Income generation activities for women
Reflection for thought Claudio Schuftan 22.03.98
impact study Ellen Vor der Bruegge 08.04.98
Re: impact study Deepti Chirmulay 23.04.98

From: Claudio Schuftan

Date: Sun, 22 Mar 1998 14:24:20 -0700

Subject: Ngonut: Reflection for thought






PHC praxis has gone through painful adaptations the world over since Alma Ata in 1978; most often not successfully.

As a rule, since 1978, other than the eight technical components of PHC having been applied, decentralizationand democratization of the planning and provision of health services, have been vastly forgotten or ignored.

When decentralization has been applied, it has seldom been interpreted as a 'devolution of power' -as intended by Alma Ata.

We have even embarked in reductionistic approaches to PHC -the most prominent of them probably having been UNICEF's 'GOBI FF'- that argued that being too ambitious in applying all technical elements of PHC was the real cause preventing us to reach ‘Health for All’. Ergo, concentrating efforts on a lesser number of elements was the way to go, the argument went on. Many health professionals, at the time, opposed the idea.

The evidence indicates it is rather the political elements of Alma Ata' PHC concept that have been conveniently overlooked iin the application of national PHC strategies. Technical issues of PHC interventions just do not play the leading role in PHC's ultimate success.

II hereby want to propose yet another adaptation to PHC. But this time one that blends the technical with the political in PHC by adding an 'unorthodox' component to PHC that more directly deals with the basic causes underlying the ill-health and malnutrition that characterize poverty worldwide: I am talking of making Income Generation Activities for Women the ninth (technical) essential element of PHC.

Disposable household income is known to correlate positively with healt and nutrition indicators. Women's IGAs affect that iincome. Income earned by women is, to a much higher degree than men's, ploughed back into family wellbeing expenditures; women's modest, frequent income simply affects income elasticities of demand for family consumables mor directly (including basic services).

Note that I am not talking here of using IGAs' revenue to finance community PHC activities, which is an option, but not my choice. I am talking about revenues going into women's household expenditures -those traditionally controlled by them. Part of the cash will definitely pay for goods and services that maintain and improve health and nutrition o family members.

A women's IGA element added to PHC has the double advantage of:

a) pegging this element to an often already existing activity and infrastructure, and

b) focusing PHC more on the basic socioeconomic determinants of ill-health and malnutrition (since simply more PHC organization and further technical interventions do not lead to perceived quantum leaps in improved health and nutrition indicators after perhaps an initial phase).

An added IGA element to PHC will certainly require new and different technical and organizational inputs. Training in credit and saving schemes and in basic management, marketing and accounting skills are just examples of some of these needed inputs.

There already exist specialized agencies with experience in launching IGAs. It is them who are to be brought in; trying to duplicate efforts is, I think, unwarranted. Let other experts increasingly work with us in health and get the job progressively done using valuable existing (o new) PHC infrastructures in the community.

Choosing the right mixture of IGAs in a given community -to avoid saturating the market with the same product(s) and to avoid the law of supply and demand working against the initiative- is important from the outset. Examples of IGAs that couldbe tried are, among many other: trading in the local staple food (replacing outside intermediaries), zero grazing schemes, agricultural production in communal land, crafts, pottery, sewing, knitting, weaving selling of water, apiculture and honey refining, poultry or other small animal raising, and community shops.

Some will argue that IGAs may be imposing additional time requirements on already overburdened women. Existing experience seems not to bare ou this contention.

Five dollars a week income is more reliable than trickle down:

Women's IGAs can, in the poorest households, result in sometimes quite significant increases in disposable household income (even if the total income from the IGA is low).

A five dollars equivalent income a week can go a long way!

"The 5$/Week Element of Primary Health" can even become a good IGA launching campaign slogan.

National economic growth --when and if it trickles down-- is expected t help reverting ill-health and malnurition in the Third World. IGAs for women have the attractive that they can potentially short-cut this 'Waiting-for-Godot or Hoping-for-Structural-Adjustment-Ever-to-Work Syndrome' by generating some additional modest household income as a true bottom-up solution.

IGAs for women do not correct the roots of the immiserizing process of an unfair political and economic system.

But IGAs for women can:

a) be 'sold' as a technical PHC element attempting to address the key determinant(s) of ill-health and malnutrition,

and b) ultimately organize and empower women in a way that prepares them fo taking more active roles in participating in health and other important decisions and actions in their communities.

In summary, what does the proposition made here mean?

It means accepting a significant paradigmatic break in PHC.

Are PHC agencies around the world ready for such a break, i.e. incorporating a non-health technical component to PHC?

I think Income Generation Ativities for Women, as the Ninth Essential Element of PHC, is an idea whose time has come.


Hanoi, March, 1998.

Claudio Schuftan MD

From: Ellen Vor der Bruegge

Date: Wed, 08 Apr 1998 09:03:28 -0700

Subject: Ngonut: impact study



Dear Ngonuts,


I could not agree more with Claudio Schuftan's statement that income-generating activities for women as the 9th Essential Element of Primary Health Care is an idea whose time has come! And the work of Freedom from Hunger over the past eight years is evidence of what can be expected.

Freedom from Hunger, an international nonprofit working with partner organizations in Africa, Asia and Latin America, offers a program called Credit with Education which links health, nutrition and enterprise education to credit and savings services in an integrated village banking strategy aimed at poor women in developing countries. The result is not only increased income for women and their families, but also better health, nutrition and business knowledge and practice leading to improved household food security and child health.

To date there has been little evidence of the impact of microcredit on maternal and child nutrition and health. A three-year longitudinal impact study of Credit with Education in Ghana, conducted by Freedom from Hunger in collaboration with the University of California, Davis (Program in International Nutrition), has provided such evidence. Village banking services for women have positive impact for children, when combined with nonformal health/nutrition education in breastfeeding, child nutrition, diarrhea treatment and prevention, immunization, family planning and better business practices.

The nutritional status (height-for-age and weight-for-age scores) of one-year-old children of participating mothers showed significant and positive differences from baseline measures as compared to one-year-olds living in control communities. There were significant and positive differences in key child health and nutrition practices, economic capacity and self-confidence of women participants. For example, participants were exclusively breastfeeding longer and were more likely to know how to prevent and treat diarrhea. Participants' children were also found to have diets of higher nutritional quality and were more likely to meet caloric intake requirements. These impacts were achieved by a program that was covering 80% of the operating costs of both the credit and education services from the interest women paid on their loans.

With this study, Freedom from Hunger hopes to bring to the attention of primary health care, child survival and microcredit agencies the tremendous potential that programs which link health/nutrition education with credit and savings services can have on the health and welfare of families. Our aim is to disseminate this proven strategy to more and more local organizations.

For anyone who is interested, Freedom from Hunger has made available the Credit with Education Impact Study as a 2-page abstract, a 12-page summary or the full 72-page report (prepay $12 to cover production and postage).

Requests should be directed to


Ellen Vor der Bruegge, Senior Vice President

Freedom from Hunger, 1644 DaVinci Ct., Davis, CA 95617

(530) 758-6200

Date: Thu, 23 Apr 1998 09:52:27 +0100

From: Deepti Chirmulay, BAIF <>

Subject: Re: Ngonut: impact study


Dear Dr. Bruegge,

The study you have mentioned is extremely interesting. Indeed we in BAIF Development Research Foundation are working on these lines, implementing integrated development programmes in rural and tribal areas in five states in India. Our experience and a study we conducted on interrelationship between socio-economic status and health status of rural households with support from IHPP, Washington DC has demonstrated this link very clearly. We have now planned a multicentric project covering 20 clusters of 20 villages each in five states in India with a strategy very simillar to the one mentioned by you. We plan to integrate primary health including women's reproductive health, economic empowerment, legal awareness and saving-credit activities to be implemented by village level functionaries, who would be supported by the people's organizations.

I would be grateful if you could share the study reports with me.

Thanking you,


Dr. Deepti Chirmulay