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For peer review onlyHealth-related outcomes among female informal workers in debt: Retrospective quasi-experimental study on the impact

of microfinance health interventions in Pakistan

Journal: BMJ Open

Manuscript ID bmjopen-2020-043544

Article Type: Original research

Date Submitted by the Author: 09-Aug-2020

Complete List of Authors: Jafree, Sara; Forman Christian CollegeZakar, Rubeena; The University of LahoreAhsan, Humna; Forman Christian CollegeMustafa, Mudasir; Utah State UniversityFischer, Florian; Charité Universitätsmedizin Berlin, Institute of Public Health; University of Applied Sciences Ravensburg-Weingarten, Doggenriedstraße

Keywords: Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, PUBLIC HEALTH, EPIDEMIOLOGY

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Health-related outcomes among female informal workers in debt:

Retrospective quasi-experimental study on the impact of microfinance health

interventions in Pakistan

Sara Rizvi Jafree, Rubeena Zakar, Humna Ahsan, Mudasir Mustafa, Florian Fischer

Dr. Sara Rizvi JafreeDepartment of Sociology, Forman Christian College University, Lahore, Pakistan; [email protected]

Prof. Dr. Rubeena ZakarInstitute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan; [email protected]

Dr. Humna AhsanDepartment of Economics, Forman Christian College University, Lahore, Pakistan; [email protected]

Mudasir MustafaDepartment of Sociology, Social Work, and Anthropology, Utah State University, Logan, United States of America; [email protected]

Dr. Florian Fischer 1) Institute of Public Health, Charité – Universitätsmedizin Berlin, Germany; [email protected] 2) Institute of Gerontological Health Services and Nursing Research, Ravensburg-Weingarten University of Applied Sciences, Germany; [email protected]

Corresponding author:Dr. Florian FischerCharité – Universitätsmedizin BerlinInstitute of Public HealthCharitéplatz 1 10117 BerlinE-Mail: [email protected]

Word count: 4,259

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1 Abstract

2 In countries where dependable public health service structure and universal financial protection

3 for health coverage is missing, particularly impoverished families are at risk. In the past years,

4 different kinds of microfinance health interventions were established to promote health among

5 disadvantaged population groups. The purpose of this study is to assess the impact of microfinance

6 health interventions (health insurance and health awareness programs) on health-related outcomes

7 of female informal workers in Pakistan. We conducted a retrospective quasi-experimental study

8 among a total of 447 female borrowers from seven microfinance providers (MFPs) in 2018. A

9 standardized tool was used for data collection. Probit regression has been used to identify the

10 probability of female borrowers gaining improvement in health outcomes based on their socio-

11 demographic characteristics. Propensity score matching (PSM) has been used to assess the overall

12 impact of health interventions. Results show that women receiving health insurance and health

13 awareness programs had greater probability of better health outcomes when they were from

14 Punjab, borrow in groups, and attend monthly meetings at MFPs. The results of the PSM show

15 significant improvements in overall perceived health status when women received health insurance

16 and improvement in the purchase of prescribed medicine when women received a health awareness

17 program. Health and social policies are vital to secure health and wellbeing of poor women

18 working in the informal sector of the economy. Targeting improved equity across female

19 population groups for health intervention will in the long run improve women’s health, capacity

20 expansion and income-earning abilities.

21

22 Keywords: borrow, informal sector, health insurance, health awareness, microfinance

23

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24 Strengths and limitations of the study

25 This study is part of a larger mixed-methods study on the well-being of female

26 microfinance borrowers.

27 Potentially the first study which focuses on female microfinance borrowers in Pakistan to

28 assess the impact of health interventions on health-related outcomes of poor women.

29 Although a quasi-experimental analysis framework has been used, the two-group cross-

30 sectional designs suffers from the limitations related to a single measurement for all

31 subjects.

32 Future studies need to consider additional burdens of loan repayment and small business

33 investment.

34

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35 Introduction

36 More than half (57%) of the female population in Pakistan is illiterate. Less than a quarter (23%)

37 of women is employed, with a majority working in the informal sector [1]. There are several

38 problems to consider with regard to the health of female informal workers in Pakistan, including

39 high rates of poverty and low health literacy, as well as inadequate access to public health services

40 [2], reinforced by low government health budget allocation for this population group [3]. In

41 addition to the overall absence of universal health coverage, there are limited coverage for public

42 health emergencies like pandemics [4] and greater risks for acquiring infectious diseases in female

43 informal workers due to mostly unsanitary living conditions in disadvantaged communities [5].

44 Pakistan has one of the largest out-of-pocket healthcare expenditures globally, with an

45 overwhelming proportion of 90% [6]. Although health insurance can become an important support

46 system for buffering the poor in out-of-pocket payments, it covers only 1% of health expenditure

47 in the country yet [2]. This is because health insurances are mainly used by richer and urban

48 populations.

49 The efficacy and limitations of private providers for health interventions in Pakistan are not clear.

50 One of the few private providers offering health interventions to women employed in the informal

51 sector are microfinance providers (including banks, institutes and non-governmental organizations

52 [NGOs]) [7]. Microfinance providers (MFPs) are mainly operational in under-developed

53 communities providing loans to the poorest women for small business development [8]. There are

54 50 MFPs operating in Pakistan, with nearly 40 reporting some form of health intervention for

55 clients, including health insurance and health awareness programs [9]. The MFPs are regulated

56 either by the State Bank of Pakistan or the Securities Exchange Commission Pakistan. An inherent

57 function of the original model of microfinance was to catalyze wider social development for

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58 women, including improved health behavior and, therefore, better health-related outcomes [10]. It

59 is in the interest of MFPs to couple health interventions with loan services as healthy clients are

60 more likely to return loans and run successful businesses [11].

61 The role of microfinance health interventions is even more critical for countries like Pakistan,

62 where poverty is high and out-of-pocket payments are not possible for impoverished families.

63 Additionally, the public sector did not have a dependable service structure for complete or quality

64 healthcare and universal financial protection for health coverage is absent [4]. More than 2 million

65 poor women are loan-takers of microfinance in the country [12]. As poor populations do not have

66 the money to take traditional health insurance, microfinancing for health insurance becomes the

67 only option for them. However, small health insurance schemes have been severely criticized for

68 their minimal impact on clients lives due to minimal coverage and large burden of disease faced

69 by poor populations [13]. Evidence also suggests that poor populations receiving minimal health

70 insurance, in the event of sustaining large health costs, may resort to damaging practices such as

71 reducing household nutrition, removing children from school, and taking more loans [14]. In the

72 most recent times of the corona pandemic, debt-ridden poor women attempting to repay loans are

73 facing even more challenges in generating income from small businesses due to social isolation

74 and lockdown [15]. Therefore, health security is a major concern in women borrowers and there

75 is a need to improve research and policy to financially protect poor women and also improve their

76 health literacy [16].

77 To the best of our knowledge, there are no studies which have used female microfinance borrowers

78 as a sample to assess the impact of health interventions on health-related outcomes of poor women

79 [17]. Using a sample of female microfinance borrowers who are availing health insurance from a

80 private provider will help to identify suited policies for disease prevention and health promotion

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81 in Pakistan. The following research questions are addressed in this study include: 1) Do female

82 borrowers of microfinance who are provided with health interventions show improved health-

83 related outcomes?, and 2) What are the socio-demographic, household, and loan portfolio

84 characteristics of female borrowers of microfinance that are associated with improved health-

85 related outcomes?

86

87 Methods

88 This study is part of a larger mixed-methods study on the wellbeing of female microfinance

89 borrowers. The qualitative part has already been published [18]. The results presented here are

90 based on a cross-sectional survey, in which females who have been borrowers of microfinance for

91 more than one year were interviewed with a structured quantitative questionnaire. We used the

92 framework of a quasi-experimental study to estimate the impact of microfinance health

93 interventions.

94

95 Sampling

96 First, seven MFPs were sampled randomly through a list available on Pakistan Microfinance

97 Network. All MFPs were asked for permission to interview their clients. Afterwards, 500 women

98 borrowing money from these MFPs were contacted to participate in the study. The sampling took

99 place in all four provinces of Pakistan (Punjab, Sindh, Balochistan, and Khyber Pakhtunkhwa

100 [KPK]), not considering the two autonomous territories and the federal territory of Islamabad. The

101 sampling frame at the level of individual women took the population weightage of the provinces

102 into account. A total of 442 women were willing to participate in the study and provided informed

103 written consent, which is a response rate of 88.4%. These women were sampled from seven cities

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104 within the four provinces (Punjab: n=252 [cities: Gujranwala, Lahore, Khanewal, Sheikhapura];

105 Sindh: n=100 [city: Matiari]; Balochistan: n=50 [city: Lasbela]; KPK: n=40 [city: Abbottabad].

106 Study participants received financial support from the following types of MFPs: four microfinance

107 banks (n=340), one microfinance institute (n=41), one government microfinance scheme (n=50),

108 and one Islamic microfinance organization (n=11),

109

110 Data collection

111 Data collection took place between February and November 2018. Each city had one research team

112 leader and two assistants in the data collection team, comprising a total of 21 persons for data

113 collection. The assistants were all MPhil graduates who had experience in field research and were

114 hired through the assistance of universities in each city. Training of the data collection team took

115 place over a two-week period and was done either in person or through video calls. The structured

116 surveys were completed on behalf of the female respondents with the assistance of the trained

117 research team, as most of the women were illiterate or semi-literate. Data collection took place in

118 face-to-face-interviews in a private space at the MFP premises, in order to preserve the privacy of

119 women in lieu of the personal questions.

120

121 Measures

122 A structured interview schedule was used for data collection (see Supplementary Appendix).

123 Questions in this tool were taken from instruments used in various studies, such as Women’s

124 Healthcare Experiences Survey [19], Baseline Nutrition and Food Security Survey by UNICEF

125 [20], WHO Multi-country Study on Women’s Health and Domestic Violence against Women [21],

126 and WHO Survey on Workplace Violence [22].

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127 This study assesses the association of health interventions offered by MFPs on four dependent

128 health-related variables: 1) women perceive health to be good overall, 2) women visit a general

129 practitioner in the last year, 3) women have the ability to purchase prescribed medicine in the last

130 year, and 4) women’s intake of multivitamins has improved in the last year. The four dependent

131 variables have been categorized as binominal and coded as either “Yes” (1) or “No” (0).

132 Several socio-demographic variables such as age (0=less than 30 years; 1=30 years and older),

133 religion (0=Muslim; 1=Other than Muslim), literacy of the female borrower (0=Illiterate;

134 1=Literate), literacy of the spouse (0=Illiterate; 1=Literate), house ownership (0=Yes; 1=No), and

135 number of depending children living in the house (0=None; 1=One or more) have been assessed

136 as confounding variables. It is necessary to control for these variables as they have an impact on

137 each of the dependent variables mentioned above. Province is also controlled as the region is a

138 proxy for socio-cultural norms which would impact how women perceive their health and whether

139 they are able to visit a general practitioner or to purchase medicine (0=Other than Punjab [Sindh,

140 Balochistan, or KPK]; 1=Punjab).

141 The other set of variables related to microfinance provider services such as loan amount

142 (0=10,000–20,000 PKR; 1=21,000 PKR and more), monthly meetings (0=No; 1=Yes), interest

143 rate, which is the amount charged on top of the principal by a lender to a borrower (0=2.5–10%;

144 1=11% and more), group loan, meaning that a group of customers are willing to guarantee each

145 other for the repayment of loan (0=No; 1=Yes), and debt age (0=1–2 years; 1=3 or more years)

146 have been included as they assess the impact of the provision of non-financial services on each of

147 the dependent variables.

148

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149 Intervention

150 Using a quasi-experimental framework, the study estimates the impact of getting access to health

151 interventions against the counterfactual of those women who are receiving the loan for small

152 business mobilization in the absence of health interventions. The control group ( consists 𝑇 = 0)

153 of women who have been provided the loan but lack the provision of health intervention and the

154 treatment group ( includes women who will have provision of both, the loan as well as 𝑇 = 1)

155 health intervention.

156 The three independent variables for microfinance health intervention are: 1) receiving health

157 insurance, 2) attended at least one health workshop, and 3) received health-related talks by loan

158 officers. The last two independent variables of health workshop and health-related talks by loan

159 officers were compounded to make one variable indicating whether the women received a health

160 awareness program (0=No; 1=Yes).

161

162 Data analysis

163 Data were analyzed using SPSS and STATA. The impact of health insurance and health awareness

164 programs provided by the MFP on the four dependent health-related variables will first be

165 estimated using a Probit estimation for the following linear regression equation:

166 𝑌𝑖 = 𝛽0 + 𝛽1𝑇 + 𝛽2𝑋𝑖 + 𝛽3𝑍𝑖 + 𝛽4𝐿𝑖 + 𝜀𝑖

167 where is the dependent variable measuring the four health-related outcomes. T is the treatment 𝑌𝑖

168 variable (1 if “yes”, and 0 otherwise) measuring the three microfinance health interventions. is 𝑋𝑖

169 a set of socio-demographic characteristics including age, religion, province, and literacy; is a 𝑍𝑖

170 set of household characteristic including house ownership and number of dependent children living

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171 in the house; is a set of loan portfolio characteristics including debt age, group loan, loan amount, 𝐿𝑖

172 interest rate, and monthly meetings; and is the error term. 𝜀𝑖

173 Following Rosenbaum and Rubin, we used Propensity Score Matching (PSM) to estimate the

174 unobserved counterfactuals and make an impact analysis of health interventions. PSM is a non-

175 parametric statistical method which matches the treated (those receiving health intervention) and

176 the controlled on the basis of conditional probability of participation, given observable

177 characteristics [23]. As we only have cross-sectional data, we can compare the dependent variables

178 related to women’s health and wellbeing in terms of those who have access to non-financial health-

179 related services provided by the microfinance provider (in this study called “health awareness

180 program”) and those who do not, as long as these services are randomly distributed and there is no

181 selection bias. The estimation of instrumental variables is one technique that is frequently used

182 within PSM. However, these results are only robust if a valid instrument is being used. As it not

183 easy to find a valid instrument in our study, we used statistical matching which has been widely

184 used before as well [24-26].

185 Our study satisfies the main conditions of PSM, which are 1) using a rich set of control variables,

186 which are observable characteristics, 2) using the same survey for treated and control groups, and

187 3) having the same community belonging to treated and control group [27]. The PSM model

188 constructs a statistical comparison group based on the probability of participating in the treatment

189 T, conditional on observed characteristics, X or the propensity score,

190 𝑝(𝑋) = 𝑃𝑟(𝑇 = 1│𝑋).

191 where T = {0, 1} is the indicator of exposure to treatment and X is the multidimensional vector of

192 pre-treatment characteristics. Following the estimation for the propensity score, the region for

193 common support is defined where distributions of the propensity score for the treatment and

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194 comparison group overlap. Observations within the control and treatment group that lie outside

195 the common support are eliminated [28]. As PSM is intended to help in identifying the impact of

196 the health intervention, we used the computation of ‘average treatment effect on the treated’

197 (ATT). We used two matching criteria (Nearest Neighbor Matching [NNM] and Kernel Matching

198 [KM]), to assess statistical significance from different perspectives and to test the robustness of

199 the results [24]. NNM is used to evaluate absolute differences between propensity scores and KM

200 is used to compare each treated unit to a weighted average of the outcomes of all untreated units.

201

202 Patient and Public Involvement

203 This research was conducted without involvement of public or patients. However, the view of

204 females was already included in the qualitative part of this mixed-methods approach, which has

205 already been published elsewhere [18].

206

207 Results

208 Sample characteristics

209 All women in our sample earned less than $4.82 per day and belonged to the poorest strata of

210 society. They were taking loans for small business mobilization to improve their life opportunities.

211 The majority of women were Muslim, from Punjab, and illiterate. About three quarters had been

212 borrowers for more than 3 years, were attending monthly meetings with loan officers, and were

213 paying interest rates less than 10%. Out of the 442 women borrowers in the sample, 64.2% (n=284)

214 were taking health insurance and 71.0% (n=314) have participated in a health awareness program

215 by attending a health workshop or receiving health talks by loan officers (Table 1).

216

217

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218 Table 1: Descriptive statistics of women borrowers receiving health interventions (n=442)

Variable

Receiving health insurance

n (%)(N=284)

Chi-square test1

Receiving health awareness program

n (%)(N=314)

Chi-square test1

Age <29 years ≥30 years

165 (58.1%)119 (41.9%)

0.557 177 (56.4%)137 (43.6%)

0.077

Religion Muslim Other

254 (89.4%)30 (10.6%)

0.740 276 (87.9%)38 (12.1%)

0.337

Province Punjab Other

197 (69.4%)87 (30.6%)

37.977*** 203 (64.6%)111 (35.4%)

16.372***

Literacy Illiterate Literate

195 (68.7%)89 (31.3%)

3.770* 219 (69.7%)95 (30.3%)

9.109**

Spouse literacy Illiterate Literate

191 (67.3%)93 (32.7%)

7.135** 199 (63.4%)115 (36.6%)

0.231

House ownership Other Owned

225 (79.2%)59 (20.8%)

9.583** 233 (74.2%)81 (25.8%)

0.030

Children None One or more

116 (40.8%)168 (59.2%)

1.907 121 (38.5%)193 (61.5%)

0.002

Debt age 1–2 years ≥3 years

75 (26.4%)209 (73.6%)

15.755*** 83 (26.4%)231 (73.6%)

21.342***

Group loan No Yes

168 (59.2%)116 (40.8%)

0.102 173 (55.1%)141 (44.9%)

5.480**

Loan amount (in PKR) 10,000–20,000 ≥21,000

123 (43.3%)161 (56.7%)

25.096*** 121 (38.5%)193 (61.5%)

6.515**

Interest rate 2.5–10% ≥11%

202 (71.7%)82 (28.9%)

1.044 237 (75.5%)77 (24.5%)

18.527***

Monthly meeting No Yes

70 (24.6%)214 (75.4%)

0.091 73 (23.2%)241 (76.8%)

2.005

Overall perceived good health No Yes

185 (65.1%)99 (34.9%)

5.545** 216 (68.8%)98 (31.2%)

0.023

Improved ability to visit general practitioner No Yes

124 (43.7%)160 (56.3%)

0.065 127 (40.4%)187 (59.6%)

3.383*

Improved ability to purchase prescribed medicine No Yes

152 (53.5%)132 (46.5%)

19.127*** 175 (55.7%)139 (44.3%)

13.073***

Improved intake of multivitamins No Yes

182 (64.1%)102 (35.9%)

6.6040** 214 (68.2%)100 (31.8%)

0.015

219 1 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level

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220

221 Women taking loans from the Government Scheme or Islamic Finance Provider were not receiving

222 health insurance interventions. However, both the Government Scheme and Islamic Finance

223 Provider were giving health awareness interventions. The Government Providers offered the

224 women a separate government health insurance scheme, called Sehat Sahulat Program, but none

225 of the study participants was availing this scheme. The Islamic Finance provider was supporting

226 Lahore-based women clients with a free medical camp for diabetes and heart disease (Table 2).

227

228 Table 2: Health insurance schemes of microfinance providers sampled in this study

Microfinance Bank(n=340)

Microfinance Institute(n=41)

Government Scheme(n=50)

Islamic Finance(n=11)

Coverage Female borrower + any family member

Female borrower + spouse

- -

Term One year One year - -Premium PKR 490–990 per

family memberPKR 1,200 (if unmarried);PKR 1,850 (married)

- -

Insurance Only hospitalizationPKR 2,000–4,000 daily

Only hospitalizationPKR 30,000

- -

Limit Between 10–30 days One-off payment - -Life insurance PKR 25,000–50,000

in event of death- - -

Other Option to take government Sehat Sahulat Program.

Health clinic in Lahore only; treating patients with diabetes and heart disease

229 Information in this table is based on data from microfinance provider loan officers

230

231 Women borrowing from the banks can take insurance for themselves and any family member.

232 They have to pay a premium ranging from PKR 490–990 per person and are insured only in the

233 event of hospital admission. However, the insurance does not cover hospital costs and instead pays

234 the client the amount of daily wages lost, ranging from PKR 2,000–4,000 daily. The scheme also

235 covers a one-off payment in the event of death ranging from PKR 25,000–50,000. Female

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236 borrowers from the microfinance institute are only covered for themselves and spouse. They have

237 to pay a premium of PKR 1,200 if unmarried or PKR 1,850 if married. Clients are provided with

238 a one-off payment of PKR 30,000 in the event of hospitalization.

239

240 Determinants of health-related outcomes after health insurance intervention

241 Table 3 presents the determinants of health-related outcomes for recipients of a health insurance.

242 Overall perceived good health was significantly associated with group borrowers, small loan

243 amount, and smaller interest rate. Improved ability to visit a general practitioner shows a positive

244 correlation with women borrowers from Punjab province, attending monthly meetings, group loan,

245 and smaller loan amount. Women had a significantly improved ability to purchase prescribed

246 medicine when they were from Punjab, took smaller loans, owned a house. The uptake of

247 multivitamins was increased in women with smaller loans, owning a house, being borrowers since

248 no longer than two years, and attending monthly meetings. Therefore, only a small loan amount

249 was a significant determinant in all four health-related outcomes among recipients of a health

250 insurance.

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251 Table 3: Probit analysis on determinants of health-related outcomes among recipients of health insurance

Overall perceivedgood health

Improved ability to visit general practitioner

Improved ability to purchase prescribed

medicine

Improvedmultivitamin

uptake

Coeff. Z-Score Coeff. Z-

Score Coeff. Z-Score Coeff. Z-

ScoreAge -0.2588 -1.43 0.2754 1.39 -0.2915 -1.51 0.0703 0.36Religion 0.4079 1.37 -0.2711 -0.97 0.4165 1.46 -0.0102 -0.03Province -0.2676 -1.04 0.9990*** 4.05 1.043*** 4.21 0.0315 0.12Literacy -0.0999 -0.49 0.2018 0.96 0.0828 0.42 0.1994 0.98Spouse literacy 0.2410 1.18 0.1779 0.85 0.2424 1.20 0.1323 0.64House ownership 0.1550 0.69 -0.3397 -1.45 -0.6825** -2.65 -0.5699** -2.17Children 0.2094 1.15 0.2213 1.20 0.1530 0.85 0.2829 1.54Debt age -0.4130 -0.16 0.1650 0.63 0.3807 1.50 -0.6088** -2.41Group loan 0.8582*** 3.76 0.4813** 2.25 0.1567 0.73 -0.3705* -1.69Loan amount -0.7765*** -3.27 -0.8863** -3.50 -1.2028*** -5.05 -1.9933*** -4.13Interest rate 0.7250** 2.94 0.2777 1.12 -0.0691 -0.28 0.2345 0.98Monthly meetings 0.1370 0.61 0.7753*** 3.58 0.0166 0.08 -0.4233* -1.84No. of observationsWald Chi2

Prob> Chi2

Log likelihood

28442.740.0001

-158.6116

28476.930.0000

-146.0385

28464.570.0000

-157.5241

28453.150.0000

-153.7125252 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level

253

254 Determinants of health-related outcomes after health awareness intervention

255 In Table 4, the determinants for all four health-related outcomes among recipients of a health

256 awareness program are presented. Women with the following characteristics have a greater

257 probability of overall perceived good health: group borrowers, smaller loans, smaller interest rates,

258 younger women, and those with literate spouses. The ability of visiting the general practitioner for

259 regular checkups in the last year was higher in women from Punjab province, with smaller loans,

260 attending monthly meetings, above 29 years of age, and non-Muslim women. Similarly, women

261 from Punjab province, having smaller loans, owning their house, and younger women had a higher

262 probability of improved ability to purchase prescribed medicine. The probability of increased

263 uptake of multivitamins was greater in women who took smaller loans, had not been in debt for

264 more than 2 years, were group borrowers, and who attended monthly meetings. As for health

265 insurance, the only variable significantly associated with all health-related outcomes among

266 recipients of a health awareness program was the small loan amount.

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267

268 Table 4: Probit analysis on determinants of health-related outcomes among recipients of health awareness 269 programs




medicine


uptake



ScoreAge -0.3747* -1.70 0.3781* 1.70 -0.4329* -2.02 0.1058 0.48Religion 0.5185 1.59 -0.5503* -1.76 0.3880 1.24 0.1904 0.56Province -0.3898 -1.24 1.3048*** 4.39 1.029*** 3.83 0.1983 0.65Literacy -0.1537 -0.65 0.2229 0.91 0.1405 0.61 0.3411 1.43Spouse literacy 0.4163* 1.80 0.2546 1.09 0.0860 0.38 0.2310 1.00House ownership 0.3495 1.42 -0.2453 -0.96 -0.6360** -2.48 -0.4271 -1.54Children 0.3209 1.55 0.2765 1.33 0.2424 1.21 0.2833 1.36Debt age -0.0066 -0.02 0.4529 1.49 0.3817 1.36 -0.7164** -2.51Group loan 0.8817*** 3.33 0.3640 1.51 0.1030 0.43 -0.6352** -2.55Loan amount -0.7199** -2.65 -0.6511** -2.28 -1.9361*** -3.52 -0.9170*** -3.35Interest rate 0.6739** 2.23 0.3860 1.28 0.2428 0.83 0.3726 1.26Monthly meetings 0.2357 0.88 0.7689** 3.08 -0.0556 -0.22 -0.5816** -2.10No. of observationsWald Chi2

Prob> Chi2

Log likelihood

31435.680.0004

-126.4054

31464.570.0000

-116.6811

31453.250.0000

-128.2105

31448.790.0000


271

272 Impact of interventions on health-related outcomes

273 The results from the PSM model (Table 5) show that women receiving health insurance had a

274 significantly greater chance of overall perceived good health. According to NNM, 17.4% of

275 women with health insurance had greater likelihood for overall perceived good health; the results

276 for KM showed a greater likelihood in 11.8%. Female borrowers receiving a health awareness

277 program from the MFP in the form of health workshop or health talk by loan officer show

278 significant improvement in their ability to purchase prescribed medicine (NNM=10.1%; KM

279 =11.7%). For the two other outcomes, neither of the interventions showed a significant effect.

280

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281 Table 5: Impact of interventions on health-related outcomes based on propensity score matching

Overallperceived

good health



medicine

Improved multivitamin

uptake



ScoreNearest Neighbor MatchingHealth insurance 0.1740*** 3.45 0.0038 0.04 0.1271 1.46 0.0343 0.38Health awareness program 0.0599 0.97 0.0141 0.23 0.1016* 1.70 0.0291 0.42

Kernel MatchingHealth insurance 0.1175* 1.67 -0.0256 -0.32 0.1062 1.21 0.0775 1.09Health awareness program 0.0240 0.42 0.0292 0.41 0.1167** 2.08 0.0703 1.15

282 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level

283

284 Discussion

285 In the absence of universal health coverage and compulsory educational enrollment, poor and

286 predominantly illiterate female informal workers and borrowers of microfinance are dependent on

287 MFP for receiving health coverage and promoting health. This study has measured four health-

288 related outcomes in female borrowers. The results show that there is inequity in uptake of health

289 insurance and health-related outcomes.

290 Women from Punjab have better health-related outcomes compared to women from Sindh,

291 Balochistan and KPK. National health surveys of Pakistan also report that Punjab has better health-

292 related outcomes compared to other provinces, as the provincial government of Punjab has greater

293 budget allocation for running health awareness campaigns [29]. The fact that our results show that

294 older women and non-Muslim women have higher likelihood of improved ability to visit general

295 practitioner after receiving health awareness intervention indicates that younger Muslim women

296 face barriers to health access due to regressive norms [30]. Muslim families are known to prevent

297 fertile women from accessing healthcare in an attempt to control their reproductive choices and

298 health options. Our results align with other research which suggests that Muslims suffer from

299 health disparities due to religious fallacies [31].

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300 Conversely, younger women show better overall perceived health and ability to purchase

301 prescribed medicine This may be because at a younger age less health issues occur and also

302 because of greater state and NGO efforts for maternal healthcare [32]. Our results confirm that

303 women under the age of 29 years receive privileged support in a patriarchal society during prime

304 childbearing years to consume maternal health related medication [33]. Women with literate

305 spouses are also showing improvement in overall general health after receiving health insurance.

306 This may be because spouse literacy has a direct effect on women’s improved health behavior and

307 mental health [34].

308 Women who borrow the loan in groups show better health-related outcomes compared to women

309 who are single borrowers. Our results suggest that women in groups share their health knowledge

310 and encourage each other toward improved health behavior [35]. Similarly, women who attend

311 monthly meetings with loan officers have better health-related outcomes. The results suggest that

312 caring loan officers are fulfilling an important responsibility in supporting women borrowers in

313 improved health behavior and health-related outcomes. Given the conservative culture of Pakistan

314 and the disadvantaged background of the female borrowers, loan-taking women might not be able

315 to utilize health services due to issues of permission or ignorance.

316 Women who receive smaller microfinance loans and do not have a long debt age show improved

317 health-related outcomes. This finding suggests that women with debt burden over a longer period

318 of time may be suffering from debt fatigue converting to declined health-related outcomes [36].

319 Women and their families who live in owned houses also have better health-related outcomes,

320 specifically related to the ability to visit general practitioners and improved uptake of

321 multivitamins. The results imply that provision of health insurance and not having to pay

322 household rents on a monthly basis translates to better health-related outcomes. Impoverished

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323 families that have to pay high rents for accommodation are usually employed in multiple jobs and

324 have little time for health and wellbeing [37].

325 The impact of microfinance is only visible on two health-related variables. Although there are no

326 effects on general practitioner visitation and uptake of multivitamins, we found that a microfinance

327 health insurance has an impact on an improved perception of general health. This shows that being

328 insured is an emotional support and wellbeing facilitator for poor women. The emotional buttress

329 provided by health insurance can go a long way in improving perceived wellbeing, which can

330 translate to greater commitment to self, family, and business development in poor women from

331 disadvantaged backgrounds [38]. In addition, microfinance health awareness interventions have

332 an impact on improved purchase of prescribed medicine. Many poor women in Pakistan do not

333 take prescribed medicine unless it is freely available due to the greater need to prioritize purchase

334 of basic necessities and household consumption [39]. The impact of microfinance interventions is

335 comparable to previous research. A review highlighted that most interventions combined

336 microfinance with health education. However, positive effects were mainly found for health

337 knowledge and behavior, but not health status [40]. A meta-analysis indicated the potential for

338 females, as microfinance may lead to changes in the use of contraceptives, strengthen female

339 empowerment and improve children’s nutrition [41].

340 However, for female borrowers of microfinance, there might be additional burdens of loan

341 repayment and small business investment. Our results suggest that illiterate and poor women of

342 the country are benefiting from health awareness in recognizing that if they do not consume

343 prescribed medicine for chronic ailments (heart disease, cholesterol, or diabetes) it can have

344 serious consequences for their own life and the future livelihood of their families. There needs to

345 be urgent recognition that a triadic health insurance safety net is necessary, instead of dependency

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346 on private providers to protect informal working women in Pakistan. Employers and the

347 government must join forces to ensure universal health insurance and – particularly in times of the

348 corona pandemic – infectious disease outbreak insurances for health emergencies. State financing

349 of healthcare is essential through increased allocations of gross domestic product (GDP),

350 government-run business profits, and increasing income and corporate tax base from the elite.

351 With regard to women microfinance borrowers, we recommend microfinance regulatory bodies to

352 urgently legislate the following reforms: (i) coverage of children and other dependents, maternity

353 costs, and non-hospitalization costs, (ii) expand coverage for religious and ethnic minorities, (iii)

354 reduce interest rates for those paying high house rents and introduce house ownership loans, (iv)

355 introduce mandatory group borrowing and monthly meetings with loan officers, and (iv) alter

356 repayment timelines and interest rate packages for women taking bigger loans.

357 We recommend the following urgent social policy improvements, which would adjoin in helping

358 health policy efforts: (i) development of public primary healthcare services for women in the

359 communities with mandatory quarterly General Practitioner meeting, (ii) upgrading of poverty

360 alleviation programs for support of poor women, (iii) capping for housing rents and improvement

361 of neighborhood sanitation to curb infection, (iv) advancement of home-based business

362 opportunities for informal women workers for income maintenance, including digitalization and

363 internet access in the homes, and (v) income supplementation and cash transfers for multivitamin

364 and food nutrition intake for immunity and health overall [42].

365

366 Limitations

367 This study has some limitations, most important the cross-sectional design. Although we were able

368 to compare the effects of an intervention because of the quasi-experimental analysis framework,

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369 two-group cross-sectional designs are suffering from the limitations related to a single

370 measurement for all subjects. Therefore, within-person changes over time are not observable.

371 Without repeated measures in a two-group design, causality cannot be identified, because temporal

372 sequencing on the intervention and outcomes cannot be established. For that reason, we

373 recommend longitudinal data collection in future studies. Furthermore, the results need to be

374 interpreted with caution, because the four health-related outcomes are non-homogenous and

375 dependent on socio-environmental factors specific to the region and community where the

376 interventions are taking place. Despite the limitations, we feel this study is significant for the

377 development of microfinance health services in Pakistan and the role of state and interest-free

378 microfinance health interventions.

379

380 Conclusion

381 It is critical to assess the health needs of women employed in the informal sector. As primary

382 caregivers at home as well as primary contributors for household income, the health of women

383 assumes a salience that would place both structures of the family and the economy at risk. Health

384 policy must consider several social policies for protecting disadvantaged women, who are poverty-

385 ridden, illiterate or semi-literate, and loan takers. Health insurance schemes and health promotion

386 at the workplace must be made mandatory by employers, microfinance providers, and the

387 government, given the cultural barriers of uptake for women. Targeting improved equity across

388 female population groups for health intervention will in the long run improve women’s health,

389 capacity expansion and income-earning abilities.

390 Designing and implementing a health and social policy protection net for female informal workers

391 requires empirical evidence regarding health interventions and socio-demographic characteristics

392 impacting on health outcomes. Since public sector health sector shortages and inefficiencies are a

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393 concern in Pakistan, the ‘health card’ must be accepted in both the private and public sector,

394 whichever is able to serve the poor first. As Pakistan is struggling with low GDP and tax collection

395 base, we recommend more research into options for social franchising, and partnership with

396 independent health insurance companies to serve disadvantaged women.

397

398 Acknowledgements

399 We thank the female borrowers who consented and gave their time to participate in the study. We

400 are grateful to our research team members in charge of logistical planning and coordination for

401 data collection across Pakistan including Rizwan Haider and Amir Naseem. Individual data

402 collection heads for each city are thanked for their efforts, especially for resolving gate keeping

403 issues, including Nida Abbas (Lahore), Zainab Asif (Abbotabad), Hina Bukhari (Gujranwala),

404 Sadia BiBi (Khanewal), Ansari Abbass (Sheikhapura), Azra Shakeel and Shumaila Sadique

405 (Matari), and Javaria Imran (Lasbela). The research assistant Bilal Asghar is also thanked for

406 entering all data.

407 We acknowledge support from the German Research Foundation (DFG) and the Open Access

408 Publication Fund of Charité – Universitätsmedizin Berlin.

409

410 Competing interests

411 The authors declare that no competing interests exist.

412

413 Funding

414 This study received funding by the Office of Research, Innovation and Commercialization at

415 Forman Christian College.

416

417 Data sharing

418 Data is available upon reasonable request from the corresponding author.

419

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420 Ethical considerations

421 Ethical approval for this study was taken from the Institutional Review Board of the Forman

422 Christian College University. Study participants were informed about the aims of the study and

423 provided informed consent either in written form or through thumb impression.

424

425 Author’s contributions

426 SRJ designed the study and was responsible for the research project, including data collection and

427 analysis; FF supervised this process. HA and MM supported in data collection. RZ and FF

428 contributed to the interpretation of the data. SRJ drafted the manuscript; all authors revised it

429 critically for important intellectual content. All authors approved the final version of this

430 manuscript.

431

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Relationship between Microfinance, Social Development and Women’s Health

Cover Letter for Participants Questionnaire Information for Women Microfinance Borrowers Researcher: Dr. Sara Rizvi Jafree, e-mail: [email protected]; 0300 400 5740

Thank you for your valuable time! Your name is not required and all research analysis will be undertaken with confidentiality and complete anonymity. At any point during the interview you may leave, if you wish to do so. (Translation in Roman Urdu: Apka Bohat Shukirya apke eemtay waat ke liye! Apke Nam Ka Bharna Zaruri Nahi Hai Aur Yeh Tehkeek Ko Khoofiya Rakha Jaye Ga. Interview ke doran ap kabhi bhi uth ke jaana chahey to apko puri ijazat hai.) The questionnaire has been designed to collect information about your loan portfolio and your self-rated health. Our aim is to understand your needs and challenges, and ultimately try to improve your loan portfolio and health access and services. ((Translation in Roman Urdu: Is questionnaire Ka Masad Hai ke apse chand sawal loan aur sehat ke bare mein puchna. Humara masad ye hai ke apke arze ki sahuliyat aur sehat dono ko behtar kiya jaye.) Your honest and reliable answers will be appreciated, so that we can recommend the best solutions with regard to optimal loan portfolios and health satisfaction. ((Translation in Roman Urdu: Apke Sache Aur Ba Aitibar Jawab Ke Shukarguzar Honge, Thake loan aur sehat ke hawale se hum apke mushkilay ya rukawaton ko Samajh Sake.) In the event that you feel disturbed or upset after answering questions or recalling memories related to health problems or experiences of violence/ harassment, you may call or text the researcher for free consultation services from trained female psychologists. ((Translation in Roman Urdu: Agar apko in sawal aur jawab ki wajeh se koi preshani ho ya koi aisa waiya yad a jaye jo apki zehni pareshani mein izafa kare, tho ap upar diye gaye number par call ya text kar ke rabta kar le. Hum apki muft mein madat zanana mahir-e-nafsiyat se karwayenge.)

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Instrument The questionnaire will be read out and completed by the researcher, on behalf of the participant. Province/City: ____________________________ Microfinance Provider:________________________ Area/locality: Participant Code:

SECTION A: SOCIO-DEMOGRAPHIC CHARACHTERISTICS

Code Entry

Q1.Age Umar?

1.20-29 2.30-39 3.40-49 4.50+

Q2.Religion Mazhab

1.Muslim 2.Christian 3.Hindu 4.Other

Q3.Province Sooba?

1.Punjabi 2.Sindhi 3.Baluchi 4.KPK

Q4.City Shehr?

1.Lahore 2.Islamabad

3.Karachi 4.Hyderabad

1.Quetta 1.Peshawar

Q5.City-Area Q6.Language spoken at home with family Madri zubaan?

Q7.Race (β) Zaat

Q8.Marital Status Kya ap shadi shuda hain?

1.Married 2.Single 3.Divorced 4.Seperated

Q9.Literacy Taleem-i-qabiliyat

1.None 2.Primary 3.Secondary 4.Graduate

Q10.Occupation Pesha

Q10.Spouse literacy Aapkay khaawand ki taleemi qabiliyat kya hai?


Q12.Spouse Occupation Apkay khawand ka pesha kya hai?

Q13.Your earning in last month Pichlay mahinay aap ki kamai kitni thi?

1.Less than 5k 2.>5k-10k 2.>10k-20k 4.Other

Q14.Your earning in last year Pichlay saal apki kitni kamai thi?


Q15.Combined household income in a month (on average) Tamaam ghar ki amdani kitni hai?


Q16.House Ownership Ghar ka malik kaun hai?

1.Owned 2.Rented 3.Living with someone

4.Other

Q17.Number of children Apkay kitnay bachay hain?

1. None 2. 1-2 3. 3-5 4. >6

Q18.Age of last child Akhri bachay ki umar?

Q19.Number of people living in house Ghar mai kitnay afraad rehte hain?

1. 1-2 2. 3-5 3. 6-9 4. >10

Sign or Thumb Impression for Written Consent

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Q20.Number of rooms in house Ghar mai kitnay kamray hain?

1. 1 2. 2-3 3. 4-5 4. >6

Q21.Are you currently taking care of a disabled/ dependent family member Kya apkay ghar mai koi mazoor/jiska ap par inhasaar ho, shakhs hai?

1.No 2.Yes If Yes, who:

Q22.Source of drinking water Pani penay ka kya zarya hai?

1.Plain Tap 2.Filtered 3.Local Pump

4.Other

Q23.Type of energy used for cooking in house Ghar mai khana pakanay ke liye kis chiz ka istemaal kartay hain? (gas, coal, electric etc.)

1.Gas 2.Wood 3.Electricity 4.Other

Q24.Do you have toilet facility in house Apkay ghar mai bait-ul-khala hai?

1.Yes 2.No If No, what do you use

Q25.How many toilets in the house Ghar mai kitnay bait-ul-khala hain?

1. None 2. 1-2 3. 3-5 4. >6

Q26.Does the toilet have a flush Bait-ul-khala mai flush hai?


Q27.Is the drainage and gutter system of your house satisfactory Ganday pani ke ikhraj ka nizaam darust hai?

1.Yes 2.No

Q28.How do you dispose of the garbage Ghar ki gandagi kahan phenkhtay hain?

1.Throw it on street/ far away

from home

2.Garbage collectors come to house

3.Set Fire 4.Other

Q29.Are you taking any health insurance (not provided by the microfinance provider)? (If so, from where, how much installment) Sehat ke liye insurance le rae hain?

1.Yes 2.No If Yes, who

SECTION B: MICROFINANCE LOAN CHARACHTERISTICS

Q30.Why are you taking loan (describe your work type, hours of work, working conditions in detail) Aap karz kyun le rahe hain? (kis tarah ka kaam hai, kitnay ghantay kaam kartay hain, jahan kaam kartay hain uskay halaat)

Q31.What type of loan are you currently taking/ duration Kis tarah ka karz le rahay hain/kitnay arsay se?

Q32.How long have you been a microfinance borrower for Kitne arsay se karz le rahay hain?

1. 1-2 years 2. 3-5 years 3. 6-9 years 4. >10 years

Q33.Is it a group loan Kya ap ne kisi ke sath mil ke karz liya hai?


Q34.How much is the loan for Kitna karz liya hai?

Q35.What is the installment rate per month Karz ko ada karnay ki mahana kist kya hai?

Q36.Do you attend monthly meetings with loan officers Karz denay walay officer se kya apki mahwar mulakaat hoti hai?

1.Yes 2.No

Q37.Do you attend weekly meetings with loan officers Karz dene walay officer se kya apki haftawar mulkaat hoti hai?

1.Yes 2.No

Q38.Who helps you in loan repayment Karz ada karnay mai kya koi apki madad karta hai?

1.No one 2.Husband 3.Parents 4.Other

Q39.What exactly has the loan been used for Ap karz kis liye istemal karti hain?

1.Business 2.Household expenditure

3.Old Loans

4.Health Costs

4.Other

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Q40.How much of the loan taken has been invested in business Karz ka kitna hissa karobar mai kharch kiya hai?

1.All 2.Half 3.Quarter 4.Other

Q41.Are you satisfied with loan amount Kya aap karz ki rakam se mutmaeen hai?

1.Yes 2.No

Q42.Are you satisfied with loan repayment rate Kya ap karz ki adaigi ki kist se mutmaeen hai?

1.Yes 2.No

Q43.Will you be renewing loan Kya aap karz dobara lena chahain gae?

1.Yes 2.No

Q44.Have you received any skill development training Kya apki silahiyaton ko barhanay ki koi tarbiyat mili hai?

1.Yes 2.No

Q45.Have you participated in any health workshop/awareness campaign/talk… Kya sehat se mutalik ap kisi agahi mohim ka hissa banay hai?

1.Yes 2.No

Q46.Has your loan officer or center ever talked to you about health awareness or access Kya karz denay walay officer ne ap se sehat ke mutalik koi agahi di hai?

1.Yes 2.No

Q47.Have you been offered saving insurance by your MFP Kya idaray ne apko bachat insurance ki peshkash ki hai?

1.Yes 2.No

Q48.Are you taking saving insurance with your MFP Kya idara ap ko bachat insurance de raha hai?

1.Yes 2.No

Q49.Have you been offered health insurance by your MFP Kya idara aap ko sehat insurance deta hai?

1.Yes 2.No

Q50.Are you taking health insurance with your MFP Kya ap idaray se sehat insurance le rahay hain?

1.Yes 2.No

Q51.Has the loan so far satisfied your business needs Kya karz ki rakam ne apki karobari zaroriyat ko pura kiya hai?

1.Yes 2.No

Q52.Has your loan taking from MF enabled you to visit a trained private general practitioner, if needed in last 12 months Karzay k baad pichlay 12 maheenay mein kya app private doctor ko dekhanay gaye hain?

1.Yes 2.No

Q53.Has your employment from MF loan enabled you to visit a trained private specialist practitioner, if needed in last 12 months Karzay k baad pichlay 12 maheenay mein kya app baday doctor ko dekhanay gaye hain?

1.Yes 2.No

Q54.How is your ability to purchase prescribed medicines (in case recommended by doctor) since loan-taking? Kya karz lene ke bad dawayan khareednay ki istata’at mai koi tabdeeli ai hai?

1.Very Good 2.Good 3.Fair 4.Poor

SECTION C WOMEN’S HEALTH CARE EXPERIENCES SURVEY

Q55. How would you rate your health in general? Apki sehat kis mayar ki hai?


Q56.Compared to other women your age, how would you rate your health Apni hum umar auraton ki nisbat aap apni sehat ka kya mayaar samjhtay hain?


Q57. Do you feel your health could be better than 1.Yes 2.No If yes, could you say why/ how:

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it is presently? Kya apki sehat ke mayaar mai koi behtari lai ja sakti hai?

Q58.Does your husband/ male relative/in-laws decide/ give approval when you or your children need consultation from a medical practitioner Kya apka khawand/susral apko doctor pe janay ki ijazat deta hai? Kya ye faisla bhi apka susral/khawand krta hai?

1.Yes 2. I decide myself independently

If yes, can you specify which relatives:

Q59.Does your husband/ male relative/in-laws decide/ give approval when you or your children need to visit a clinic/ hospital Kya apka khawand/susral apko hospital janay ki ijazat deta hai or kya ye faisla kaun leta hai?



Please indicate if you have experienced any of the following health issues in the last 12 months?

1.Yes 2.No

Q60.Minor illness like the flu or an infection Pichlay 12 mahinay mai apko nazla ya infection hua hai?

Q61.Had to go for a checkup or routine physical exam Jismani muaaenay ke liye gae hain?

Q62.Were you pregnant? Kya app hamla theen?

Q63.Did you need family planning or preconceptional services? Kya apko munsoba bandi ki zaroorat thee?

Q64.Did you have an injury that you have not already mentioned? Kya apko koi chot lagi hai?

Q65.Did you need care for a chronic health problem, (that is one that goes on for a long time)? Kya apko kisi taweel bemari ke liye hospital jana para hai?

Q66.Did you need surgery for a condition not already mentioned? Kya apko operation keranay ki zaroorat parhi?

If yes, what?

Q67.Were you feeling depressed, anxious, or highly stressed? Kya iski waja se apko kisi kisam ka zehni dabao ya bechaini mehsoos hui hai?

Could you pinpoint why?

Have you had one of the following tests in the last 12 months?

1.Yes 2.No

Q68.Colon cancer screening, such as a check for blood in your stool, sigmoidoscopy, or colonoscopy

Q69.Test for glaucoma or pressure in the eye Q70.Blood cholesterol test Q71.Check for high blood pressure Q72.Test for diabetes Q73.Breast exam by a doctor or nurse Q74.Mammogram Q75.Pap test Q76.Bone density test (for osteoporosis) Q77.Genetic screening test Q78.Screening for HIV/AIDS

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Q79.Screening for other sexually transmitted diseases

Q80.Dental exam Q81.Shot for flu or pneumonia Q82.Pregnancy test Q83.Family planning services or contraception Q84.Tests for infertility Q85.Abortion information or services Q86.Alcohol or drug abuse counseling or treatment

In the past 12 months, did any of your health care providers or microfinance loan managers talk with you or give you information about? (pichlay 12 mahino mai kya apkay doctor/nurse ya apkay karz dene walay officer ne aap se in chizon ke baray mai maloomat di hain?)

1.Yes 2.No If yes, can you specify who gave you this information:

Q87.Smoking, second-hand smoke, or quitting smoking Tambako noshi, kisi aisay shaks k saath bethtna/rehna jo tambako noshi mein mulawis ho, ya tambako noshi chorna

Q88.Nutrition or diet (Khuraak)

Q89.Alcohol or drug use Shraab ya adviyaat?

Q90.Physical fitness or exercise Jismani sehat ya warzish?

Q91.Menopause or hormone replacement therapy San – e - yaas ya hormone tabdeeli therapy?

Q92.Violence in the home or workplace Kya ghar ya kaam pe kisi tashadud ka shikar hue hain?

Q93.Work or financial problems Kaam ya muaashi mushkilaat ka samna hua hai?

Q94.Family or relationship problems Ghar walon ya rishtadaron ke masa’il?

Q95.Importance of child health and nutrition Bachon ki sehat or khuraak ki ehmiyat?

Q96.Stress management Zehani dabao ko kum karna

Q97.Preventing unintended pregnancies & birth spacing Bachon ke darmiya wakfa?

Q98.Using alternative therapies, such as herbs or acupuncture

Q99.Preventing osteoporosis Hadion ke dard se bachao

Are there any dietary supplements that you have used in the last 12 months?

1.Yes 2.No

Q100.Vitamin C Q101.Vitamin D Q102.Vitamin E Q103.B Complex Q104.Calcium Q105.Pregnancy Vitamin Q106.Lactation Vitamin

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Q107.General Multi-vitamin What is your personal preference for health services? Tibbi saholiyat se mutalik apki zaati tarjihaat kya hain?

1.Yes 2.No 3.Indfferent

Q108.Family (e.g. mother/ mother-in-law/ aunt) Ghar walay?

If Yes, describe who:

Q109.A women’s health center where you can get most of your basic health care, including gynecological care, in one place Khawateen ki sehat markaz?

Q110.Trusted community member Baradari?

Q111.A nurse or LHW (Not a physician/ surgeon/ medical consultant)

Q112.PublicHospital Q113.Local female healer Q114.Private Clinic Q115.In general, how difficult have you found it to talk to health care providers about your personal health concerns? doctor/nurse se baat krna apko kitna mushkil lagta hai?

1.Very difficult 2.Somewhat difficult

2.Not too difficult

3.Not difficult at all

Please rate the health practitioner services as you have experienced them?

1.Excellent 2.Good 3.Fair 4.Poor

Q116.Listening to what you have to say Kya apki baat ghor se suntay hain?

Q117.Talking to you in a respectful and caring manner

Kya ap se izzat se baat kartay hai?

Q118.Speaking to you in the language/ dialect you understand better

Kya apse apki madri zubaan mai baat krtay hai

Q119.Answering your questions clearly Ap ke sawalon ka sahi se jawaab detay hai?

Q120.Giving you the opportunity to ask all of your questions Apko sawaal puchnay ka wakt detay hai?

Q121.Helping you to feel comfortable talking about your personal or sensitive health concerns Kya ap asaani se unhe apnay masaael ke baray mai bata deti hain?

Q122.Giving you complete health information Kya sehat se mutalik tamaam jankari detay hain?

Q123.Discussing alternative therapies, diet and lifestyle Kya ap se mutabadil therapy ya khuraq ya roz mara ki zindagi guzarnay kay tareekay pe tabadal e khayal kya hai?

Q124.Giving you complete information about any tests or services Test ke baray mai mukamal jaankari detay hain?

Q125.Giving you the results of your tests Test ke nataij batatay hain?

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Q126.Giving you complete information about all your options for treatments Kya ilaaj ke mutalik apko mukamal jaankari detay hai?

Q127.Giving you the opportunity to make important decisions about your health care Kya sehat se mutalik tamam faislay apko karnay detay hai?

Q128.Giving you written or printed information when you need it Malumaat likh kr dete hai?

Q129.Spending enough time with you during your visits Apko tasali bakhsh wakt detay hai?

Q130.Treating you like a partner in your health care Apka sathi bun kr apki sehat ka khayal rakhtay hai?

Which are the primary/ most important sources you depend on for making health decisions? Sehat se mutalik faislon ke liye ap kis se mashwara leti hai?

Tick relevant options

Q131.Husband Q132.Mother in law Q133.Other in-laws (list please) Q134.Blood family (parents, siblings, children…) Q135.Newspapers / magazines Q136.Heath newsletter Q137.TV Q138.Radio Q139.Microfinance provider Q140.Internet Q141.Mobile services Q142.Family/ friends Q143.Community Q144.Medical Practitioner Q145.Local Healer Q146.Local Imam/ religious leader Q147.Other (Please list) Current Health Risks Q148.Do you currently smoke? Kya app tambako noshi mein mulawis hain?

1.Yes

2.No

Q149.How many in a day? Din ke kitnay ?

Q150.Does anyone else smoke in the house when you/ children are in same room? Kya koi aur tambako noshi mein mulawis hain

1.Yes 2.No If yes, who is this:

Q151.Do you feel anxious, stressed, depressed, suicidal? Kya app kabhi bechain hotay hain ya zehni dabao ka shakar ya khud kushi ka khayal aya hai?

1.Yes 2.No

Indicate which:

Q152.Do you take any drugs (to relieve yourselves of stress or an ailment? Kya app in ke liye koi dawa laitay hain?

1.Yes

2.No

If yes, which ones:

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In the past 5 years, has a doctor ever told you that you have any of the following conditions Kya pichlay paanch salon mai doctor ne aapko bataya ke apko ye bemari hai?


Q153.Hypertension/ BP High blood pressure

Q154.Heart disease Dil ki bemari

Q155.High cholesterol Q156.Diabetes (sugar)

Q157.Depression Zehni dabao

Q158.Anxiety Bechaini

Q159.Migraine headaches (sar dard)

Q160.Arthritis Joro ki dard

Q161.Osteoporosis Q162.Obesity/ Over-weight problems (mutapa)

Q163.Urinary incontinence (pishaap ki takleef)

Q164.Cancer Q165.Eating disorder like bulimia/ anorexia Khanay k hawaly se koi mushkil, jaisay bhook na lagna ya kha k ulti kerna

Q166.Thyroid problems Q167.Malaria/ Dengue Are you facing any disability which? Kya aap kisi mazoori ka shikaar hain?

1.Yes

2.No

Q168.Keeps you from participating fully in your ability to take care of your family Jiski waja se ap apnay ghar walon ka khayal na rakh sakain

If yes, please describe this disability:

Q169.Keeps you from participating fully in your ability to continue with your business Apnay karobaar mai sahi se kaam na kr sakain


SECTION D BASELINE NUTRITION AND FOOD SECURITY SURVEY UNICEF

Q170.In the past 6 months did you find it too expensive to purchase the foods you needed to feed your family? Pichlay 6 maah mai kya apko khaandan ko palnay ke liye khana lenay mai mushkilaat hoti hai?

1.Yes

2.No

Q171.Did you find it too expensive to purchase fruit? Kya phal khareedna bohat mehnga hai?

1.Yes

2.No

Q172.Did you find it too expensive to purchase 1.Yes

2.No

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vegetables? Kya sabzi khareedna bohat mehnga hai?

Q173.Did you find it too expensive to purchase meat? Kya gosht khareedna bohat mehnga hai?

1.Yes

2.No

Q174.Did you find it too expensive to purchase eggs? Kya anday khareedna bohat mehnga hai?

1.Yes

2.No

Q175.Did you find it too expensive to purchase milk? Kya doodh khareedna bohat mehnga hai?

1.Yes

2.No

Q176.Did you find it too expensive to purchase wheat, for roti? Kya roti khareedna bohat mehnga hai?

1.Yes

2.No

Q177.In the last 3 months were you worried about running out of food because of high costs? Pichlay 3 maah mai mehngai ki waja se khana na khareed panay ka dart ha?

1.Yes

2.No

Q178.In the last 3 months did you run out of food because of expense? Pichlay 3 maah mai kya mehngai ki waja se kabhi ghar mai khana khatam ho gaya ho?

1.Yes

2.No

Q179.In the last 3 months did you or any other adult in the house skip meals because there was not enough food? Pichlay 3 maah mai aap ya kisi or ghar walay se khana kum honay ki waja se khana na khaya ho?

1.Yes

2.No

Q180.In the last 3 months did you ever think your children are still hungry because of not being fed enough food? Pichlay 3 maah mai apko kabhi laga ke apkay bachay bhookay hai kyunkay khana pura nai tha?

1.Yes

2.No

Q181.In the last 3 months did any of your children go to bed hungry? Pichlay 3 maah mai kya apkay bachay kabhi bhookay soe houn?

1.Yes

2.No

SECTION E WHO MULTI-COUNTRY STUDY ON WOMEN’S HEALTH AND DOMESTIC VIOLENCE AGAINST WOMEN Psychological violence experienced at home 1.Yes 2.No If yes, who were these

household members?

Q182.Has someone in your home insulted you or made you feel bad about yourself? Kya ghar mai kisi ne apki bezati ki hai?

Q183.Has someone in your home belittled or humiliated you in front of other people? Kya ghar mai kisi ne apko dosron ke samnay hakeer dikhaya hai?

Q184.Has someone in your home done things to scare or intimidate you on purpose? Kya ghar mai kisi ne apko daraya hai?

Q185.Has someone in your home threatened to hurt you or someone you care about? Kisi ne apko damkhaya hai?

Physical violence experienced at home 1.Yes 2.No If yes, who were these

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household members? Q186.Has someone in your home slapped you or thrown something at you that could hurt you? Kya kisi ne apko thapar lagaya ho ya app e koi chiz phenki ho jisse apko chot lagi ho?

Q187.Has someone in your home pushed or shoved you? Ghar pe apko kisi ne dhaka diya hai?

Q188.Has someone in your home hit you with his fist or with something else that could hurt you? Kisi ne apko mukkay marain hai?

Q189.Has someone in your home kicked you, dragged you or beaten you up? Kisi ne apko laat mari ho ya ghaseeta ho?

Q190.Has someone in your home choked or burnt you on purpose? Kisi ne jaan bojh kr apka gala dabanay ki, ya jalanay ki koshish ki hai?

Q191.Has he threatened to use or actually used a gun, knife or other weapon against you? Apkay khilaf koi hathyaar istemal kiya hai?

Sexual violence experienced at home 1.Yes 2.No

Q191.Has your husband physically forced you to have sexual intercourse when you didn’t want to? Kya apke shohar ne kisi kisam ka jinsi tushadad kiya hai?

Q192.Did you ever have sexual intercourse when you didn’t want because you were afraid of what your husband might do? Kiya app ne kabhi apnay shohar k darr se uss ke saath jinsi taluqat rakhain hain?

Q193.Has your husband forced you to do something sexual that you found degrading or humiliating? Kya apkay shohar ne kabhi app se aisay jinsi kaam keraye hain jin se app sharminda ya zilat mehsoos kerain?

SECTION F SURVEY OF WORKPLACE VIOLENCE WHO

Q194.Describe where exactly your work takes place, when outside of home Ghar se bahir kahan kaam karti hai?

Q195.What kind of people do you interact with mostly for work, outside of home (gender Kam pe kis tarah ke log se mulakat hoi hai?

Q196.What are the hours that you are required to work outside of home Ghar se bahir kaam ke silsalay mai kitnay ghnatay lagtay hai?

Q197.Which security measure is available to you outside of home in case of fear of violence (male relative accompanying, phone, moving in crowd…) Tashadud ki soorat mai kaam pr koi hifazati intezam hotay hai?

Physical Violence (PV) at the workplace Q198.In the last 12 months, have you been physically attacked in your workplace/ when you are working outside of home? Ghar se bahir kaam kartay wakt kisi tarah ke tashadud ka shikar

1.Yes 2.No

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hui hain? Q199.Was this PV with a weapon? (If yes, what kind) Kya is tashadud ke liye koi aslaah istemal kiya gaya tha?

Q200.Is this a typical incident at your workplace/ when you are working outside of home? Kya is tarah ka tashadud kaam pr mamool ki baat hai?

1.Yes 2.No

Q201.Who attacked you? Kis ne app r tashadud kiya?

Q202.Where exactly did it take place? Tashadud kis jaga hua?

Q203.What time was it? Kis wakt hua?

Q204.Do you think it could be prevented? Kya is tashadud roka ja sakta tha?

1.Yes 2.No

Q205.Were you injured? Kya apko kisi kisam ki chot ai thi?

1.Yes 2.No

Q206.Did you require treatment for the injury? Kya is chot/zakham ke liye apko kisi ilaj ki zarorat hui?

1.Yes 2.No If yes, can you describe this treatment:

Q207.How did you respond to the incident? Tashadud ke natijay mai ap ne kya kiya?

Did you suffer any of the following due to PV: Q208.Repeated, disturbing memories, thoughts, or images of the attack? Tashadud ke bad kya apko iske baray mai aksar khayalat atay the?

1.Yes 2.No

Q209.Avoiding thinking about or talking about the attack or avoiding having feelings related to it? Kya is tashadud ke baray mai baat karne se ap ghabrati thi?

1.Yes 2.No

Q210.Being "super-alert" or watchful and on guard? Tashadud ke bad dar ke rehne lagi?

1.Yes 2.No

Q211.Feeling like everything you did was an effort? Har kaam mushkil ho gaya?

1.Yes 2.No

Verbal Violence (VV) at the workplace Q212.In the last 12 months, have you been verbally assaulted in your workplace/ when you are working outside of home? Kya pichlay 12 mah mai kaam pr kisi ne ap pr zabani tashadud kiya hai?

1.Yes 2.No

Q213.How often has this happened in the last 12 months? Kitni dafa?

1.Daily 2.About once in a week

3.About once in a month

4.Other

Q214.Is this a typical incident at your workplace/ when you are working outside of home? Kya ye kaam pr mamool ki baat hai?

1.Yes 2.No

Q215.Who abused you? Kis ne aap per zabani tashadud kiya?

Q216.Where exactly did it take place? Kahan kiya?

Q217.What time was it? Kis wakt kiya?

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Q218.Do you think it could be prevented? Kya isse roka ja sakta tha?

1.Yes 2.No

Q219.How did you respond to the incident? Iske natijay mai aap ne kya kiya?

Did you suffer any of the following due to VV: Q220.Repeated, disturbing memories, thoughts, or images of the attack? Tashadud ke bad kya apko iske baray mai aksar khayalat atay the?

1.Yes 2.No


1.Yes 2.No


1.Yes 2.No


1.Yes 2.No

Sexual Harassment (SH) at the workplace Q224.In the last 12 months, have you been sexually harassed in your workplace/ when you are working outside of home? Kya pichlay 12 maheenay mein ap ko kisi kisam k jinsi harasaan ka samna kerna parha hai?

1.Yes 2.No

Q225.How often have you been sexually harassed in the last 12 months? Pichlay 12 maheenay mein yeh kitni dafa hua?



4.Other

Q226.Is this a typical incident at your workplace/ when you are working outside of home? Kya yeh kaam kernay wali jaga pe amoman hota hai?

1.Yes 2.No

Q227.Who attacked you? Hamla awar kaun tha?

Q228.Where exactly did it take place? Yeh kis jaga pe hua?

Q229.What time was it? Waqt kya tha?

Q230.Do you think it could be prevented? Kya app isko rok sakti theen?

1.Yes 2.No

Q231.How did you respond to the incident? Apnay iska samna kaisay kiya?

Did you suffer any of the following due to SH: Q232.Repeated, disturbing memories, thoughts, or images of the attack? Kya apko iss hadsay k baad baar baar buray khaylat ya yaadain pareshan kerti hain?

1.Yes 2.No

Q233.Avoiding thinking about or talking about the attack or avoiding having feelings related to it? Kya app iss hadsay ko bhulanay ki koshih ya iskay baray mein baat kernay se guraiz kertay hain?

1.Yes 2.No

Q234.Being "super-alert" or watchful and on guard?

1.Yes 2.No

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Kya app chak o chawbund rehtay hain? Q235.Feeling like everything you did was an effort? Kya apko zehni dabao mehsoos hota hai?

1.Yes 2.No

Racial Harassment (RH) at the workplace Q236.In the last 12 months, have you been racially harassed in your workplace/ when you are working outside of home? Pichlay 12 maah mai apki zaat ki waja se kisi ne apko harasaan kiya hai?

1.Yes 2.No

Q237.How often have you been racially harassed in the last 12 months? Kitni dafa?



4.Other

Q238.Is this a typical incident at your workplace/ when you are working outside of home? Ghar se bahir kaam pe kya ye aam ma’mool ki baat hai?

1.Yes 2.No

Q239.Who attacked you? Kis ne harasaan kiya?

Q240.Where exactly did it take place? Kahan

Q241.What time was it? Kis wakt?

Q242.Do you think it could be prevented? Kya issay roka ja sakta tha?

1.Yes 2.No


Did you suffer any of the following due to RH: Q244.Repeated, disturbing memories, thoughts, or images of the attack? Tashadud ke bad kya apko iske baray mai aksar khayalat atay the?

1.Yes 2.No


1.Yes 2.No


1.Yes 2.No


1.Yes 2.No

SECTION F OPEN-ENDED QUESTIONS

Q248.What are the main health challenges you face in the last 12 months? Pichlay sal mein kaunsi sehat ki takleef thi apko? Behtareen tibbi saholiyat ke wasool mai sub se eham 3 rukawatain?

Q249.What are the top 3 barriers preventing you from access to health services? Kaunsi theen chezay apko sehat ki sahulat laney mein rukawat hai

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Q250. What are the main problems which prevent you from being satisfied with your health since taking loan? Kaunsi sehat ke mutalik cheezay apko ----- ?

β- Punjabis (1), Pashtuns (2), Sindhis (3), Siddis (4), Saraikis (5), Muhajirs (6), Balochis (7), Hindkowans (8), Chitralis (9), Gujarati (10), Kashmiris (11), Kalash (12), Burusho (13), Brahui (14), Khowar (15), Hazara (16), Shina (17), Kalyu (18), Balti (19), Afghan refugees (20), Other (21). *- Doctors clinic (private/primary-secondary) (1), Hospital Clinic (tertiary) (2), LHW (3), BHU (4), Local Hakim (5), Homeopath (6), Other (7). +- No money (1), not serious/ took care it of it myself (2), too busy (3), no childcare (4), no transport (5), too embarrassed (6), don’t have permission (7), prescription/ paperwork/ referral got lost (8), didn’t know where to get care (9), provider too far away (10), don’t like the local provider (11), couldn’t find specific specialist (12), other (13). # Physical violence refers to the use of physical force against another person or group, that results in physical harm, sexual or psychological harm. It can include beating, kicking, slapping, stabbing, shooting, pushing, biting, and/or pinching, among others. Psychological violence is defined as: Intentional use of power, including threat of physical force, against another person or group, that can result in harm to physical, mental, spiritual, moral or social development. Psychological violence includes verbal abuse, bullying/mobbing, harassment, and threats. Sexual Harassment refers to any unwanted, unreciprocated and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to be threatened, humiliated or embarrassed. Racial Harassment refers to any threatening conduct that is based on race, color, language, national origin, religion, association with a minority, birth or other status that is unreciprocated or unwanted and which affects the dignity of women and men at work. @ took no action (1), tried to pretend it never happened (1), told the person to stop (1), tried to defend myself (1), told friends/family (1), sought counseling (1), told a colleague (1), reported it to a colleague (1), discussed/ complained to MF loan officer (1), sought help from MFP (1), sought help from the union/community (1), pursued prosecution (1), other (1)

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https://en.wikipedia.org/wiki/Punjabis

https://en.wikipedia.org/wiki/Pashtuns

https://en.wikipedia.org/wiki/Sindhis

https://en.wikipedia.org/wiki/Siddis

https://en.wikipedia.org/wiki/Saraiki_people

https://en.wikipedia.org/wiki/Muhajir_people

https://en.wikipedia.org/wiki/Baloch_people

https://en.wikipedia.org/wiki/Hindkowans

https://en.wikipedia.org/wiki/Chitrali_people

https://en.wikipedia.org/wiki/Gujarati_people

https://en.wikipedia.org/wiki/Kashmiri_people

https://en.wikipedia.org/wiki/Kalash_people

https://en.wikipedia.org/wiki/Burusho_people

https://en.wikipedia.org/wiki/Brahui_people

https://en.wikipedia.org/wiki/Khowar_people

https://en.wikipedia.org/wiki/Hazaras

https://en.wikipedia.org/wiki/Shina_people

https://en.wikipedia.org/w/index.php?title=Kalyu&action=edit&redlink=1

https://en.wikipedia.org/wiki/Balti_people

https://en.wikipedia.org/wiki/Afghans_in_Pakistan


For peer review onlyImpact of microfinance health interventions on health-

related outcomes among female informal workers in Pakistan: A retrospective quasi-experimental study

Journal: BMJ Open

Manuscript ID bmjopen-2020-043544.R1

Article Type: Original research

Date Submitted by the Author: 02-Nov-2020

Complete List of Authors: Jafree, Sara; Forman Christian CollegeZakar, Rubeena; The University of LahoreAhsan, Humna; Forman Christian CollegeMustafa, Mudasir; Utah State UniversityFischer, Florian; Charité Universitätsmedizin Berlin, Institute of Public Health; University of Applied Sciences Ravensburg-Weingarten, Doggenriedstraße

<b>Primary Subject Heading</b>: Public health

Secondary Subject Heading: Epidemiology, Evidence based practice, Global health

Keywords: Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, PUBLIC HEALTH, EPIDEMIOLOGY


BMJ Open on F

ebruary 2, 2022 by guest. Protected by copyright.

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j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-043544 on 5 January 2021. Dow

nloaded from


For peer review onlyI, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance with the terms applicable for US Federal Government officers or employees acting as part of their official duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence.

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- 1 -

Impact of microfinance health interventions on health-related outcomes

among female informal workers in Pakistan: A retrospective quasi-

experimental study

Sara Rizvi Jafree, Rubeena Zakar, Humna Ahsan, Mudasir Mustafa, Florian Fischer

Dr. Sara Rizvi JafreeDepartment of Sociology, Forman Christian College University, Lahore, Pakistan; [email protected]

Prof. Dr. Rubeena ZakarInstitute of Social and Cultural Studies, University of the Punjab, Lahore, Pakistan; [email protected]

Dr. Humna AhsanDepartment of Economics, Forman Christian College University, Lahore, Pakistan; [email protected]

Mudasir MustafaDepartment of Sociology, Social Work, and Anthropology, Utah State University, Logan, United States of America; [email protected]

Dr. Florian Fischer 1) Institute of Public Health, Charité – Universitätsmedizin Berlin, Germany; [email protected] 2) Institute of Gerontological Health Services and Nursing Research, Ravensburg-Weingarten University of Applied Sciences, Germany; [email protected]

Corresponding author:Dr. Florian FischerCharité – Universitätsmedizin BerlinInstitute of Public HealthCharitéplatz 1 10117 BerlinE-Mail: [email protected]

Word count: 4,941

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1 Abstract

2 Objective: The purpose of this study is to assess the impact of microfinance health interventions

3 (health insurance and health-awareness programmes) on health-related outcomes among female

4 informal workers in Pakistan.

5 Design: We conducted a retrospective, quasi-experimental study among a total of 442 female

6 borrowers from seven microfinance providers (MFPs) across four provinces of Pakistan in 2018.

7 A standardised tool was used for data collection. Probit regression was used to identify the

8 probability of female borrowers gaining improvements in health outcomes based on their socio-

9 demographic characteristics. Propensity score matching (PSM) was used to assess the overall

10 impact of health interventions.

11 Primary outcome measures: Four health-related outcomes reported by the women were used:

12 perception of good health overall, ability to visit a general practitioner, ability to purchase

13 prescribed medicine, and intake of multivitamins.

14 Results: We found that women receiving health interventions had a greater probability of better

15 health outcomes when they were from Punjab province, borrowing in groups, and attending

16 monthly meetings at MFPs. Even with a small loan amount, all four health-related outcomes were

17 significantly associated with receiving health insurance and health-awareness programmes. PSM

18 results show a greater likelihood of overall perceived good health (NNM=17.4%; KM=11.8%)

19 when health insurance is provided and a significant improvement in the ability to purchase

20 prescribed medicine when a health-awareness programme is provided (NNM=10.1%; KM

21 =11.7%).

22 Conclusion: Health and social policies are vital to secure health and wellbeing among poor women

23 working in the informal sector. Targeting improved equity across female population groups for

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24 health interventions will in the long run improve poor women’s health, income-earning abilities,

25 and capacity expansion for small businesses.

26 Keywords: borrow, informal sector, health insurance, health awareness, microfinance

27

28 Strengths and limitations of the study

29 This study uses a nationally representative sample of 442 female borrowers of

30 microfinance from four provinces in Pakistan.

31 It is the first study which focuses on female microfinance borrowers in Pakistan to assess

32 the impact of health interventions on health-related outcomes among poor women.

33 We were able to identify health improvements when women received health insurance and

34 health-awareness programmes.

35 Due to the cross-sectional study design and quasi-experimental analysis framework, the

36 results must be interpreted with caution.

37 Future studies need to consider additional burdens of loan repayment and small-business

38 investment.

39

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40 Introduction

41 More than half (57%) of the female population of Pakistan is illiterate. Less than a quarter (23%)

42 of women are employed, with a majority working in the informal sector [1]. Informal workers in

43 Pakistan are usually self-employed or involved in small-scale work. They are not protected by the

44 country’s labour laws and regulations. Therefore, they do not receive employment benefits like a

45 permanent contract, minimum wage, medical allowances, a pension or provident fund. There are

46 several problems to consider with regard to the health of female informal workers in Pakistan,

47 including high rates of poverty and low health literacy, as well as inadequate access to public

48 health services [2], reinforced by low government health budget allocations for this population

49 group [3]. In addition to the overall absence of universal health coverage, there is limited coverage

50 for public health emergencies like pandemics [4] and greater risks of acquiring infectious diseases

51 among female informal workers due to mostly unsanitary living conditions in disadvantaged

52 communities [5]. Pakistan has one of the largest out-of-pocket healthcare expenditures globally,

53 at an overwhelming proportion of 90% [6]. Although health insurance can become an important

54 support system for buffering the poor against out-of-pocket payments, so far it covers only 1% of

55 health expenditure in the country [2]. This is because health insurance is mainly used by richer and

56 urban populations.

57 The efficacy and limitations of private providers of health interventions in Pakistan are not clear.

58 One of the few private providers offering health interventions to women employed in the informal

59 sector are microfinance providers (including banks, institutes and non-governmental organisations

60 [NGOs]) [7]. Microfinance providers (MFPs) are mainly operational in under-developed

61 communities, providing loans to the poorest women for small-business development [8]. There are

62 50 MFPs operating in Pakistan, with nearly 40 reporting some form of health intervention for

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63 clients, including health insurance and health-awareness programmes [9]. The MFPs are regulated

64 either by the State Bank of Pakistan or the Securities Exchange Commission of Pakistan. An

65 inherent function of the original model of microfinance was to catalyse wider social development

66 for women, including improved health behaviour and, therefore, better health-related outcomes

67 [10]. It is in the interests of MFPs to couple health interventions with loan services because healthy

68 clients are more likely to repay loans and run successful businesses [11].

69 The role of microfinance health interventions is critical in countries like Pakistan, where poverty

70 is high and out-of-pocket payments are not possible for impoverished families. Additionally, the

71 public sector does not have a dependable service structure for complete or quality healthcare and

72 universal financial protection for health coverage is absent [4]. More than two million poor women

73 are loan-takers of microfinance in the country [12]. As poor populations do not have the money to

74 take out traditional health insurance, microfinancing for health insurance becomes the only option

75 for them. However, small health insurance schemes have been severely criticised for their minimal

76 impact on clients’ lives due to their minimal coverage and the large burden of disease faced by

77 poor populations [13]. Evidence also suggests that poor populations holding minimal health

78 insurance, in the event of sustaining large healthcare costs, may resort to damaging practices such

79 as reducing household nutrition, removing children from school, and taking out more loans [14].

80 During the most recent times of the coronavirus pandemic, debt-ridden poor women attempting to

81 repay loans are facing even more challenges in generating income from small businesses due to

82 social isolation and lockdown [15]. Therefore, health security is a major concern among female

83 borrowers and there is a need to improve research and policy in order to financially protect poor

84 women and improve their health literacy [16].

85

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86 Aims of the study

87 To the best of our knowledge, there are no studies that have used female microfinance borrowers

88 as a sample to assess the impact of health interventions on health-related outcomes among poor

89 women [17]. Our objective for this study was to use a sample of female microfinance borrowers,

90 who are availing themselves of health insurance from a private provider, to help identify suitable

91 policies for disease prevention and health promotion in Pakistan. The following research questions

92 are addressed in this study: 1) Do female borrowers of microfinance who are provided with health

93 interventions show improved health-related outcomes? 2) What are the socio-demographic,

94 household, and loan portfolio characteristics of female borrowers of microfinance that are

95 associated with improved health-related outcomes?

96

97 Methods

98 This study is part of a larger, mixed-methods study on the wellbeing of female microfinance

99 borrowers. The qualitative part has already been published [18]. The results presented here are

100 based on a cross-sectional survey, in which women who had been borrowers of microfinance for

101 more than one year were interviewed using a structured, quantitative questionnaire. We used the

102 framework of a quasi-experimental study to estimate the impact of microfinance health

103 interventions. The data was analysed using SPSS and STATA.

104

105 Sampling

106 We used a list available on the Pakistan Microfinance Network to contact the 20 MFPs across

107 Pakistan. Seven MFPs agreed to provide permission to interview their clients. The sampling took

108 place in all four provinces of Pakistan (Punjab, Sindh, Balochistan, and Khyber Pakhtunkhwa

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109 [KPK]), but not in the two autonomous territories or the federal territory of Islamabad. The

110 sampling frame at the level of individual women took the population weightage of the provinces

111 into account. We were able to contact 500 women randomly, as they visited the MFP offices to

112 make their monthly loan repayment. A final total of 442 women were willing to participate and

113 provided informed written consent, which is a response rate of 88.4%. These women were sampled

114 from seven cities within the four provinces, based on MFP permission and access (Punjab: n=252

115 [cities: Gujranwala, Lahore, Khanewal, Sheikhapura]; Sindh: n=100 [city: Matiari]; Balochistan:

116 n=50 [city: Lasbela]; KPK: n=40 [city: Abbottabad]. Study participants received financial support

117 from the following types of MFPs: four microfinance banks (n=340), one microfinance institute

118 (n=41), one government microfinance scheme (n=50), and one Islamic microfinance organisation

119 (n=11).

120 Information related to the services provided by the sampled MFPs in this study is presented in

121 Table 1. None of the MFPs provide mandatory health insurance schemes. Neither the government

122 scheme nor the Islamic finance provider were offering health insurance, but they were providing

123 health awareness interventions. The government scheme offered a separate health insurance

124 scheme (called the Sehat Sahulat Programme), but none of the study participants was enrolled in

125 this scheme. Women borrowing from banks have the option to take out health insurance for

126 themselves and any family members. They have to pay a premium ranging from PKR 490–990

127 (USD 3.00–6.08)1 per person and are insured only in the event of hospital admission. However,

128 the insurance does not cover hospital costs but instead pays the client the amount of daily wages

129 lost, ranging from PKR 2,000–4,000 (USD 12.28–24.56) daily. The scheme also covers a one-off

130 payment in the event of death, ranging from PKR 25,000–50,000 (USD 153.55–307.10). Female

1 All PKR to USD conversions in this study have made done at the rate of 1 USD = 162.805 PKR.

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131 borrowers from the microfinance institute are only covered for themselves and their spouse. They

132 have to pay a premium of PKR 1,200 (USD 7.37) if unmarried or PKR 1,850 (USD 11.36) if

133 married. Clients are provided with a one-off payment of PKR 30,000 (USD 184.25) in the event

134 of hospitalisation.

135

136 Table 1: Health insurance schemes of microfinance providers sampled in this study

Microfinance bank(n=340)

Microfinance institute(n=41)

Government scheme(n=50)

Islamic finance(n=11)

Coverage Female borrower and any family member

Female borrower and spouse

- -

Term One year One year - -Premium PKR 490–990 per

family memberPKR 1,200 (if unmarried);PKR 1,850 (if married)

- -

Insurance Only hospitalization(PKR 2,000–4,000 daily)

Only hospitalizationPKR 30,000 (one-off payment)

- -

Limit Between 10–30 days One-off payment - -Life insurance PKR 25,000–50,000

in case of death- - -

Other Option to take government Sehat Sahulat Program

Health clinic in Lahore only; treating patients with diabetes and heart disease

137 Information in this table is based on data from MFPs sampled in this study

138

139 Data collection

140 Data collection took place between February and November 2018. Each city had one research team

141 leader and two assistants in the data collection team, comprising a total of 21 people undertaking

142 data collection. The assistants were all MPhil graduates who had experience of field research and

143 were hired through the assistance of the universities in each city. Training of the data collection

144 team took place over a two-week period and was conducted either in person or through video calls.

145 Data collection took place in face-to-face interviews in a private space at the MFP premises, in

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146 order to preserve the women’s privacy due to the personal nature of the questions. The structured

147 surveys were completed on behalf of the female respondents with the assistance of the trained

148 research team. During pilot-testing, we utilised both a self-administered and researcher-

149 administered approach, and found that the latter showed lower rates of non-response. This could

150 be due to the length of the questionnaire and the low literacy rate among the interviewed women.

151 Although the questionnaire was translated into Urdu, women having less than eight years of

152 schooling required assistance to read and fill in the questionnaire.

153

154 Measures

155 A structured interview schedule was used for data collection (Supplementary File 1). Questions in

156 this tool were taken from instruments used in various studies, such as the Women’s Healthcare

157 Experiences Survey [19], the Baseline Nutrition and Food Security Survey developed by UNICEF

158 [20], the WHO Multi-Country Study on Women’s Health and Domestic Violence against Women

159 [21], and the WHO Survey on Workplace Violence [22].

160

161 Dependent variables: Health outcomes

162 This study assesses the association of health interventions offered by MFPs with four dependent

163 health-related outcome variables: 1) women perceive health to be good overall, 2) women visited

164 a general practitioner in the last year, 3) women had the ability to purchase prescribed medicine in

165 the last year, and 4) women’s intake of multivitamins has improved in the last year. The four

166 dependent variables were categorised as binominal and coded as either “Yes” (1) or “No” (0).

167

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168 Independent variables: Socio-demographic and loan characteristics

169 Several socio-demographic variables, such as age (0=less than 30 years; 1=30 years and older),

170 religion (0=Muslim; 1=Other than Muslim), literacy of the female borrower (0=Illiterate;

171 1=Literate), literacy of the spouse (0=Illiterate; 1=Literate), house ownership (0=Yes; 1=No), and

172 number of dependent children living in the house (0=None; 1=One or more) were assessed as

173 confounding variables. It is necessary to control for these variables because they have an impact

174 on each of the dependent variables mentioned above. Province is also controlled because the region

175 is a proxy for socio-cultural norms that would impact upon how women perceive their health and

176 whether they are able to visit a general practitioner or purchase medicine (0=Other than Punjab

177 [Sindh, Balochistan, or KPK]; 1=Punjab).

178 The other set of variables is related to microfinance provider services, such as: loan amount

179 (0=10,000–20,000 PKR; 1=21,000 PKR or more), monthly meetings (0=No; 1=Yes), interest rate,

180 which is the amount charged on top of the principal by a lender to a borrower (0=2.5–10%; 1=11%

181 or more), group loan, meaning that a group of customers are willing to guarantee each other for

182 the repayment of the loan (0=No; 1=Yes), and debt age (0=1–2 years; 1=3 or more years). These

183 have been included because they assess the impact of the provision of non-financial services on

184 each of the dependent variables.

185

186 Independent variables: Health intervention

187 The three independent variables for microfinance health intervention are: 1) receiving health

188 insurance, 2) attended at least one health workshop, and 3) received health-related talks by loan

189 officers. The two independent variables of health workshop and health-related talks by loan

190 officers were compounded to make one variable indicating whether the women had attended a

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191 health-awareness programme (0=No; 1=Yes). In this way, the control group for the study (T=0)

192 consists of female borrowers who lack the provision of a health intervention, and the treatment

193 group (T=1) includes female borrowers who are receiving a health intervention.

194

195 Comparison group

196 Using a quasi-experimental framework, the study estimates the impact of gaining access to health

197 interventions (health insurance and health-awareness programmes) against the counterfactual of

198 those women who are receiving a loan for small business mobilisation in the absence of health

199 interventions.

200

201 Probit analysis

202 The impacts of health insurance and health-awareness programmes provided by the MFP on the

203 four dependent, health-related variables have first been estimated using a probit estimation for the

204 following linear regression equation:

205 𝑌𝑖 = 𝛽0 + 𝛽1𝑇 + 𝛽2𝑋𝑖 + 𝛽3𝑍𝑖 + 𝛽4𝐿𝑖 + 𝜀𝑖


207 variable (1 if “yes”, and 0 otherwise) measuring the three microfinance health interventions. is 𝑋𝑖

208 a set of socio-demographic characteristics including age, religion, province, and literacy; is a 𝑍𝑖

209 set of household characteristics, including house ownership and number of dependent children

210 living in the house; is a set of loan portfolio characteristics including debt age, group loan, loan 𝐿𝑖

211 amount, interest rate, and monthly meetings; and is the error term. 𝜀𝑖

212

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213 Propensity score matching

214 We used Propensity Score Matching (PSM) to estimate the unobserved counterfactuals and make

215 an impact analysis of health interventions. PSM is a non-parametric statistical method which

216 matches the treated (those receiving the health intervention) and the controlled on the basis of

217 conditional probability of participation, given the observable characteristics [23]. As we only have

218 cross-sectional data, we can compare the dependent variables related to women’s health in terms

219 of those who have access to non-financial, health-related services provided by the microfinance

220 provider (in this study called the “health-awareness programme”) and those who do not, as long

221 as these services are randomly distributed and there is no selection bias. The estimation of

222 instrumental variables is one technique that is frequently used within PSM. However, these results

223 are only robust if a valid instrument is being used. As it was not easy to find a valid instrument for

224 our study, we used statistical matching, which has also been widely used before [24-26].

225 The study will be using the following functional form:

226 𝑌𝑖 = 𝛽0 + 𝛽1𝑇 + 𝛽1𝑋𝑖 + 𝜀𝑖


228 variable (1 if “yes”, and 0 otherwise) measuring the microfinance health interventions. are the 𝑋𝑖

229 covariates used for matching the data, including age, religion, literacy, spouse’s literacy, house

230 ownership, access to drinking water, access to gutter drainage, access to toilet facility, children,

231 debt age, group loan, loan amount, interest rate, and monthly meetings, and is the error term. 𝜀𝑖

232 These control variables have been used in a large and growing volume of studies [27].

233 Our study satisfies the main conditions of PSM, which are: 1) using a rich set of control variables,

234 which are observable characteristics, 2) using the same survey for treated and control groups, and

235 3) having the same community belonging to the treated and control groups [28]. The PSM model

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236 constructs a statistical comparison group based on the probability of participating in the treatment

237 T, conditional on observed characteristics, X, or the propensity score:

238 𝑝(𝑋) = 𝑃𝑟(𝑇 = 1│𝑋).

239 where T = {0, 1} is the indicator of exposure to treatment and X is the multidimensional vector of

240 pre-treatment characteristics. Following the estimation of the propensity score, the region for

241 common support is defined as being where distributions of the propensity score for the treatment

242 and comparison group overlap. Observations within the control and treatment group that lie outside

243 the region for common support are eliminated [29]. As PSM is intended to help in identifying the

244 impact of the health intervention, we used the computation of “average treatment effect on the

245 treated” (ATT). We used two matching criteria (Nearest Neighbour Matching [NNM] and Kernel

246 Matching [KM]), to assess statistical significance from different perspectives and to test the

247 robustness of the results [24]. NNM is used to evaluate absolute differences between propensity

248 scores, and KM is used to compare each treated unit to a weighted average of the outcomes of all

249 untreated units.

250

251 Patient and public involvement

252 This research was conducted without the involvement of the public or patients. However, the views

253 of women from this study have been published elsewhere [18].

254

255 Results

256 Sample characteristics

257 All the women in our sample earned less than $4.82 per day and belonged to the poorest stratum

258 of society. They were taking out loans for small business mobilisation in order to improve their

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259 life opportunities. The majority of the women were Muslim, from Punjab, and illiterate. About

260 three-quarters had been borrowers for more than three years, were attending monthly meetings

261 with loan officers, and were paying interest rates of less than 10%. Out of the 442 female borrowers

262 in the sample, 64.2% (n=284) had taken out health insurance (Table 2) and 71.0% (n=314) had

263 participated in a health-awareness programme by attending a health workshop or receiving health

264 talks by loan officers (Table 3).

265

266 Table 2: Descriptive statistics of women borrowers with regard to health insurance

Variable

Not receiving health insurance

n (%) (n=158)

Receiving health insurance

n (%)(n=284)

Chi-square test1


86 (54.4%)72 (45.6%)

165 (58.1%)119 (41.9%)

0.557


137 (86.7%) 21 (13.3%)

254 (89.4%)30 (10.6%)

0.740


62 (39.2%)96 (60.8%)

197 (69.4%)87 (30.6%)

37.977***


94 (59.5%)64 (40.5%)

195 (68.7%)89 (31.3%)

3.770*


86 (54.4%)72 (45.6%)

191 (67.3%)93 (32.7%)

7.135**


104 (65.8%) 54 (34.2%)

225 (79.2%)59 (20.8%)

9.583**


54 (34.2%)104 (65.8%)

116 (40.8%)168 (59.2%)

1.907


71 (44.9%)87 (55.1%)

75 (26.4%)209 (73.6%)

15.755***

Group loan No Yes

91 (57.6%)67 (42.4%)

168 (59.2%)116 (40.8%)

0.102

Loan amount PKR 10,000–20,000 (USD 61.42-122.84) PKR 21,000–100,000 (USD 129.45-616.41)

31 (19.6%)127 (80.4%)

123 (43.3%)161 (56.7%)

25.096***

Interest rate 2.5–10% ≥11%

105 (66.5%)53 (33.5%)

202 (71.7%)82 (28.9%)

1.044

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Monthly meeting No Yes

41 (25.9%)117 (74.1%)

70 (24.6%)214 (75.4%)

0.091


120 (75.9%)38 (24.1%)

185 (65.1%)99 (34.9%)

5.545**


67 (42.4%)91 (57.6%)

124 (43.7%)160 (56.3%)

0.065


118 (74.7%)40 (25.3%)

152 (53.5%)132 (46.5%)

19.127***


120 (75.9%)38 (24.1%)

182 (64.1%)102 (35.9%)

6.6040**

267 1 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level268269 Table 3: Descriptive statistics of women borrowers with regard to health awareness

Variable

Not receiving health awareness

n (%)(n=128)

Receiving health awareness

n (%)(n=314)

Chi-square test1


74 (57.8%)54 (42.2%)

177 (56.4%)137 (43.6%)

0.077


115 (89.8%)13 (10.2%)

276 (87.9%)38 (12.1%)

0.337


56 (43.8%)72 (56.3%)

203 (64.6%)111 (35.4%)

16.372***


70 (54.7%)58 (45.3%)

219 (69.7%)95 (30.3%)

9.109**


78 (60.9%)50 (39.1%)

199 (63.4%)115 (36.6%)

0.231


96 (75.0%)32 (25.0%)

233 (74.2%)81 (25.8%)

0.030


49 (38.3%)79 (61.7%)

121 (38.5%)193 (61.5%)

0.002


63 (49.2%)65 (50.8%)

83 (26.4%)231 (73.6%)

21.342***

Group loan No Yes

86 (67.2%)42 (32.8%)

173 (55.1%)141 (44.9%)

5.480**

Loan amount PKR 10,000–20,000 (USD 61.42-122.84) PKR 21,000–100,000 (USD 129.45-616.41)

33 (25.8%)95 (74.2%)

121 (38.5%)193 (61.5%)

6.515**

Interest rate 2.5–10% 70 (54.7%) 237 (75.5%) 18.527***

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≥11% 58 (45.3%) 77 (24.5%)Monthly meeting No Yes

38 (29.7%)90 (70.3%)

73 (23.2%)241 (76.8%)

2.005


89 (69.5%)39 (30.5%)

216 (68.8%)98 (31.2%)

0.023


64 (50.0%)64 (50.0%)

127 (40.4%)187 (59.6%)

3.383*


95 (74.2%)33 (25.8%)

175 (55.7%)139 (44.3%)

13.073***


88 (68.8%)40 (31.3%)

214 (68.2%)100 (31.8%)

0.015

270

271 Determinants of health-related outcomes after the health insurance intervention

272 Table 4 presents the determinants of health-related outcomes for recipients of health insurance.

273 Overall, perceived good health was significantly associated with group borrowers, small loan

274 amounts, and lower interest rates. Improved ability to visit a general practitioner shows a positive

275 correlation with female borrowers from Punjab province, who attending monthly meetings, had a

276 group loan, and a smaller loan amount. Women had a significantly improved ability to purchase

277 prescribed medicine when they were from Punjab, took out smaller loans, and owned a house. The

278 uptake of multivitamins was increased among women with smaller loans, who owned a house, had

279 been borrowers for no longer than two years, and were attending monthly meetings. Therefore,

280 only a small loan amount was a significant determinant in all four health-related outcomes among

281 recipients of health insurance.

282

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283 Table 4: Probit analysis on determinants of health-related outcomes among recipients of health insurance




medicine


uptake



ScoreAge -0.2588 -1.43 0.2754 1.39 -0.2915 -1.51 0.0703 0.36Religion 0.4079 1.37 -0.2711 -0.97 0.4165 1.46 -0.0102 -0.03Province -0.2676 -1.04 0.9990*** 4.05 1.043*** 4.21 0.0315 0.12Literacy -0.0999 -0.49 0.2018 0.96 0.0828 0.42 0.1994 0.98Spouse literacy 0.2410 1.18 0.1779 0.85 0.2424 1.20 0.1323 0.64House ownership 0.1550 0.69 -0.3397 -1.45 -0.6825** -2.65 -0.5699** -2.17Children 0.2094 1.15 0.2213 1.20 0.1530 0.85 0.2829 1.54Debt age -0.4130 -0.16 0.1650 0.63 0.3807 1.50 -0.6088** -2.41Group loan 0.8582*** 3.76 0.4813** 2.25 0.1567 0.73 -0.3705* -1.69Loan amount -0.7765*** -3.27 -0.8863** -3.50 -1.2028*** -5.05 -1.9933*** -4.13Interest rate 0.7250** 2.94 0.2777 1.12 -0.0691 -0.28 0.2345 0.98Monthly meetings 0.1370 0.61 0.7753*** 3.58 0.0166 0.08 -0.4233* -1.84No. of observationsWald Chi2

Prob> Chi2

Log likelihood

28442.740.0001

-158.6116

28476.930.0000

-146.0385

28464.570.0000

-157.5241

28453.150.0000


285

286 Determinants of health-related outcomes after the health-awareness intervention

287 In Table 5, the determinants for all four health-related outcomes among recipients of a health-

288 awareness programme are presented. Women with the following characteristics have a greater

289 probability of overall perceived good health: group borrowers, smaller loans, lower interest rates,

290 younger women, and those with literate spouses. The ability to visit a general practitioner for

291 regular check-ups during the previous year was higher among women from Punjab province, with

292 smaller loans, attending monthly meetings, above 29 years of age, and who were non-Muslim.

293 Similarly, women from Punjab province, having smaller loans, owning their house, and younger

294 women had a higher probability of improved ability to purchase prescribed medicine. The

295 probability of increased uptake of multivitamins was greater in women who took out smaller loans,

296 had not been in debt for more than two years, were group borrowers, and who attended monthly

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297 meetings. The only variable that was significantly associated with all four health-related outcomes

298 among recipients of a health-awareness programme was the small loan amount.

299

300 Table 5: Probit analysis on determinants of health-related outcomes among recipients of health awareness 301 programs




medicine


uptake



ScoreAge -0.3747* -1.70 0.3781* 1.70 -0.4329* -2.02 0.1058 0.48Religion 0.5185 1.59 -0.5503* -1.76 0.3880 1.24 0.1904 0.56Province -0.3898 -1.24 1.3048*** 4.39 1.029*** 3.83 0.1983 0.65Literacy -0.1537 -0.65 0.2229 0.91 0.1405 0.61 0.3411 1.43Spouse literacy 0.4163* 1.80 0.2546 1.09 0.0860 0.38 0.2310 1.00House ownership 0.3495 1.42 -0.2453 -0.96 -0.6360** -2.48 -0.4271 -1.54Children 0.3209 1.55 0.2765 1.33 0.2424 1.21 0.2833 1.36Debt age -0.0066 -0.02 0.4529 1.49 0.3817 1.36 -0.7164** -2.51Group loan 0.8817*** 3.33 0.3640 1.51 0.1030 0.43 -0.6352** -2.55Loan amount -0.7199** -2.65 -0.6511** -2.28 -1.9361*** -3.52 -0.9170*** -3.35Interest rate 0.6739** 2.23 0.3860 1.28 0.2428 0.83 0.3726 1.26Monthly meetings 0.2357 0.88 0.7689** 3.08 -0.0556 -0.22 -0.5816** -2.10No. of observationsWald Chi2

Prob> Chi2

Log likelihood

31435.680.0004

-126.4054

31464.570.0000

-116.6811

31453.250.0000

-128.2105

31448.790.0000

-121.2616302 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level303

304 Balancing covariates and common support diagnostics

305 Figure 1(a) exhibits the Kernel Density graphs for the propensity score of treated and control

306 groups before matching, while Figure 1(b) exhibits it after matching. It can be clearly seen that the

307 kernel densities are significantly overlapping in the latter, indicating that the treatment and control

308 groups have a comparable propensity score as estimated using the covariates. A similar

309 comparison of treatment and control groups can be observed in Figures 2(a) and 2(b) using

310 histograms.

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311 Figures 3(a) and 3(b) exhibit the common support between the control and treatment groups. While

312 in Figure 3(a) we can see that certain observations in the treated group are not matched, in Figure

313 3(b) all the observations in the treated and control groups are successfully matched.

314 The balancing of covariates can also be observed using standardised mean difference and ratio of

315 variances. Table 6 gives the standardised mean difference and ratio of variances for the control

316 and treatment groups before and after matching. It can be observed that the standardised mean

317 difference in the matched sample is much improved and close to zero for all covariates. The ratio

318 of variances is approximately equal to one in the matched sample for all covariates except monthly

319 meetings. Using these diagnostics, we can infer that the sample has matched well using propensity

320 score matching.

321

322 Table 6:Balancing of covariates using standardized mean difference and ratio of variances

Standardized differences Variance ratioRaw Matched Raw Matched

Age -0.1320698 -0.1058939 0.9619896 0.9611875Religion 0.1586396 -0.0071039 1.451878 0.9828996Literacy -0.3073917 -0.1159204 0.7931779 0.9171598Spouse literacy -0.0719588 0.027969 0.9641836 1.014213Earning month -0.0491266 0.0305069 1.129418 0.9202911House ownership 0.2189877 0.1585524 0.7669609 0.8061959Drinking water 0.2226595 0.0116275 0.6952835 0.9813404Toilet Facility 0.0445714 0.1247478 0.9471727 0.8276644Gutter drainage -0.0290293 0.0423519 1.035531 0.9496166Group loan 0.0250079 0.0549512 1.01166 1.017812Loan amount -0.6030964 -0.1454947 1.331749 1.081931Interest rate -0.0851667 0.0594108 1.075376 0.9483068Monthly meetings 0.5404452 0.337374 0.4480249 0.6085328

323

324 Impact of the interventions on health-related outcomes

325 The descriptive statistics for comparison between control and treatment group for health insurance

326 (Supplementary Table 1) and the health-awareness programme (Supplementary Table 2), before

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327 and after matching, depict the elimination of imbalance with respect to almost all covariates before

328 and after matching. Table 7 shows that women receiving health insurance had a significantly

329 greater chance of overall perceived good health. According to NNM, 17.4% of women with health

330 insurance had a greater likelihood of overall perceived good health; the results for KM showed a

331 greater likelihood in 11.8%. Female borrowers receiving a health-awareness programme from the

332 MFP in the form of a health workshop or health talk by the loan officer show a significant

333 improvement in their ability to purchase prescribed medicine (NNM=10.1%; KM=11.7%). For the

334 other two outcomes, neither of the interventions showed a significant effect.

335

336 Table 7: Impact of interventions on health-related outcomes based on propensity score matching

Overallperceived

good health



medicine

Improved multivitamin

uptake



ScoreNearest Neighbor MatchingHealth insurance 0.1740*** 3.45 0.0038 0.04 0.1271 1.46 0.0343 0.38Health awareness program 0.0599 0.97 0.0141 0.23 0.1016* 1.70 0.0291 0.42

Kernel MatchingHealth insurance 0.1175* 1.67 -0.0256 -0.32 0.1062 1.21 0.0775 1.09Health awareness program 0.0240 0.42 0.0292 0.41 0.1167** 2.08 0.0703 1.15

337 *** Significant at 1% level, ** Significant at 5% level, * Significant at 10% level338 Note: The covariates used for matching include age, religion, literacy, spouse literacy house ownership, access to 339 drinking water, access to gutter drainage, access to toilet facility, children, debt age, group loan, loan amount, 340 interest rate, and monthly meetings. 341 Matching is performed with 1 nearest neighbor in terms of propensity score.

342

343 Discussion

344 In the absence of universal health coverage or compulsory educational enrolment, poor and

345 predominantly illiterate female informal workers and borrowers of microfinance are dependent

346 upon MFP for receiving health coverage and promoting health. This study has measured four

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347 health-related outcomes in female borrowers. The results show that there is inequity in the uptake

348 of health insurance and health-related outcomes.

349 Women from Punjab have better health-related outcomes compared to women from Sindh,

350 Balochistan and KPK. National health surveys of Pakistan also report that Punjab has better health-

351 related outcomes compared to other provinces, because the provincial government of Punjab has

352 a greater budget allocation for running health-awareness campaigns [30]. The fact that our results

353 show that older women and non-Muslim women have a greater likelihood of improved ability to

354 visit a general practitioner after receiving a health-awareness intervention indicates that younger

355 Muslim women face barriers to healthcare access due to regressive norms [31]. Muslim families

356 are known to prevent fertile women from accessing healthcare in an attempt to control their

357 reproductive choices and health options. Our results align with other research, which suggests that

358 Muslims suffer from health disparities due to religious fallacies [32].

359 Conversely, younger women show better overall perceived health and ability to purchase

360 prescribed medicine. This may be because at a younger age fewer health issues occur, and also

361 because of greater state and NGO efforts directed towards maternal healthcare [33]. Our results

362 confirm that women under the age of 29 years receive privileged support in a patriarchal society

363 during their prime childbearing years to consume maternal-health-related medication [34]. Women

364 with literate spouses also show improvements in overall general health after receiving health

365 insurance. This may be because spouse literacy has a direct effect on women’s improved healthcare

366 behaviour and mental health [35].

367 Women who take out their loan in groups show better health-related outcomes compared to women

368 who are single borrowers. Our results suggest that women in groups share their healthcare

369 knowledge and encourage each other towards improved healthcare behaviour [36]. Similarly,

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370 women who attend monthly meetings with loan officers have better health-related outcomes. The

371 results suggest that caring loan officers are fulfilling an important responsibility in supporting

372 female borrowers to engage in improved health behaviour and health-related outcomes. Given the

373 conservative culture of Pakistan and the disadvantaged backgrounds of these female borrowers,

374 loan-taking women might not be able to utilise healthcare services due to issues of permission or

375 ignorance.

376 Women who receive smaller microfinance loans and do not have a long debt age show improved

377 health-related outcomes. The finding that only women who receive smaller loans show

378 significantly better health-related outcomes may be seen as an endogenous result (i.e., because

379 individuals who need only a small loan may be better off to start with in terms of health), and

380 difficult to interpret in terms of causality, given the cross-sectional nature of the data. However,

381 we have only sampled women from the poorest stratum, and they have taken out small loans

382 because they are not eligible for bigger loans. Therefore, one can expect that there is no association

383 between health condition at the time of loan-taking and the loan amount.

384 Furthermore, the finding related to debt age suggests that women with a debt burden over a longer

385 period of time may be suffering from debt fatigue, which is converting to declining health-related

386 outcomes [37]. Women and their families who own their houses also have better health-related

387 outcomes, specifically related to the ability to visit general practitioners and improved uptake of

388 multivitamins. The results imply that the provision of health insurance and not having to pay

389 household rents on a monthly basis translates into better health-related outcomes. Impoverished

390 families who have to pay high rents for accommodation are usually employed in multiple jobs and

391 have little time for health and wellbeing [38].

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392 The impact of microfinance is only visible on two health-related variables. Although there are no

393 effects on general practitioner visits or uptake of multivitamins, we found that microfinance health

394 insurance has an impact by creating an improved perception of general health. This shows that

395 being insured is an emotional support and wellbeing facilitator for poor women. The emotional

396 buttress provided by health insurance can go a long way towards improving perceived wellbeing,

397 which can translate into a greater commitment to self, family, and business development among

398 poor women from disadvantaged backgrounds [39]. In addition, microfinance health-awareness

399 interventions have an impact by improving the purchase of prescribed medicine. Many poor

400 women in Pakistan do not take prescribed medicine unless it is freely available due to the greater

401 need to prioritise the purchase of basic necessities and household consumption [40]. The impact

402 of microfinance interventions is comparable to previous research. A review highlighted that most

403 interventions combined microfinance with health education. However, positive effects were

404 mainly found for health knowledge and behaviour, but not health status [41]. A meta-analysis

405 indicated the potential for women and girls, because microfinance may lead to changes in the use

406 of contraceptives, strengthen female empowerment and improve children’s nutrition [42].

407 However, for female borrowers of microfinance, there might be additional burdens in the form of

408 loan repayments and small-business investment. Our results suggest that illiterate and poor women

409 in the country are benefiting from health awareness by recognising that if they do not consume

410 prescribed medicine for chronic ailments (heart disease, cholesterol, or diabetes) it can have

411 serious consequences for their own lives and the future livelihood of their families. There needs to

412 be an urgent recognition that a triadic health insurance safety net is necessary, instead of

413 dependency on private providers to protect informal working women in Pakistan. Employers and

414 the government must join forces to ensure universal health insurance and – particularly in these

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415 times of the coronavirus pandemic – infectious disease outbreak insurance for health emergencies.

416 State financing of healthcare is essential through an increased allocation of gross domestic product

417 (GDP), government-run business profits, and increasing the income and corporate tax base from

418 the elite.

419 With regard to female microfinance borrowers, we recommend microfinance regulatory bodies to

420 urgently legislate the following reforms: (i) coverage for children and other dependents, maternity

421 costs, and non-hospitalisation costs, (ii) expand coverage for religious and ethnic minorities, (iii)

422 reduce interest rates for those paying high housing rents and introduce home ownership loans, (iv)

423 introduce mandatory group borrowing and monthly meetings with loan officers, and (iv) alter

424 repayment timelines and interest-rate packages for women taking out bigger loans.

425 We recommend the following urgent social policy improvements, which would join in helping

426 health policy efforts: (i) the development of public primary healthcare services for women in the

427 communities, with a mandatory quarterly general practitioner meeting, (ii) the upgrading of

428 poverty alleviation programmes to support poor women, (iii) the capping of housing rents and

429 improvements in neighbourhood sanitation to curb infection, (iv) the advancement of home-based

430 business opportunities for informal female workers to assist in maintaining incomes, including

431 digitalisation and internet access in their homes, and (v) income supplementation and cash

432 transfers for multivitamins and food nutritional intake to improve overall immunity and health

433 [43].

434

435 Limitations

436 This study has some limitations, most importantly the cross-sectional design. Although we were

437 able to compare the effects of an intervention because of the quasi-experimental analysis

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438 framework, two-group cross-sectional designs suffer from the limitations related to a single

439 measurement for all subjects. Therefore, within-person changes over time are not observable.

440 Without repeated measures in a two-group design, causality cannot be identified, because temporal

441 sequencing on the intervention and outcomes cannot be established. For that reason, we

442 recommend longitudinal data collection in future studies. This study focused on comparatively

443 small loans. Therefore, the impact of larger loans (> PKR 100,000) on health is not known.

444 Furthermore, the results need to be interpreted with caution, because the four health-related

445 outcomes are non-homogeneous and dependent on socio-environmental factors that are specific to

446 the region and community where the interventions are taking place. In addition, outcome data are

447 based on self-reporting, which can lead to potential measurement errors. Despite these limitations,

448 we feel that this study is significant for the development of microfinance health services in Pakistan

449 and the role of state and interest-free microfinance health interventions.

450

451 Conclusion

452 It is critical to assess the health needs of women employed in the informal sector. As primary

453 caregivers at home as well as primary contributors to household income, women’s health assumes

454 a salience that could place the structures of both the family and the economy at risk. Health policy

455 must consider several social policies for protecting disadvantaged women, who are poverty-ridden,

456 illiterate or semi-literate, and loan takers. Health insurance schemes and health promotion in the

457 workplace must be made mandatory for employers, microfinance providers, and the government,

458 given the cultural barriers to uptake for women. Targeting improved equity across female

459 population groups for health interventions will in the long run improve women’s health, capacity

460 expansion and income-earning abilities.

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461 Designing and implementing a health and social policy protection net for female informal workers

462 requires empirical evidence regarding which health interventions and socio-demographic

463 characteristics impact upon health outcomes. Since public-sector and health-sector shortages and

464 inefficiencies are a concern in Pakistan, the ‘health card’ must be accepted in both the private and

465 public sector, whichever is able to serve the poor first. As Pakistan is struggling with a low GDP

466 and tax collection base, we recommend more research into options for social franchising, and

467 partnerships with independent health insurance companies to serve disadvantaged women.

468

469 Acknowledgements

470 We thank the female borrowers who consented and gave their time to participate in the study. We

471 are grateful to our research team members in charge of logistical planning and coordination for

472 data collection across Pakistan including Rizwan Haider and Amir Naseem. Individual data

473 collection heads for each city are thanked for their efforts, especially for resolving gate keeping

474 issues, including Nida Abbas (Lahore), Zainab Asif (Abbotabad), Hina Bukhari (Gujranwala),

475 Sadia BiBi (Khanewal), Ansari Abbass (Sheikhapura), Azra Shakeel and Shumaila Sadique

476 (Matari), and Javaria Imran (Lasbela). The research assistant Bilal Asghar is also thanked for

477 entering all data.

478 We acknowledge support from the German Research Foundation (DFG) and the Open Access

479 Publication Fund of Charité – Universitätsmedizin Berlin.

480

481 Competing interests

482 The authors declare that no competing interests exist.

483

484 Funding

485 This study received funding by the Office of Research, Innovation and Commercialization at

486 Forman Christian College. The grant number is IRB-180/04-2017. The funding body was not

487 involved in data collection, data analysis, or data interpretation and presentation.

488

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489 Data sharing

490 Data is available upon reasonable request from the corresponding author.

491

492 Ethical considerations

493 Ethical approval for this study was taken from the Institutional Review Board of the Forman

494 Christian College University. Study participants were informed about the aims of the study and

495 provided informed consent either in written form or through thumb impression.

496

497 Author’s contributions

498 SRJ designed the study and was responsible for the research project, including data collection and

499 analysis; FF supervised this process. HA and MM supported in data collection. RZ and FF

500 contributed to the interpretation of the data. SRJ drafted the manuscript; all authors revised it

501 critically for important intellectual content. All authors approved the final version of this

502 manuscript.

503

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Figure 1: Kernel Density balancing plot (a) before and (b) after matching

255x104mm (144 x 144 DPI)

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Figure 2: Density balancing plot (a) before and (b) after matching

256x106mm (144 x 144 DPI)

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Figure 3: Common support graph of propensity scores (a) before and (b) after matching

256x104mm (144 x 144 DPI)

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Relationship between Microfinance, Social Development and Women’s Health

Cover Letter for Participants Questionnaire Information for Women Microfinance Borrowers Researcher: Dr. Sara Rizvi Jafree, e-mail: [email protected]; 0300 400 5740

Thank you for your valuable time! Your name is not required and all research analysis will be undertaken with confidentiality and complete anonymity. At any point during the interview you may leave, if you wish to do so. (Translation in Roman Urdu: Apka Bohat Shukirya apke eemtay waat ke liye! Apke Nam Ka Bharna Zaruri Nahi Hai Aur Yeh Tehkeek Ko Khoofiya Rakha Jaye Ga. Interview ke doran ap kabhi bhi uth ke jaana chahey to apko puri ijazat hai.) The questionnaire has been designed to collect information about your loan portfolio and your self-rated health. Our aim is to understand your needs and challenges, and ultimately try to improve your loan portfolio and health access and services. ((Translation in Roman Urdu: Is questionnaire Ka Masad Hai ke apse chand sawal loan aur sehat ke bare mein puchna. Humara masad ye hai ke apke arze ki sahuliyat aur sehat dono ko behtar kiya jaye.) Your honest and reliable answers will be appreciated, so that we can recommend the best solutions with regard to optimal loan portfolios and health satisfaction. ((Translation in Roman Urdu: Apke Sache Aur Ba Aitibar Jawab Ke Shukarguzar Honge, Thake loan aur sehat ke hawale se hum apke mushkilay ya rukawaton ko Samajh Sake.) In the event that you feel disturbed or upset after answering questions or recalling memories related to health problems or experiences of violence/ harassment, you may call or text the researcher for free consultation services from trained female psychologists. ((Translation in Roman Urdu: Agar apko in sawal aur jawab ki wajeh se koi preshani ho ya koi aisa waiya yad a jaye jo apki zehni pareshani mein izafa kare, tho ap upar diye gaye number par call ya text kar ke rabta kar le. Hum apki muft mein madat zanana mahir-e-nafsiyat se karwayenge.)

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Instrument The questionnaire will be read out and completed by the researcher, on behalf of the participant. Province/City: ____________________________ Microfinance Provider:________________________ Area/locality: Participant Code:

SECTION A: SOCIO-DEMOGRAPHIC CHARACHTERISTICS

Code Entry

Q1.Age Umar?

1.20-29 2.30-39 3.40-49 4.50+

Q2.Religion Mazhab

1.Muslim 2.Christian 3.Hindu 4.Other

Q3.Province Sooba?

1.Punjabi 2.Sindhi 3.Baluchi 4.KPK

Q4.City Shehr?

1.Lahore 2.Islamabad

3.Karachi 4.Hyderabad

1.Quetta 1.Peshawar

Q5.City-Area Q6.Language spoken at home with family Madri zubaan?

Q7.Race (β) Zaat

Q8.Marital Status Kya ap shadi shuda hain?

1.Married 2.Single 3.Divorced 4.Seperated

Q9.Literacy Taleem-i-qabiliyat


Q10.Occupation Pesha

Q10.Spouse literacy Aapkay khaawand ki taleemi qabiliyat kya hai?


Q12.Spouse Occupation Apkay khawand ka pesha kya hai?

Q13.Your earning in last month Pichlay mahinay aap ki kamai kitni thi?


Q14.Your earning in last year Pichlay saal apki kitni kamai thi?


Q15.Combined household income in a month (on average) Tamaam ghar ki amdani kitni hai?


Q16.House Ownership Ghar ka malik kaun hai?

1.Owned 2.Rented 3.Living with someone

4.Other

Q17.Number of children Apkay kitnay bachay hain?

1. None 2. 1-2 3. 3-5 4. >6

Q18.Age of last child Akhri bachay ki umar?

Q19.Number of people living in house Ghar mai kitnay afraad rehte hain?

1. 1-2 2. 3-5 3. 6-9 4. >10

Sign or Thumb Impression for Written Consent

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Q20.Number of rooms in house Ghar mai kitnay kamray hain?

1. 1 2. 2-3 3. 4-5 4. >6

Q21.Are you currently taking care of a disabled/ dependent family member Kya apkay ghar mai koi mazoor/jiska ap par inhasaar ho, shakhs hai?

1.No 2.Yes If Yes, who:

Q22.Source of drinking water Pani penay ka kya zarya hai?

1.Plain Tap 2.Filtered 3.Local Pump

4.Other

Q23.Type of energy used for cooking in house Ghar mai khana pakanay ke liye kis chiz ka istemaal kartay hain? (gas, coal, electric etc.)

1.Gas 2.Wood 3.Electricity 4.Other

Q24.Do you have toilet facility in house Apkay ghar mai bait-ul-khala hai?


Q25.How many toilets in the house Ghar mai kitnay bait-ul-khala hain?

1. None 2. 1-2 3. 3-5 4. >6

Q26.Does the toilet have a flush Bait-ul-khala mai flush hai?


Q27.Is the drainage and gutter system of your house satisfactory Ganday pani ke ikhraj ka nizaam darust hai?

1.Yes 2.No

Q28.How do you dispose of the garbage Ghar ki gandagi kahan phenkhtay hain?

1.Throw it on street/ far away

from home

2.Garbage collectors come to house

3.Set Fire 4.Other

Q29.Are you taking any health insurance (not provided by the microfinance provider)? (If so, from where, how much installment) Sehat ke liye insurance le rae hain?


SECTION B: MICROFINANCE LOAN CHARACHTERISTICS

Q30.Why are you taking loan (describe your work type, hours of work, working conditions in detail) Aap karz kyun le rahe hain? (kis tarah ka kaam hai, kitnay ghantay kaam kartay hain, jahan kaam kartay hain uskay halaat)

Q31.What type of loan are you currently taking/ duration Kis tarah ka karz le rahay hain/kitnay arsay se?

Q32.How long have you been a microfinance borrower for Kitne arsay se karz le rahay hain?

1. 1-2 years 2. 3-5 years 3. 6-9 years 4. >10 years

Q33.Is it a group loan Kya ap ne kisi ke sath mil ke karz liya hai?


Q34.How much is the loan for Kitna karz liya hai?

Q35.What is the installment rate per month Karz ko ada karnay ki mahana kist kya hai?

Q36.Do you attend monthly meetings with loan officers Karz denay walay officer se kya apki mahwar mulakaat hoti hai?

1.Yes 2.No

Q37.Do you attend weekly meetings with loan officers Karz dene walay officer se kya apki haftawar mulkaat hoti hai?

1.Yes 2.No

Q38.Who helps you in loan repayment Karz ada karnay mai kya koi apki madad karta hai?

1.No one 2.Husband 3.Parents 4.Other

Q39.What exactly has the loan been used for Ap karz kis liye istemal karti hain?

1.Business 2.Household expenditure

3.Old Loans

4.Health Costs

4.Other

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Q40.How much of the loan taken has been invested in business Karz ka kitna hissa karobar mai kharch kiya hai?

1.All 2.Half 3.Quarter 4.Other

Q41.Are you satisfied with loan amount Kya aap karz ki rakam se mutmaeen hai?

1.Yes 2.No

Q42.Are you satisfied with loan repayment rate Kya ap karz ki adaigi ki kist se mutmaeen hai?

1.Yes 2.No

Q43.Will you be renewing loan Kya aap karz dobara lena chahain gae?

1.Yes 2.No

Q44.Have you received any skill development training Kya apki silahiyaton ko barhanay ki koi tarbiyat mili hai?

1.Yes 2.No

Q45.Have you participated in any health workshop/awareness campaign/talk… Kya sehat se mutalik ap kisi agahi mohim ka hissa banay hai?

1.Yes 2.No

Q46.Has your loan officer or center ever talked to you about health awareness or access Kya karz denay walay officer ne ap se sehat ke mutalik koi agahi di hai?

1.Yes 2.No

Q47.Have you been offered saving insurance by your MFP Kya idaray ne apko bachat insurance ki peshkash ki hai?

1.Yes 2.No

Q48.Are you taking saving insurance with your MFP Kya idara ap ko bachat insurance de raha hai?

1.Yes 2.No

Q49.Have you been offered health insurance by your MFP Kya idara aap ko sehat insurance deta hai?

1.Yes 2.No

Q50.Are you taking health insurance with your MFP Kya ap idaray se sehat insurance le rahay hain?

1.Yes 2.No

Q51.Has the loan so far satisfied your business needs Kya karz ki rakam ne apki karobari zaroriyat ko pura kiya hai?

1.Yes 2.No

Q52.Has your loan taking from MF enabled you to visit a trained private general practitioner, if needed in last 12 months Karzay k baad pichlay 12 maheenay mein kya app private doctor ko dekhanay gaye hain?

1.Yes 2.No

Q53.Has your employment from MF loan enabled you to visit a trained private specialist practitioner, if needed in last 12 months Karzay k baad pichlay 12 maheenay mein kya app baday doctor ko dekhanay gaye hain?

1.Yes 2.No

Q54.How is your ability to purchase prescribed medicines (in case recommended by doctor) since loan-taking? Kya karz lene ke bad dawayan khareednay ki istata’at mai koi tabdeeli ai hai?


SECTION C WOMEN’S HEALTH CARE EXPERIENCES SURVEY

Q55. How would you rate your health in general? Apki sehat kis mayar ki hai?


Q56.Compared to other women your age, how would you rate your health Apni hum umar auraton ki nisbat aap apni sehat ka kya mayaar samjhtay hain?


Q57. Do you feel your health could be better than 1.Yes 2.No If yes, could you say why/ how:

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it is presently? Kya apki sehat ke mayaar mai koi behtari lai ja sakti hai?

Q58.Does your husband/ male relative/in-laws decide/ give approval when you or your children need consultation from a medical practitioner Kya apka khawand/susral apko doctor pe janay ki ijazat deta hai? Kya ye faisla bhi apka susral/khawand krta hai?



Q59.Does your husband/ male relative/in-laws decide/ give approval when you or your children need to visit a clinic/ hospital Kya apka khawand/susral apko hospital janay ki ijazat deta hai or kya ye faisla kaun leta hai?



Please indicate if you have experienced any of the following health issues in the last 12 months?

1.Yes 2.No

Q60.Minor illness like the flu or an infection Pichlay 12 mahinay mai apko nazla ya infection hua hai?

Q61.Had to go for a checkup or routine physical exam Jismani muaaenay ke liye gae hain?

Q62.Were you pregnant? Kya app hamla theen?

Q63.Did you need family planning or preconceptional services? Kya apko munsoba bandi ki zaroorat thee?

Q64.Did you have an injury that you have not already mentioned? Kya apko koi chot lagi hai?

Q65.Did you need care for a chronic health problem, (that is one that goes on for a long time)? Kya apko kisi taweel bemari ke liye hospital jana para hai?

Q66.Did you need surgery for a condition not already mentioned? Kya apko operation keranay ki zaroorat parhi?

If yes, what?

Q67.Were you feeling depressed, anxious, or highly stressed? Kya iski waja se apko kisi kisam ka zehni dabao ya bechaini mehsoos hui hai?

Could you pinpoint why?

Have you had one of the following tests in the last 12 months?

1.Yes 2.No

Q68.Colon cancer screening, such as a check for blood in your stool, sigmoidoscopy, or colonoscopy

Q69.Test for glaucoma or pressure in the eye Q70.Blood cholesterol test Q71.Check for high blood pressure Q72.Test for diabetes Q73.Breast exam by a doctor or nurse Q74.Mammogram Q75.Pap test Q76.Bone density test (for osteoporosis) Q77.Genetic screening test Q78.Screening for HIV/AIDS

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Q79.Screening for other sexually transmitted diseases

Q80.Dental exam Q81.Shot for flu or pneumonia Q82.Pregnancy test Q83.Family planning services or contraception Q84.Tests for infertility Q85.Abortion information or services Q86.Alcohol or drug abuse counseling or treatment

In the past 12 months, did any of your health care providers or microfinance loan managers talk with you or give you information about? (pichlay 12 mahino mai kya apkay doctor/nurse ya apkay karz dene walay officer ne aap se in chizon ke baray mai maloomat di hain?)

1.Yes 2.No If yes, can you specify who gave you this information:

Q87.Smoking, second-hand smoke, or quitting smoking Tambako noshi, kisi aisay shaks k saath bethtna/rehna jo tambako noshi mein mulawis ho, ya tambako noshi chorna

Q88.Nutrition or diet (Khuraak)

Q89.Alcohol or drug use Shraab ya adviyaat?

Q90.Physical fitness or exercise Jismani sehat ya warzish?

Q91.Menopause or hormone replacement therapy San – e - yaas ya hormone tabdeeli therapy?

Q92.Violence in the home or workplace Kya ghar ya kaam pe kisi tashadud ka shikar hue hain?

Q93.Work or financial problems Kaam ya muaashi mushkilaat ka samna hua hai?

Q94.Family or relationship problems Ghar walon ya rishtadaron ke masa’il?

Q95.Importance of child health and nutrition Bachon ki sehat or khuraak ki ehmiyat?

Q96.Stress management Zehani dabao ko kum karna

Q97.Preventing unintended pregnancies & birth spacing Bachon ke darmiya wakfa?

Q98.Using alternative therapies, such as herbs or acupuncture

Q99.Preventing osteoporosis Hadion ke dard se bachao

Are there any dietary supplements that you have used in the last 12 months?

1.Yes 2.No

Q100.Vitamin C Q101.Vitamin D Q102.Vitamin E Q103.B Complex Q104.Calcium Q105.Pregnancy Vitamin Q106.Lactation Vitamin

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Q107.General Multi-vitamin What is your personal preference for health services? Tibbi saholiyat se mutalik apki zaati tarjihaat kya hain?

1.Yes 2.No 3.Indfferent

Q108.Family (e.g. mother/ mother-in-law/ aunt) Ghar walay?

If Yes, describe who:

Q109.A women’s health center where you can get most of your basic health care, including gynecological care, in one place Khawateen ki sehat markaz?

Q110.Trusted community member Baradari?

Q111.A nurse or LHW (Not a physician/ surgeon/ medical consultant)

Q112.PublicHospital Q113.Local female healer Q114.Private Clinic Q115.In general, how difficult have you found it to talk to health care providers about your personal health concerns? doctor/nurse se baat krna apko kitna mushkil lagta hai?

1.Very difficult 2.Somewhat difficult

2.Not too difficult

3.Not difficult at all

Please rate the health practitioner services as you have experienced them?

1.Excellent 2.Good 3.Fair 4.Poor

Q116.Listening to what you have to say Kya apki baat ghor se suntay hain?

Q117.Talking to you in a respectful and caring manner

Kya ap se izzat se baat kartay hai?

Q118.Speaking to you in the language/ dialect you understand better

Kya apse apki madri zubaan mai baat krtay hai

Q119.Answering your questions clearly Ap ke sawalon ka sahi se jawaab detay hai?

Q120.Giving you the opportunity to ask all of your questions Apko sawaal puchnay ka wakt detay hai?

Q121.Helping you to feel comfortable talking about your personal or sensitive health concerns Kya ap asaani se unhe apnay masaael ke baray mai bata deti hain?

Q122.Giving you complete health information Kya sehat se mutalik tamaam jankari detay hain?

Q123.Discussing alternative therapies, diet and lifestyle Kya ap se mutabadil therapy ya khuraq ya roz mara ki zindagi guzarnay kay tareekay pe tabadal e khayal kya hai?

Q124.Giving you complete information about any tests or services Test ke baray mai mukamal jaankari detay hain?

Q125.Giving you the results of your tests Test ke nataij batatay hain?

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Q126.Giving you complete information about all your options for treatments Kya ilaaj ke mutalik apko mukamal jaankari detay hai?

Q127.Giving you the opportunity to make important decisions about your health care Kya sehat se mutalik tamam faislay apko karnay detay hai?

Q128.Giving you written or printed information when you need it Malumaat likh kr dete hai?

Q129.Spending enough time with you during your visits Apko tasali bakhsh wakt detay hai?

Q130.Treating you like a partner in your health care Apka sathi bun kr apki sehat ka khayal rakhtay hai?

Which are the primary/ most important sources you depend on for making health decisions? Sehat se mutalik faislon ke liye ap kis se mashwara leti hai?


Q131.Husband Q132.Mother in law Q133.Other in-laws (list please) Q134.Blood family (parents, siblings, children…) Q135.Newspapers / magazines Q136.Heath newsletter Q137.TV Q138.Radio Q139.Microfinance provider Q140.Internet Q141.Mobile services Q142.Family/ friends Q143.Community Q144.Medical Practitioner Q145.Local Healer Q146.Local Imam/ religious leader Q147.Other (Please list) Current Health Risks Q148.Do you currently smoke? Kya app tambako noshi mein mulawis hain?

1.Yes

2.No

Q149.How many in a day? Din ke kitnay ?

Q150.Does anyone else smoke in the house when you/ children are in same room? Kya koi aur tambako noshi mein mulawis hain

1.Yes 2.No If yes, who is this:

Q151.Do you feel anxious, stressed, depressed, suicidal? Kya app kabhi bechain hotay hain ya zehni dabao ka shakar ya khud kushi ka khayal aya hai?

1.Yes 2.No

Indicate which:

Q152.Do you take any drugs (to relieve yourselves of stress or an ailment? Kya app in ke liye koi dawa laitay hain?

1.Yes

2.No

If yes, which ones:

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In the past 5 years, has a doctor ever told you that you have any of the following conditions Kya pichlay paanch salon mai doctor ne aapko bataya ke apko ye bemari hai?


Q153.Hypertension/ BP High blood pressure

Q154.Heart disease Dil ki bemari

Q155.High cholesterol Q156.Diabetes (sugar)

Q157.Depression Zehni dabao

Q158.Anxiety Bechaini

Q159.Migraine headaches (sar dard)

Q160.Arthritis Joro ki dard

Q161.Osteoporosis Q162.Obesity/ Over-weight problems (mutapa)

Q163.Urinary incontinence (pishaap ki takleef)

Q164.Cancer Q165.Eating disorder like bulimia/ anorexia Khanay k hawaly se koi mushkil, jaisay bhook na lagna ya kha k ulti kerna

Q166.Thyroid problems Q167.Malaria/ Dengue Are you facing any disability which? Kya aap kisi mazoori ka shikaar hain?

1.Yes

2.No

Q168.Keeps you from participating fully in your ability to take care of your family Jiski waja se ap apnay ghar walon ka khayal na rakh sakain


Q169.Keeps you from participating fully in your ability to continue with your business Apnay karobaar mai sahi se kaam na kr sakain


SECTION D BASELINE NUTRITION AND FOOD SECURITY SURVEY UNICEF

Q170.In the past 6 months did you find it too expensive to purchase the foods you needed to feed your family? Pichlay 6 maah mai kya apko khaandan ko palnay ke liye khana lenay mai mushkilaat hoti hai?

1.Yes

2.No

Q171.Did you find it too expensive to purchase fruit? Kya phal khareedna bohat mehnga hai?

1.Yes

2.No

Q172.Did you find it too expensive to purchase 1.Yes

2.No

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vegetables? Kya sabzi khareedna bohat mehnga hai?

Q173.Did you find it too expensive to purchase meat? Kya gosht khareedna bohat mehnga hai?

1.Yes

2.No

Q174.Did you find it too expensive to purchase eggs? Kya anday khareedna bohat mehnga hai?

1.Yes

2.No

Q175.Did you find it too expensive to purchase milk? Kya doodh khareedna bohat mehnga hai?

1.Yes

2.No

Q176.Did you find it too expensive to purchase wheat, for roti? Kya roti khareedna bohat mehnga hai?

1.Yes

2.No

Q177.In the last 3 months were you worried about running out of food because of high costs? Pichlay 3 maah mai mehngai ki waja se khana na khareed panay ka dart ha?

1.Yes

2.No

Q178.In the last 3 months did you run out of food because of expense? Pichlay 3 maah mai kya mehngai ki waja se kabhi ghar mai khana khatam ho gaya ho?

1.Yes

2.No

Q179.In the last 3 months did you or any other adult in the house skip meals because there was not enough food? Pichlay 3 maah mai aap ya kisi or ghar walay se khana kum honay ki waja se khana na khaya ho?

1.Yes

2.No

Q180.In the last 3 months did you ever think your children are still hungry because of not being fed enough food? Pichlay 3 maah mai apko kabhi laga ke apkay bachay bhookay hai kyunkay khana pura nai tha?

1.Yes

2.No

Q181.In the last 3 months did any of your children go to bed hungry? Pichlay 3 maah mai kya apkay bachay kabhi bhookay soe houn?

1.Yes

2.No

SECTION E WHO MULTI-COUNTRY STUDY ON WOMEN’S HEALTH AND DOMESTIC VIOLENCE AGAINST WOMEN Psychological violence experienced at home 1.Yes 2.No If yes, who were these

household members?

Q182.Has someone in your home insulted you or made you feel bad about yourself? Kya ghar mai kisi ne apki bezati ki hai?

Q183.Has someone in your home belittled or humiliated you in front of other people? Kya ghar mai kisi ne apko dosron ke samnay hakeer dikhaya hai?

Q184.Has someone in your home done things to scare or intimidate you on purpose? Kya ghar mai kisi ne apko daraya hai?

Q185.Has someone in your home threatened to hurt you or someone you care about? Kisi ne apko damkhaya hai?

Physical violence experienced at home 1.Yes 2.No If yes, who were these

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household members? Q186.Has someone in your home slapped you or thrown something at you that could hurt you? Kya kisi ne apko thapar lagaya ho ya app e koi chiz phenki ho jisse apko chot lagi ho?

Q187.Has someone in your home pushed or shoved you? Ghar pe apko kisi ne dhaka diya hai?

Q188.Has someone in your home hit you with his fist or with something else that could hurt you? Kisi ne apko mukkay marain hai?

Q189.Has someone in your home kicked you, dragged you or beaten you up? Kisi ne apko laat mari ho ya ghaseeta ho?

Q190.Has someone in your home choked or burnt you on purpose? Kisi ne jaan bojh kr apka gala dabanay ki, ya jalanay ki koshish ki hai?

Q191.Has he threatened to use or actually used a gun, knife or other weapon against you? Apkay khilaf koi hathyaar istemal kiya hai?

Sexual violence experienced at home 1.Yes 2.No

Q191.Has your husband physically forced you to have sexual intercourse when you didn’t want to? Kya apke shohar ne kisi kisam ka jinsi tushadad kiya hai?

Q192.Did you ever have sexual intercourse when you didn’t want because you were afraid of what your husband might do? Kiya app ne kabhi apnay shohar k darr se uss ke saath jinsi taluqat rakhain hain?

Q193.Has your husband forced you to do something sexual that you found degrading or humiliating? Kya apkay shohar ne kabhi app se aisay jinsi kaam keraye hain jin se app sharminda ya zilat mehsoos kerain?

SECTION F SURVEY OF WORKPLACE VIOLENCE WHO

Q194.Describe where exactly your work takes place, when outside of home Ghar se bahir kahan kaam karti hai?

Q195.What kind of people do you interact with mostly for work, outside of home (gender Kam pe kis tarah ke log se mulakat hoi hai?

Q196.What are the hours that you are required to work outside of home Ghar se bahir kaam ke silsalay mai kitnay ghnatay lagtay hai?

Q197.Which security measure is available to you outside of home in case of fear of violence (male relative accompanying, phone, moving in crowd…) Tashadud ki soorat mai kaam pr koi hifazati intezam hotay hai?

Physical Violence (PV) at the workplace Q198.In the last 12 months, have you been physically attacked in your workplace/ when you are working outside of home? Ghar se bahir kaam kartay wakt kisi tarah ke tashadud ka shikar

1.Yes 2.No

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hui hain? Q199.Was this PV with a weapon? (If yes, what kind) Kya is tashadud ke liye koi aslaah istemal kiya gaya tha?

Q200.Is this a typical incident at your workplace/ when you are working outside of home? Kya is tarah ka tashadud kaam pr mamool ki baat hai?

1.Yes 2.No

Q201.Who attacked you? Kis ne app r tashadud kiya?

Q202.Where exactly did it take place? Tashadud kis jaga hua?

Q203.What time was it? Kis wakt hua?

Q204.Do you think it could be prevented? Kya is tashadud roka ja sakta tha?

1.Yes 2.No

Q205.Were you injured? Kya apko kisi kisam ki chot ai thi?

1.Yes 2.No

Q206.Did you require treatment for the injury? Kya is chot/zakham ke liye apko kisi ilaj ki zarorat hui?

1.Yes 2.No If yes, can you describe this treatment:

Q207.How did you respond to the incident? Tashadud ke natijay mai ap ne kya kiya?

Did you suffer any of the following due to PV: Q208.Repeated, disturbing memories, thoughts, or images of the attack? Tashadud ke bad kya apko iske baray mai aksar khayalat atay the?

1.Yes 2.No


1.Yes 2.No


1.Yes 2.No


1.Yes 2.No

Verbal Violence (VV) at the workplace Q212.In the last 12 months, have you been verbally assaulted in your workplace/ when you are working outside of home? Kya pichlay 12 mah mai kaam pr kisi ne ap pr zabani tashadud kiya hai?

1.Yes 2.No

Q213.How often has this happened in the last 12 months? Kitni dafa?



4.Other

Q214.Is this a typical incident at your workplace/ when you are working outside of home? Kya ye kaam pr mamool ki baat hai?

1.Yes 2.No

Q215.Who abused you? Kis ne aap per zabani tashadud kiya?

Q216.Where exactly did it take place? Kahan kiya?

Q217.What time was it? Kis wakt kiya?

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Q218.Do you think it could be prevented? Kya isse roka ja sakta tha?

1.Yes 2.No


Did you suffer any of the following due to VV: Q220.Repeated, disturbing memories, thoughts, or images of the attack? Tashadud ke bad kya apko iske baray mai aksar khayalat atay the?

1.Yes 2.No


1.Yes 2.No


1.Yes 2.No


1.Yes 2.No

Sexual Harassment (SH) at the workplace Q224.In the last 12 months, have you been sexually harassed in your workplace/ when you are working outside of home? Kya pichlay 12 maheenay mein ap ko kisi kisam k jinsi harasaan ka samna kerna parha hai?

1.Yes 2.No

Q225.How often have you been sexually harassed in the last 12 months? Pichlay 12 maheenay mein yeh kitni dafa hua?



4.Other

Q226.Is this a typical incident at your workplace/ when you are working outside of home? Kya yeh kaam kernay wali jaga pe amoman hota hai?

1.Yes 2.No

Q227.Who attacked you? Hamla awar kaun tha?

Q228.Where exactly did it take place? Yeh kis jaga pe hua?

Q229.What time was it? Waqt kya tha?

Q230.Do you think it could be prevented? Kya app isko rok sakti theen?

1.Yes 2.No

Q231.How did you respond to the incident? Apnay iska samna kaisay kiya?

Did you suffer any of the following due to SH: Q232.Repeated, disturbing memories, thoughts, or images of the attack? Kya apko iss hadsay k baad baar baar buray khaylat ya yaadain pareshan kerti hain?

1.Yes 2.No

Q233.Avoiding thinking about or talking about the attack or avoiding having feelings related to it? Kya app iss hadsay ko bhulanay ki koshih ya iskay baray mein baat kernay se guraiz kertay hain?

1.Yes 2.No

Q234.Being "super-alert" or watchful and on guard?

1.Yes 2.No

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Kya app chak o chawbund rehtay hain? Q235.Feeling like everything you did was an effort? Kya apko zehni dabao mehsoos hota hai?

1.Yes 2.No

Racial Harassment (RH) at the workplace Q236.In the last 12 months, have you been racially harassed in your workplace/ when you are working outside of home? Pichlay 12 maah mai apki zaat ki waja se kisi ne apko harasaan kiya hai?

1.Yes 2.No

Q237.How often have you been racially harassed in the last 12 months? Kitni dafa?



4.Other

Q238.Is this a typical incident at your workplace/ when you are working outside of home? Ghar se bahir kaam pe kya ye aam ma’mool ki baat hai?

1.Yes 2.No

Q239.Who attacked you? Kis ne harasaan kiya?

Q240.Where exactly did it take place? Kahan

Q241.What time was it? Kis wakt?

Q242.Do you think it could be prevented? Kya issay roka ja sakta tha?

1.Yes 2.No


Did you suffer any of the following due to RH: Q244.Repeated, disturbing memories, thoughts, or images of the attack? Tashadud ke bad kya apko iske baray mai aksar khayalat atay the?

1.Yes 2.No


1.Yes 2.No


1.Yes 2.No


1.Yes 2.No

SECTION F OPEN-ENDED QUESTIONS

Q248.What are the main health challenges you face in the last 12 months? Pichlay sal mein kaunsi sehat ki takleef thi apko? Behtareen tibbi saholiyat ke wasool mai sub se eham 3 rukawatain?

Q249.What are the top 3 barriers preventing you from access to health services? Kaunsi theen chezay apko sehat ki sahulat laney mein rukawat hai

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Q250. What are the main problems which prevent you from being satisfied with your health since taking loan? Kaunsi sehat ke mutalik cheezay apko ----- ?

β- Punjabis (1), Pashtuns (2), Sindhis (3), Siddis (4), Saraikis (5), Muhajirs (6), Balochis (7), Hindkowans (8), Chitralis (9), Gujarati (10), Kashmiris (11), Kalash (12), Burusho (13), Brahui (14), Khowar (15), Hazara (16), Shina (17), Kalyu (18), Balti (19), Afghan refugees (20), Other (21). *- Doctors clinic (private/primary-secondary) (1), Hospital Clinic (tertiary) (2), LHW (3), BHU (4), Local Hakim (5), Homeopath (6), Other (7). +- No money (1), not serious/ took care it of it myself (2), too busy (3), no childcare (4), no transport (5), too embarrassed (6), don’t have permission (7), prescription/ paperwork/ referral got lost (8), didn’t know where to get care (9), provider too far away (10), don’t like the local provider (11), couldn’t find specific specialist (12), other (13). # Physical violence refers to the use of physical force against another person or group, that results in physical harm, sexual or psychological harm. It can include beating, kicking, slapping, stabbing, shooting, pushing, biting, and/or pinching, among others. Psychological violence is defined as: Intentional use of power, including threat of physical force, against another person or group, that can result in harm to physical, mental, spiritual, moral or social development. Psychological violence includes verbal abuse, bullying/mobbing, harassment, and threats. Sexual Harassment refers to any unwanted, unreciprocated and unwelcome behavior of a sexual nature that is offensive to the person involved, and causes that person to be threatened, humiliated or embarrassed. Racial Harassment refers to any threatening conduct that is based on race, color, language, national origin, religion, association with a minority, birth or other status that is unreciprocated or unwanted and which affects the dignity of women and men at work. @ took no action (1), tried to pretend it never happened (1), told the person to stop (1), tried to defend myself (1), told friends/family (1), sought counseling (1), told a colleague (1), reported it to a colleague (1), discussed/ complained to MF loan officer (1), sought help from MFP (1), sought help from the union/community (1), pursued prosecution (1), other (1)

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https://en.wikipedia.org/wiki/Punjabis

https://en.wikipedia.org/wiki/Pashtuns

https://en.wikipedia.org/wiki/Sindhis

https://en.wikipedia.org/wiki/Siddis

https://en.wikipedia.org/wiki/Saraiki_people

https://en.wikipedia.org/wiki/Muhajir_people

https://en.wikipedia.org/wiki/Baloch_people

https://en.wikipedia.org/wiki/Hindkowans

https://en.wikipedia.org/wiki/Chitrali_people

https://en.wikipedia.org/wiki/Gujarati_people

https://en.wikipedia.org/wiki/Kashmiri_people

https://en.wikipedia.org/wiki/Kalash_people

https://en.wikipedia.org/wiki/Burusho_people

https://en.wikipedia.org/wiki/Brahui_people

https://en.wikipedia.org/wiki/Khowar_people

https://en.wikipedia.org/wiki/Hazaras

https://en.wikipedia.org/wiki/Shina_people

https://en.wikipedia.org/w/index.php?title=Kalyu&action=edit&redlink=1

https://en.wikipedia.org/wiki/Balti_people

https://en.wikipedia.org/wiki/Afghans_in_Pakistan



Supplementary Table 1a: Descriptive statistics before matching for health insurance (T=0 and T=1)

Variable No health insurance (T=0)

Health insurance (T=1)

Mean SD Mean SD Difference p-value Age 0.455 0.499 0.390 0.489 0.065 0.188 Religion 0.097 0.297 0.150 0.358 -0.052 0.103 Literacy 0.396 0.490 0.253 0.436 0.142 0.003 Spouse Literacy 0.385 0.488 0.351 0.479 0.035 0.473 House ownership 0.712 0.454 0.805 0.397 -0.093 0.032 Children 0.563 0.497 0.714 0.453 -0.152 0.002 Drinking water 0.771 0.421 0.857 0.351 -0.086 0.034 Toilet facility 0.760 0.428 0.779 0.416 -0.019 0.657 Gutter drainage 0.747 0.436 0.733 0.443 0.013 0.771 Debt age 0.670 0.471 0.669 0.472 0.001 0.978 Group loan 0.410 0.493 0.422 0.496 -0.012 0.802 Loan amount 0.750 0.433 0.468 0.501 0.283 <0.001 Interest rate 0.708 0.455 0.669 0.472 0.040 0.391 Monthly meetings 0.674 0.470 0.890 0.314 -0.216 <0.001

Supplementary Table 1b: Descriptive statistics after matching for health insurance (T=0 and T=1)

Variable No health insurance (T=0)

Health insurance (T=1)

Mean SD Mean SD Difference p-value Age 0.450 0.500 0.433 0.498 0.017 0.796 Religion 0.125 0.332 0.150 0.359 -0.025 0.576 Literacy 0.308 0.464 0.308 0.464 0 1.000 Spouse literacy 0.425 0.496 0.375 0.486 0.050 0.431 House ownership 0.825 0.382 0.792 0.408 0.033 0.514 Children 0.650 0.479 0.642 0.482 0.008 0.893 Drinking water 0.833 0.374 0.817 0.389 0.017 0.735 Toilet facility 0.842 0.367 0.792 0.408 0.050 0.319 Gutter drainage 0.725 0.448 0.750 0.435 -0.025 0.662 Debt age 0.658 0.476 0.683 0.467 -0.025 0.682 Group loan 0.467 0.501 0.400 0.492 0.067 0.299 Loan amount 0.475 0.501 0.483 0.502 -0.008 0.898 Interest rate 0.667 0.473 0.625 0.486 0.042 0.502 Monthly meetings 0.892 0.312 0.858 0.350 0.333 0.437

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Supplementary Table 2a: Descriptive statistics before matching for health awareness programme (T=0 and T=1)

Variable No health awareness programme

(T=0)

Health awareness programme

(T=1)

Mean SD Mean SD Difference p-value Age 0.476 0.501 0.394 0.490 0.082 0.084 Religion 0.087 0.283 0.140 0.348 -0.05 0.086 Literacy 0.383 0.487 0.314 0.465 0.070 0.124 Spouse literacy 0.379 0.486 0.369 0.483 0.010 0.829 House ownership 0.762 0.427 0.729 0.446 0.033 0.424 Children 0.573 0.496 0.653 0.477 -0.080 0.086 Drinking water 0.820 0.385 0.784 0.412 0.037 0.034 Toilet facility 0.728 0.446 0.801 0.400 -0.727 0.072 Gutter drainage 0.699 0.460 0.780 0.415 -0.081 0.053 Debt age 0.636 0.482 0.699 0.460 -0.063 0.159 Group loan 0.442 0.498 0.390 0.489 0.052 0.270 Loan amount 0.767 0.424 0.551 0.498 0.216 0.000 Interest rate 0.660 0.475 0.725 0.448 -0.064 0.143 Monthly meetings 0.626 0.485 0.856 0.352 -0.230 <0.001

Supplementary Table 2b: Descriptive statistics after matching for health awareness programme (T=0 and T=1)

Variable No health awareness programme

(T=0)

Health awareness programme

(T=1)

Mean SD Mean SD Difference p-value Age 0.469 0.502 0.424 0.496 0.045 0.923 Religion 0.135 0.343 0.139 0.347 -0.003 0.940 Literacy 0.344 0.477 0.285 0.453 0.059 0.334 Spouse literacy 0.375 0.487 0.417 0.495 -0.042 0.521 House ownership 0.833 0.375 0.792 0.408 0.042 0.424 Children 0.604 0.491 0.674 0.471 -0.069 0.272 Drinking water 0.813 0.392 0.833 0.374 -0.021 0.679 Toilet facility 0.781 0.416 0.840 0.368 -0.059 0.249 Gutter drainage 0.677 0.477 0.778 0.417 -0.101 0.083 Debt age 0.667 0.474 0.674 0.470 -0.007 0.911 Group loan 0.448 0.500 0.424 0.496 0.024 0.711 Loan amount 0.573 0.497 0.417 0.495 0.156 0.018 Interest rate 0.667 0.474 0.632 0.484 0.035 0.584 Monthly meetings 0.854 0.355 0.889 0.315 -0.035 0.428

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