseline survey and also had received health education.
4.2 Findings of the baseline and end line studies
4.2.1 Check-ups for blood pressure and blood sugar:
The baseline study revealed that 69 percent and 76 percent of the sample never had their blood
pressure or blood sugar (glucose) levels, respectively, checked. More than half of the sample over the
age of 55 years had never got their BP and blood sugar checked. Amazing transformation is noticed in
the end line survey: 100 percent of the sample had their check-up of blood glucose and blood pressure
in the last year (table-1).
Table-1: Frequency of check-ups (all participants)
Frequency of check-up

Blood Pressure Blood Glucose
Baseline End line Baseline End line
Never checked 69% 0% 76% 0%
Irregular check-ups 9% 0% 7% 0%
Once in 12 months 5% 76% 3% 76%
Once in 6 months 10% 3% 8% 3%
Once a month 7% 21% 6% 21%
Among those who are diagnosed to be suffering from hypertension and diabetes (a subset of table-1),
the frequency of check-ups was much better. The baseline revealed 46 percent of those who were
suffering from blood pressure and 49 percent of those suffering from diabetes, respectively, had their
check-up once a month; 11 percent and 14 percent of the diagnosed, respectively, had their check-up
once in six months. The behavior of those diagnosed with hypertension and diabetes as reflected in the
end line survey is much different from the total population: 100 percent of the diagnosed have monthly
check-ups as opposed to 21 percent of the total population.
The baseline study revealed that only 27 percent went to public hospitals for their check-up while the
end line study showed that 69 percent went to public hospitals. Apart from availing the services of
Arogya Mithras, people are getting their BP and blood sugar checked whenever they get a chance to

visit the public hospital, which can be attributed to their appreciation of the message for regular check-
ups.

4.2.2 Mode of transportation, time taken, and cost incurred:
The baseline showed persons availing mostly public transport (57 percent) for going for a check-up,
followed by 31 percent who go “by foot” (meaning they did not take public or private transportation). In
comparison, the end line survey revealed that 100 percent went “by foot”; many of the participants

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availed door step service being offered by the Arogya Mithras. This is also reflected in the cost for
transportation and testing with 100 percent of the end line sample spending Rs. 0-50 for the cost of the
test and transport for BP/ blood sugar, as compared to 34 percent in the baseline sample. This clearly
shows that with the introduction of Arogya Mithra services, many clients benefit by not spending on
transportation (table-2).
Table-2: Mode of transportation
Mode of transportation Baseline End line
By foot 31% 100%
Public transport 57% 0%
Private transport 12% 0%
4.2.3 Healthy eating habits:
The education module covered the foods to be eaten frequently, moderately, and rarely in order to
maintain good health. There was good awareness about the foods to be eaten frequently (particularly
about the importance of vegetables) and rarely even before introducing the health lessons. However,
more persons became aware of healthy eating habits after the lessons (table-3).
Table-3: Healthy eating habits
Food type

Should be frequently eaten Should be rarely eaten
Baseline End line Baseline End line

Vegetables 97% 100%
Whole grains 31% 47%
Maida 71% 83%
Deep fried snacks 54% 79%
Sweets 60% 89%
Red meat 69% 86%
As seen in table-3 above, respondents’ awareness about foods to be consumed rarely increased
significantly as compared to the baseline as did their awareness of needing to eat whole grains
frequently. However, their awareness of needing to consume vegetables frequently, there was only a
slight improvement in the knowledge levels because, even without education, they knew they were
good for health.

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4.2.4 Awareness about diabetes and hypertension:
Table-4 below shows that awareness about the risks associated with high blood pressure and blood
sugar has slightly improved with education.
Table-4: Awareness about diabetes and hypertension

Question

Percent who knew the correct answer
Baseline End line
Risk of stroke is high for patients of high BP 51% 62%
Risk of kidney problems is high for patients of high BP 9% 20%
Risk of blindness is high for patients of diabetes 32% 53%
Risk of kidney problems is high for patients of diabetes 22% 34%
Risk of losing toes is high for patients of high diabetes 48% 57%
4.2.5 Awareness about unhealthy habits leading to hypertension and diabetes:
The studies revealed improvement in awareness about the unhealthy habits that lead to hypertension
(high blood pressure) and diabetes (high blood sugar). However, somehow the importance of being
active to prevent high BP and diabetes has not gone well (table-5).
Table-5: Awareness about unhealthy habits leading to high BP and diabetes

Unhealthy habit

Factor contributing to high blood
pressure

Factor contributing to high blood

sugar
Baseline End line Baseline End line
Drinking too much colas, coffee, tea 39% 62% 53% 62%
Being inactive 14% 9% 9% 9%
Not keeping a healthy weight 10% 23% 11% 23%
Smoking or breathing in smoke 16% 20% 11% 20%
Alcohol use 14% 18% 17% 18%
4.2.6 Awareness about the importance of medical check-ups:
The health education stressed the importance of regular check-ups for prevention and early detection of
cancer, hypertension, and diabetes. Participants in the education module have appreciated this message
and also seem to have started practicing new behaviors to varying degrees (table-6 and -7).
Table-6: Awareness about the importance of medical check-ups
Which medical check-ups one should undergo at least once a year?

Percent who knew the correct answer
Baseline End line
Blood test for diabetes 52% 85%
Blood pressure test 70% 85%
Pap test for cancer near womb 3% 4%
Breast exam for cancer 2% 5%

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Table-7: Medical check-ups during the previous year
Had a check-up the previous year for blood pressure and blood sugar Baseline End line
Blood test for diabetes 33% 85%
Blood pressure test 44% 85%
Pap test for cancer near womb 2% 4%
Breast exam for cancer 1% 5%
Participants were not aware of the importance of check-ups for breast and cervical cancer before
education. Unfortunately, the message about these check-ups has not been understood even after
education. During the health sessions for some reason, many women also felt that unless they have
some symptoms they will not voluntarily go for expensive check-ups such as a Pap test. However, in
respect of BP and blood sugar, they are more open to have frequent check-ups.
4.3 Qualitative surveys
In addition to quantitative baseline and end line surveys, qualitative studies were conducted, including
individual interviews and focus group discussions. Interviews of the key responsible persons were also
taken.
4.3.1 Interview with K. Paul Thomas, Founder and Chairman, ESAF Group
Q. Do you think initiatives like that of Community Health Worker/Entrepreneur have the potential and
scope for scaling up?
K. Paul Thomas: Yes, definitely. With the rise in lifestyle disease in our society, it is high time we start
working together, and the best model is the community-based model where we train the community
women to deliver health education or awareness and they are also equipped to do the health
monitoring. As such, door step services can reduce the transportation cost and there will be huge
demand for such services. Through focus group discussions, we came to know the willingness of clients
to pay for such services; that prompted us to implement the pilot project. This initiative was designed to
generate some income for the health entrepreneurs. If we go towards the northern part of India, we can
think of training Arogya Mithras on communicable diseases, women and child health also, so the scope
looks quite enormous.
Q. Do you think any MFI can start such an initiative, or should they have prior experience in health
education/health care, etc.?

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KPT: I think any MFI can start such an initiative provided they
have the passion and commitment to see positive health
transformation in the lives of their clients. For implementing
such social sector projects, the MFI needs to plan carefully
and be willing to deploy dedicated staff. MFI should be able
to invest time, efforts, and resources. Close monitoring is of
course absolutely essential.
ESAF’s vision and mission very clearly stress holistic
transformation in the lives of its clients and we are convinced
this cannot be achieved unless the health issues are
addressed.
Q. What are your plans to replicate this model across all the
branches of ESAF?
KPT: Before the replication, we will have to study the success
and failures of this pilot. We are assessing the financial
sustainability of this project also because the Arogya Mithras are mostly women from low income
families and the moment they do not get enough patients to have a reasonable income for themselves,
they will be quite disappointed. Once we have been able to fix these issues, we can think of replicating
and scaling up. But, I can assure you that the model will definitely be replicated with much more
viability.
Q. Do you think Arogya Mithra model will always have to be subsidized, or can it become sustainable?
KPT: Sustainability is very important. We need to train the Arogya Mithras in diverse activities. For
example, they can be marketing agents to sell low cost sanitary napkins, nutritious weaning foods for
children, etc. We need to explore further.
We are discussing if we can have an integrated health model where we make it mandatory for every
woman who takes a loan from us to undergo hemoglobin, blood pressure, and blood sugar check-up.
But we need to work on the economics. ESAF conducts regularly NCD screening camps for their clients.
In such camps, we will engage the Arogya Mithras and pay for their services.
ESAF is keen to scale up the project in a way that the challenges met during the pilot project are
addressed. Replicating the model to 200 branches where ESAF is working will require dedicated staff to
select and train the Arogya Mithras and monitor their work. Sustainability of Arogya Mithras will also
depend on continuous work and regular income for them. ESAF is toying with the idea of a mandatory
medical check-up, for all their clients with each loan cycle and engage the Arogya Mithras for measuring
hemoglobin, blood pressure, and blood sugar. And, ESAF could pay the fees to Arogya Mithras. That will
Attendees at an ESAF health camp

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generate continuous work. ESAF is engaged in analyzing the cost-benefit of such a large scale
intervention.
4.3.2 Interview with Jacob Samuel, Co-founder and Advisor-Social Performance Management,
ESAF
Q. Your role in the implementation of the Arogya Mithra project was quite crucial as you were involved in
the selection of the Arogya Mithras, their training, and overseeing the entire project. How do you rate
the success of this project?
Jacob Samuel: I would give it 8 marks out of 10. The community health worker project is a pilot and
ESAF’s maiden attempt in this direction. So, we gave our best to address all the emerging needs and
issues at the right time. We had to give inputs that were beyond the scope of the project proposal. For
example we had envisaged only one training for the Arogya Mithras, but we found that it was not
enough as many of them discontinued because they could not be away from domestic responsibilities.
So we had to conduct 3 rounds of trainings, including one refresher training where we had invited our
medical officer from ESAF Hospital. We had the support from ESAF Hospital as we used to conduct our
monthly reviews in the hospital and also our nursing
superintendent trained the Arogya Mithras in checking the
BP using the conventional BP apparatus. Here we had the
support from the staff of ESAF Hospital, SPM department,
ESAF Society to give their required expertise from time to
time. We could implement this project because of all these
support systems. Microfinance staff of ESAF alone could not
have implemented this project so successfully.
We know there are gaps in the implementation and that
without ESAF’s handholding the Arogya Mithras will not able
to function on their own fully. Probably we should have had
the sustainability plans by the time the project ended. But
even now we are utilizing the services of all the Arogya
Mithras in our NCD camps so that they get a reasonable
income out of it.
Q. If you replicate this model, what would you consider?
JS: The selection of Arogya Mithras is very important. Unless the women have support from their family
she will never be able to give her 100 percent. Also, if women have very small children at home without
any support system, then even if they wish, they are not in a position to continue. Any prior experience
of community work, especially if they are ASHA workers, will be an added advantage. A good linkage and
networking should be established with government health system/clubs/associations etc. so that the
Measuring blood pressure

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services of Arogya Mithras are not confined only to microfinance clients and their families. Unless the
whole effort is worth a good return for them, they will not be motivated.
4.3.4 Focus group discussions
Focus group discussions were done with 3 groups of members, viz.
 Those who underwent health education and enrolled themselves as clients for the health
monitoring services of Arogya Mithras.
 Those who underwent education but did not join as clients for the health monitoring services of
Arogya Mithras.
 Those who did not attend education but enrolled as clients of Arogya Mithras.
The focus group discussions brought out clearly that the members had a very clear understanding about
the foods to be eaten frequently and rarely to prevent hypertension and diabetes. They also had a good
understanding about the quantities of sugar, salt, and oil to be consumed. Naturally, such understanding
was not there among those who did not attend the education.

The education module stressed the need for five check-ups annually for every woman viz. general check-
up of eyes, ears, etc., as well as blood pressure, blood sugar, breast cancer, and cervical cancer. Those

who underwent education remembered clearly the five tests. Those who did not receive education,
understandably, did not know about these tests.
When enquired with the group that received education but had not become clients of Arogya Mithras,
their response was that they would rather avail free service at the Government Primary Health Centers
than availing fee based service offered by the Arogya Mithras.
5.0 CONCLUSIONS
5.1 Microfinance clients who are school-educated can successfully facilitate Freedom from Hunger
education modules, adopting adult learning principles. However, proper training is important.
5.2 Though work as community health workers (Arogya Mithras) is very demanding and gives a very
small and uncertain income, microfinance clients in the project area showed initially considerable
interest to take up this responsibility. However, there were many drop outs at the level of training and
later after they started practicing as Arogya Mithras. The low income and the family responsibilities,
which did not allow them to be away from home for long hours were responsible for the drop out. Only
those who have very strong commitment to the cause and support from their family members survived
in this job.
5.3 Those community women who have some experience of working in the health sector such as ASHA
(Accredited Social Health Activist) or Anganwadi workers (both are front-line health workers trained and

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supported by the Government of India) have a better chance of success as Arogya Mithras as they have
already built a good rapport with the community. Such candidates have an added advantage of already
possessing certain skills and training needed by a community health worker.
5.4 Freedom from Hunger’s education module, “Healthy Habits for Life,” has yielded impressive results
in terms of change of behavior and practices. The baseline study revealed 69 percent and 76 percent of
the sample never had any check-up for BP and blood sugar, respectively, whereas the end line study
showed almost everybody having been tested within the last 12 months.
5.5 A high percentage of members knew even before the
baseline that frequent eating of sweets, red meat, deep fried
snacks, and food made of maida (finely milled refined and
bleached wheat flour) is bad for health. Education enhanced
their awareness of these facts. Similarly, there was a slight
improvement in knowing the health risks of high blood
pressure and blood sugar with education.
5.6 Awareness was very poor before the education module
about the importance of regular check-ups for breast and
cervical cancer and about the importance of being active and
doing physical exercise. However, even after education, there
is very little improvement in the appreciation levels on these
two issues.
5.7 If the tests reveal they do not have high blood pressure or
blood sugar, this experience shows that poor people (in this
case in rural areas, but also applicable in other settings) do
not want to spend on repeating the tests at regular intervals.
5.8 Arogya Mithra clients are also demanding additional services from Arogya Mithras such as
measurement of cholesterol, hemoglobin etc. There was also demand for medicines like paracetamol,
oral rehydration solution (ORS) packets, etc. ESAF will have a discussion with their clients, and if the
demand for diverse health related services is established, they may design suitable products for the
same.
5.9 ESAF will continue to support the Arogya Mithras even after the completion of the pilot project.
ESAF is exploring more income earning opportunities for the Arogya Mithras. ESAF’s support till the
income of Arogya Mithras enhances and stabilizes is very crucial.
5.10 ESAF is also contemplating to introduce Arogya Mithra concept to other operational areas in Kerala
state where there is better scope for their sustainability. ESAF is also considering deploying Arogya
Mithra services in poor and backward states such as Chattisgarh, which has very poor record of women
A health screening camp patient

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and child health. However, it is imperative that ESAF subsidizes the Arogya Mithras for considerably long
periods.
ACKNOWLEDGEMENTS
The authors are grateful to Johnson & Johnson for their grant support to implement and evaluate this
project.
The authors would like to thank Freedom from Hunger for the technical assistance in implementing this
project. In particular, they would like to thank Dr. Gabriela Salvador and Dr. Soumitra Dutta for their
valuable comments and guidance in implementing and finalizing this report.
The authors would like to thank Mr. Paul Thomas, CEO of ESAF, for his commitment and keen interest in
implementing this project. His encouragement and constant guidance inspired the Arogya Mithras very
much.
The authors would like to thank Mr. Jacob Samuel, director of programs at ESAF, who ensured smooth
implementation of the project by interacting regularly with the staff of ESAF hospital, branches, and the
Arogya Mithras.
The authors are grateful to Ms. Sirisha Papineni, senior research associate at IFMR, and Dr. Jasmine
Lydia for the high quality baseline and end line surveys they conducted.

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