Key Messages
When you think about planning for empowerment you also have to think about resources that have to be devoted solely for that purpose and incorporating them into an otherwise complex situation of changing the delivery system.
—Diệp Vương
Women-owned clinics … [have] even more additional complications. In many of the countries, you need collateral. For collateral you need property rights. You need to have your title deeds. You need to own your business. Often these women do not own anything. Their husband owns it, or their father.
—Monique Dolfing-Vogelenzang
Gender has the ability to knock down verticals. Investing in women is a way to cut across traditional silos such as agriculture, health care, and environment, and to empower women through multisector approaches.
—Beth Bafford
Women’s lack of power in financial and political domains has resulted in a global gender imbalance that has far-reaching implications at individual, family, and societal levels. Empowering women improves the health of women and their family, builds linkages within communities, and promotes economic development. Participants discussed the means by which women can be empowered, particularly through increasing their economic participation, and shared potential future areas for investment.
WOMEN’S EMPOWERMENT: INTENTIONAL INCORPORATION1
Diệp Vương cited The World Bank definition of empowerment in her opening remarks:
Empowerment is the process of increasing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes. Central to this process are actions that both build individual and collective assets, and improve the efficiency and fairness of the organizational and institutional context that govern the use of these assets. (World Bank Group, 2011)
She emphasized that the elements of “capacity to choose,” “building individual and collective assets,” and the “context that governs the use of these assets” deserve specific attention. She noted that it would be possible to achieve innovative models of health care delivery without incorporating empowerment approaches, but she cautioned that they might not be long-term or sustainable models. Rather, she recommended not only to include empowerment, but also to recognize the need to devote resources solely for that purpose.
This involvement also should reflect appropriate participation and representation. Vương noted that even when disciplines are predominantly composed of women, men often hold higher-ranking and higher-paid positions of leadership. To ensure adequate participation of women, she asserted that a key element is asset building, including soft assets such as skills and knowledge or harder assets such as funds. In terms of skills, she said it is particularly important to distinguish between the role of a nurse or midwife as a professional delivering care and services and the traditional perspective of women in nurturing positions.
Empowerment of women also means empowerment of the community. For the provision of health care, this includes training providers within communities who come from those communities. Vương shared a story of trying to obtain care for a client in a rural town with limited options. The
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1 This section summarizes information presented by Diệp Vương, Pacific Links Foundation (PALS).
FIGURE 2-1 Social impact investing.
SOURCE: Bafford, 2014.
local physicians offered one very expensive and invasive procedure to treat her, so Vương and her client raised funds to travel to the city for a second opinion. It was there they discovered another less invasive and less expensive alternative that they elected to pursue. Vương believes that this lack of heath care choice for underserved populations is an opportunity for nurses and midwives to provide missing services to rural and other disadvantaged communities. She also asserted that even though provision of care is often limited by constrained resources, many times there is still an opportunity to create a marketplace for affordable health care with customers who have the ability to pay.
INVESTING IN WOMEN’S EMPOWERMENT2
The Calvert Foundation is an impact debt provider based in the United States, Beth Bafford explained. As a nonprofit organization, it issues and deploys debt capital. The capital is pooled into funds that are invested in communities both in the United States and abroad via community development financial institutions, which finance ventures such as health clinics, community centers, affordable housing, small businesses, microfinance, and fair trade (see Figure 2-1).
Bafford noted that a few trends are occurring in the investment space.
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2 This section summarizes information presented by Beth Bafford, Calvert Foundation.
First, a huge wealth transfer—almost $40 trillion—will happen over the next decade to millennials, who care about aligning their spending with their values. Secondly, crowdfunding is currently a popular topic; it connects people in a more direct way to the outcomes they are funding. Thirdly, investing based on values has led to the growth of socially responsible investing and impact investing, which had traditionally been inaccessible via previous modes of investment. Lastly, she said that there is an increased need for private capital in communities where government funding has been diverted.
The Women Investing in Women Initiative
The Calvert Foundation has concentrated on innovative investment products that intentionally focus on women and their empowerment. Women Investing in Women Initiative (WIN WIN) is one such approach, which aims to more directly align similar values between investors and recipients. It is not only a community development finance initiative, Bafford explained, but also a means of creating a portfolio with a more specific identity. WIN WIN began as a pilot, with an initial capitalization of $20 million raised from investors interested in women’s economic empowerment. The second half of the initiative—identifying organizations for investment—was more complicated. Bafford noted,
[It was a] balance between rigor (academic and intellectual rigor) and flexibility for our borrowers. People look to us to have rigor in how we look at impact and how we evaluate the impact of our work. But we also have borrowers who do not want to be tied down by the burden of impact metrics that do not align with their ways of doing business.
To receive financing from the initiative, organizations had to meet one of two criteria. The first is the organization supports women—the majority of clients are women, there is a mandate to serve women in its mission, there is a specific program targeting women within the organization, or the majority of the organization’s products or services are beneficial to women. The second is the organization has women’s empowerment related services—there is adequate female representation on leadership teams or boards, or the organization has received industry-wide recognition for working with women. The Calvert Foundation also created a third option to individually select programs they felt were empowering to women.
Outcomes and Lessons Learned
Bafford shared some of the outcomes of the program with workshop participants. She said there are 850 new investors, with 83 percent investing
online. Additionally, the new initiative reached a younger, predominantly female market; Bafford explained that this demographic shift provides possible opportunities for reaching younger generations to educate them about investing for social impact early in their careers. $20.1 million was deployed into 16 organizations that financed more than 160 small businesses. Seventy-five percent of the borrowers had a majority female management, with investments in affordable housing, financial inclusion, environment, and health care.
There were some important lessons learned as well. Bafford said there is power in investment, particularly in converting individual assets into something that is aligned with values. There is also latent demand; individuals want to invest in women and need to be given ways to do so. Another lesson learned was that investing in women is a way to cut across traditional silos such as agriculture, health care, and environment, and to empower women through multisector approaches. Lastly, she said, portfolio creation should be inclusive and aspirational, and should strike a balance between ensuring fidelity to portfolio investment goals and maintaining flexibility to grow and adapt.
SOCIAL ENTERPRISE AND WOMEN’S EMPOWERMENT3
Monique Dolfing-Vogelenzang described the PharmAccess Group, a Dutch organization started to provide access to HIV/AIDS treatment in Africa, in a time when no such treatment was provided due to complication and expense. PharmAccess fills similar gaps today—health insurance provision in community-based care, introduction of quality standards, health care investment via loans, and consulting with public–private partnerships.
The Medical Credit Fund
Within the PharmAccess Group, Dolfing-Vogelenzang heads the Medical Credit Fund (MCF), whose mission is to enable primary health care providers to access capital to improve quality of care and expanded services. In some low-income settings, she said, local government cannot always provide all of the services, and the private sector is often the default provider. But these private health care facilities are underfunded and lack access to capital, either locally or through donors. She noted there are a number of reasons for this, including weak financial and administration structures, but other reasons include collateral and contractual issues common to small and medium enterprises particularly in health care.
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3 This section summarizes information presented by Monique Dolfing-Vogelenzang, PharmAccess Group.
Risk Reduction Programs
The MCF, together with PharmAccess, has developed two risk reduction programs. The first is a medical upgrading and business plan to improve quality and efficiency and assessment of results, called SafeCare (further discussed in Chapter 6). The second is a financial program, which is a step-by-step approach to accessing capital at banks at affordable terms and conditions to enable expansion of services.
The two programs are linked and offered through local partners to build capacity through health networks and to provide loans. Loans are provided in amounts ranging between $5,000 and $350,000 with reasonable terms and partial guarantee through the MCF (with the local banks increasingly taking on risk). The MCF works with loan recipients to create business plans, increase efficiency, and guide investment toward quality issues. The fund also works with local implementing partners, such as local nongovernmental organizations, international franchise organizations, and associations of doctors. It is a hybrid fund with international investors, and its risk is reduced by the inclusion of donor funding from entities such as the U.S. Agency for International Development (USAID) and the Dutch government.
Challenges
Currently, the MCF has funded almost 600 loans, with 26 percent of them made to enterprises headed by women. At the same time, women make up the bulk of the staff in a lot of male-headed clinics. Dolfing-Vogelenzang noted that there are additional challenges faced with women entrepreneurs:
- Collateral, usually property, is often required to obtain a loan. However, in many countries, women cannot exercise property rights.
- Lack of financial and business education poses a barrier to small business owners, particularly women.
- Midwife facilities are often located in rural areas, where there are few banks and the threshold for obtaining a loan is higher.
- Clinics are usually small, often run by one woman who needs to be in place to provide services and who cannot easily attend business trainings.
- Professional associations usually lack a strong secretariat, without which donors are not encouraged to provide funds.
Examples of Enterprises
In her remarks, Dolfing-Vogelenzang provided additional information about three of their partners and projects. One is the Kisumu Medical and Education Trust (K-MET) that is a network of more than 300 clinics throughout Kenya that provides health services to women. The second is a public–private partnership (PPP) between PharmAccess and the Ghanaian Ministry of Health for addressing a shortage of maternal health services in rural areas by setting up midwife franchise clinics in Ghana. This example is described in Box 2-1. The third involves a mobile health payment system that entails three critical steps as outlined in Box 2-2.
Kisumu Medical and Education Trust (K-MET)
K-MET was started by midwife Monica Oguttu with seed capital in the west of Africa. K-MET provides training in Kenya and other parts of East Africa and has built a network of clinics for improving women’s health. One of their focuses is quality improvement, and they also saw the need to be able to support their network members (clinics) to access additional capital to grow and improve their quality. The MCF provided that capital, and in partnership they have supported more than 200 clinics in quality improvement. K-MET has also trained more than 1,000 community health workers and established Sisterhood for Change (shown in Figure 2-3) to empower girls in education.
Midwife Franchise Clinics in Ghana
PharmAccess and the Ghanaian Ministry of Health are working to establish a public–private partnership to develop a network of private maternity clinics in peri-urban and rural areas. This is a for-profit franchise model in which individual midwives are provided with standard guidelines, procedures, and a business model to develop their practice.
Mobile Money and mHealth (Mobile Health) in Kenya
PharmAcess is developing a health care payment infrastructure as a way for consumers to finance their health care needs by making use of the rapidly developing mobile payments market. This would be used at accredited facilities that provide a certain level of care, and would allow channeling funds for specific health benefits to beneficiaries through a mobile wallet. PharmAccess believes that this innovation will be a mechanism for pooling resources, and would also empower both patients and facilities to increase access to and improve quality of services.
BOX 2-1
PPP Midwife Franchise Clinics Ghanaa
Introduction
PharmAccess and the Ghanaian Ministry of Health are planning a public–private partnership (PPP) to address the shortage of maternal health services in rural areas. The investment concerns the establishment of a network of private maternity clinics.
Background
Despite significant investments, maternal mortality in Ghana is still high with 350 per 100,000 live births. Of the 800,000 deliveries per year, only 48 to 60 percent are currently attended by a skilled health worker (see Figure 2-2). This is due to a shortage of supply of maternal health services, especially in the rural areas. Over the last years, the Ghanaian government has increased the training capacity for midwives to 1,500 per year, but they have limited employment opportunities.
The PPP aims to address this issue by providing midwives with the opportunity to set a viable private midwifery practice in these rural areas. The government of Ghana intends to contribute to some of the operational expenses of the clinics, while fees are to be paid for by the National Health Insurance Scheme.
The Investment
The initial investment considers a combination of debt and equity into the private enterprise supporting the network and the provision of debt to the midwife entrepreneurs to co-finance their investment in the clinics. The private enterprise will provide support services to the clinics against a fee (e.g., training, information and communications technology, purchasing, quality control)—partly covered by the government—and act as a franchisor.
Social and Economic Impact
The partnership has a high social and economic impact in various areas that include
FIGURE 2-2 Assisted deliveries in Ghana.
SOURCE: Dolfing-Vogelenzang, 2014. Material original to PharmAccess.
- Increasing the availability of quality maternal health services with an accompanied increase in skilled birth attendance. With 20 clinics, the network is expected to handle 6,000 deliveries per year, largely in low-income populations, which will likely decrease maternal and child mortality.
- Improving employment opportunities for midwives in rural areas in Ghana thereby reducing brain drain of health workers to urban areas and abroad.
- Setting an example for public–private partnerships in priority health areas in developing countries.
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a The text in this box is reprinted with permission from Dolfing-Vogelenzang, 2014. SOURCE: Dolfing-Vogelenzang, 2014. Material original to PharmAccess.
BOX 2-2
Mobile Health: An integrated Approach, empowering Patientsa
Step 1: Health Payment infrastructure
- Create mobile health payment infrastructure to allow pooling of various sources of funds; (group) savings, remittances
- Improve business case for health care providers to invest in quality
Step 2: Quality Standards
- Establish national system for quality assessments using SafeCare standards
- Embed quality in the public system through cooperation with National Hospital Insurance Fund and Ministry of Health
Step 3: investments
- Invest in quality and business improvement of private health care providers through the MCF
- Build the business case for private investments in the health sector
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a The text in this box is reprinted with permission from Dolfing-Vogelenzang. SOURCE: Dolfing-Vogelenzang, 2014. Material original to PharmAccess.
FIGURE 2-3 Sisterhood for Change.
SOURCE: K-MET, n.d.
IMPORTANT LESSONS IN WOMEN’S EMPOWERMENT
Participants discussed further challenges and opportunities in investing in women and their empowerment, which include
- Identifying the gap between the development of an innovation and its scale-up: Often new innovations are identified and applauded, but without a specific plan for scalability and expansion, they cannot grow.
- Bringing investors and donors to patients in a more direct way: Some current innovations seek to match patients with specific (and often costly) health needs to prescreened donors who can quickly mobilize funds. For example, one participant mentioned that Heart Fund Pakistan is working on developing a mobile platform to link donors to patients who come into emergency services and hospitals and cannot afford their care, in order to transfer funds in a short time frame. This participant questioned whether a knowledge exchange platform such as this might facilitate the growth of direct matching services, particularly regarding access by women.
- Defining empowerment: The World Bank definition of empowerment is very capital- and investment-oriented, but individuals such as Patricia Hill Collins, professor of sociology at the University of Maryland, College Park, have proposed a social justice–oriented paradigm of resisting the dominating forces that disempower women. One way that disempowerment is inadvertently promoted is through implementation without “on the ground” input.
- Replicating success: Programs do not always translate to other countries or new settings and at times require extensive adaptation. This includes transferring programs between the commercial, for-profit space and the public sector as noted by one of the participants.
REFERENCES
Bafford, B. 2014. Our experience with women’s empowerment: A case study from the Calvert Foundation. Presented at the IOM workshop: Empowering women and strengthening health systems and services through investing in nursing and midwifery enterprise: Lessons from lower-income countries. Bellagio, Italy, September 9.
Dolfing-Vogelenzang, M. 2014. Women’s empowerment. Presented at the IOM workshop: Empowering women and strengthening health systems and services through investing in nursing and midwifery enterprise: Lessons from lower-income countries. Bellagio, Italy, September 9.
K-MET (Kisumu Medical and Education Trust). n.d. K-MET website. http://www.kmet.co.ke (accessed January 13, 2015).
World Bank Group. 2011. Empowerment. http://go.worldbank.org/GOB032TQ40 (accessed November 3, 2014).
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