When creditor and health provider collide: exploring microfinance-based hospitals in Bangladesh
Date Issued
2015
Date
2015
Author(s)
Tseng, Yu-hwei
Abstract
Introduction: Health programs implemented by microfinance institutions (MFIs) aim to benefit the poor, but whether these services reach the poorest remains uncertain. This study intended to investigate the patient profiles and policies in the hospitals operated by microfinance institutions (MFI hospitals) in Bangladesh and make a comparison with public hospitals to determine if such initiatives were consistent with their pro-poor mandate. This research came in two parts. The first part paid attention to patients. A survey was conducted to examine patients’ hospital utilization by predisposing, enabling and need determinants. The second part focused on hospitals. It took advantage of qualitative approach to probe into the service delivery, manpower, financing and other aspects of the health care system through in-depth interviews and observation. Drawing on the evidence derived from stakeholders such as providers, users, policy makers and practitioners, implications of MFI hospital-based programs were discussed. Methods: In this cross-sectional study, the author used the convenience sampling method to administer an interviewer-assisted questionnaire survey among 347 female outpatients, with 177 in MFI hospitals and 170 in public hospitals. Independent variables were patient characteristics categorized into predisposing factors (age, education, marital status, family size), enabling factors (microcredit membership, household income) and need factors (self-rated health, perceived needs for care). The statistical method of Generalized Estimating Equations (GEE) was employed to evaluate how these factors contributed to MFI hospital use. In the qualitative approach, details on the provision of hospital care in the public and MFI sectors were collected among 27 stakeholders, including microcredit practitioners and borrowers, MFI hospital managers, MFI regulatory bodies, care providers, academics, and health officials at central and local levels. Respondents were recruited by using purposive sampling to ensure inclusion of critical cases from two types of care. Other data sources included researchers’ observation, field notes and publications provided by interviewees. Data were analyzed using framework analysis which established steps to deal with data according to key issues and themes. Key themes included service delivery, resources, provider behavior, manpower, utilization, affordability and implications. Finally, results from the interviews were combined with findings from the quantitative study before drawing conclusions. Results: Use of MFI hospitals was significantly associated with microcredit membership over 5 years (OR=2.9, p<.01), moderately poor household (OR=4.09, p<.001), non-poor household (OR=7.34, p<.01) and need for preventive care (OR=3.4, p<.01), compared with public hospitals. Microcredit members had a higher tendency towards utilization but membership effect pertained to the non- and moderately-poor. Compared with the patients who were non-members and the poorest, microcredit members who were non-poor had the highest likelihood (OR=7.46, p<.001) to visit MFI hospitals, followed by members with moderate income (OR=6.91, p<.001) and then non-members in non-poor households (OR=4.48, p<.01). Those who were members but the poorest had a negative association (OR=0.42), though not significant. Despite a higher utilization of preventive services in MFI hospitals, expenditure there was significantly higher. Qualitative probe found that, although public hospitals provided universal and low-cost care, the public sector suffered from insufficient workforce and infrastructure. In MFI hospitals charges were slightly cheaper than private clinics but much costlier than their public counterparts. To contain cost, MFI hospitals had highly flexible manpower arrangements. To generate income, MFI hospitals adopted proactive strategies to solicit desired patients. They not only selected patients through the pricing schedule but avoided complicated cases and left the poor patients to the public sector. Interviews also revealed that MFIs and government officers had divergent interpretations regarding complementarity and social responsibilities. While government officers expected collaboration at the field level and in prevention, MFIs opted for client segmentation. Finally, governing authorities were inconclusive about commercialization of MFI health programs. Conclusion: Inequity was more pronounced in MFI hospitals than public ones. By detaching themselves from the poor, the claims to serve the poor became rhetoric. The government, in addition to facilitating growth of MFIs, it seemed to take a laissez-faire policy with regards to MFIs’ hospital venture. Thus, using microcredit as a platform to deliver public goods or strengthen health system might not be a good idea without explicit policy guidance. The researcher suggested that health programs of MFIs be separated from the credit wing and reorganized toward primary health care to make care equitable and universally accessible. Hospital initiatives in the microfinance sector should be examined and regulated by both the health and microcredit regulatory authorities. This study holds practical implications for governments, development agencies and microfinance practitioners.
Subjects
microcredit
microfinance institution
Bangladesh
hospital care utilization
health inequality
poverty alleviation
Type
thesis
File(s)![Thumbnail Image]()
Loading...
Name
ntu-104-F95845108-1.pdf
Size
23.32 KB
Format
Adobe PDF
Checksum
(MD5):91e60fe9120ec78c0d6c13e22042a17b