The effect of self help groups on access to maternal ... · The effect of self help groups on access to maternal health services: evidence from rural ... variable was presence of

Electronic copy available at: http://ssrn.com/abstract=2157310Electronic copy available at: http://ssrn.com/abstract=2157310

1

The effect of self help groups on access to maternal health services:

evidence from rural India

Somen Saha1*, Peter Annear

1, Swati Pathak

2

Abstract

Background: The main challenge for achieving universal health coverage in India is ensuring

effective coverage for poor and vulnerable communities, with high levels of income and

gender inequity in access to health care. Self help groups (SHGs), a small economically

homogeneous affinity group of the rural poor voluntarily coming together to save small

amount and provide collateral free loans, is considered the cornerstone of much of the

microfinance activity. SHGs are perceived to influence health outcome, particularly maternal

and child health knowledge and service utilization. Evidence about the impact of SHGs on

health has, however, have been derived from pilot level interventions and is thus limited in

scope. Widening this scope by using data from the national District Level Household Survey

(DLHS-3), this paper analyzes the influence of the presence of SHGs on maternal health

service uptake in rural India.

Methods: DLHS-3 collected information on 643,944 ever married women from 22,825

villages in India. The primary predictor variable was presence of SHG in village. The

outcome variables were: institutional delivery; feeding newborns colostrums; knowledge

about female sterilization, IUD, oral pills, emergency contraception, and female condom; and

ever used oral pills, IUD, and female sterilization. Stepwise logistic regression was applied

to estimate the influence controlling for respondent education, occupation, heard or seen

health messages, availability of educational facilities, and the existence of a village health

and sanitation committee.

Results: Respondents from villages with SHG were more likely to have delivered in an

institution, feed newborn colostrums, know and utilize family planning products and services.

These results are positive and significant after controlling for individual and village level

1 Nossal Institute for Global Health University of Melbourne, Level 4, Alan Gilbert Building, 161 Barry St, Carlton,

Victoria, 3010, Australia. 2 Indian Institute of Management, Ahmedabad, Gujarat 380015, India

* Corresponding author: Nossal Institute for Global Health University of Melbourne, Level 4, Alan Gilbert Building, 161

Barry St, Carlton, Victoria, 3010, Australia. Tel: +61 0415 914 459. Email: [email protected].

Electronic copy available at: http://ssrn.com/abstract=2157310Electronic copy available at: http://ssrn.com/abstract=2157310

2

heterogeneities, and are consistent with existing literature that the social capital generated

through women’s participation in SHG, influence health outcome.

Conclusion: The study concludes that the presence of SHGs in a village is associated with

higher knowledge of family planning and maternal health service uptake in rural India. Also

our results indicates the need for complementary health programmes to build up on the

solidarity and social capital generated as a result of the association, to have maximum impact

on community health. To achieve the goal of improving public health, there is a need to

better understand the benefit of systematic collaboration between public health community

and these grassroots organizations.

3

Introduction

As India quest to achieve universal health coverage, the main challenge would be to expand

coverage to its citizens with protection from the costs of at least some basic health services.

The poor generally have worse health outcomes and access to care compared to the non-poor.

Evidences from low and middle income countries shows access barriers to health services are

likely to be more difficult to overcome for the poor and other vulnerable groups, as the costs

of access, lack of information and cultural barriers impede them from benefiting from public

spending (Ensor & Cooper, 2004; McNamee, Ternent, & Hussein, 2009). Poor health

contributes to the persistence of India’s high poverty rates, with health expenditures driving

39 million families into poverty each year (Selvaraj & Karan, 2009). Even when treatment is

sought, significantly smaller sums of money are spent on treatment of women than on men

(Iyer, Sen, & George, 2007). DLHS -3 (2007-08) data reveal that in rural India only 37.9%

women delivered their last child in an institution, and unmet need for limiting and spacing

were 22.8% and 14.1% respectively. While the problems of poor health are multi-

dimensional, approaches to find their solutions are largely unisectoral. Ensor and Cooper

(Ensor & Cooper, 2004) note that interventions to address barriers to health services should

follow pragmatic policy routes that go beyond the traditional boundaries of the public health

sector. Outside the health sector SHGs have emerged as a development strategy having a

primary focus on poverty alleviation and empowerment of women. In India there has been a

particular focus to improve financial accessibility to ensure sustainability of social services,

thus, in effect, transforming and expanding self-help groups into economically oriented co-

operatives (Nayar KR, 2004). SHGs can, in many ways, be considered the cornerstone of

much of the microfinance activity in India. These small groups (10-20 members each) of

predominantly rural women coming together to form savings and credit organizations, are

well established in the country. Ninety-three million clients (impacting over 300 million

people including households) are engaged by Microfinance Institutions (MFIs) and SHG -

Bank Linkage programmes (Srinivasan, 2012) (Figure 1).

4

Figure 1: Microfinance Client Outreach in India (2010–2011)

Source: Microfinance India State of the Sector Report 2011, Access India

SHG has essentially emerged as a developmental paradigm for women with the need for

access to capital, specifically articulated by women during the United Nation’s Conference

on Women and Development in Mexico City in 1975. Katz (Katz, 1981) defined self-help

groups as “Voluntary, small group structures for mutual aid and the accomplishment of a

special purpose”. They are usually formed by peers who have come together for mutual

assistance in satisfying a common need, overcoming a common handicap or life-disrupting

problem, and bringing about desired social and/or personal change. The initiators and

members of such groups perceive that their needs are not, or cannot be, met by or through

existing social institutions. Self-help groups emphasize face-to-face social interactions and

the assumption of personal responsibility by members. They often provide material

assistance, as well as emotional support; they are frequently ‘cause’-oriented, and promulgate

an ideology or values through which members may attain an enhanced sense of personal

identity." Structurally, a SHG is a small economically homogeneous affinity group of the

rural poor voluntarily coming together to save an amount regularly, which is deposited in a

common fund to meet members’ emergency needs and to provide collateral free loans

decided by the group (Jha, 2000). Organizations based on the Gandhian philosophy of self-

reliance had already been popularized during the freedom movement in British India (Nayar

KR, 2004). In response to SHG growth and influence, policymakers took notice and

established a countrywide Self-Help Group Bank Linkage Programme (SBLP) in the early

1990s. SBLP, promoted aggressively by NABARD, links mature SHGs with the formal

62.5

31.4

0

10

20

30

40

50

60

70C

ust

om

ers

in M

illi

on

s

Type of Instituion

SHG

MFI

5

banking system (commercial banks, Regional Rural Banks and cooperative banks). SHGs are

linked to Regional Rural Banks (RRB), commercial banks and cooperative banks to access

microcredit as a source of additional capital for the group members to supplement their

savings. The Government of India through Swarnajayanti Gram Swarojgar Yojana (SGSY)

intended to provide self-employment to millions of villagers. Poor families living below the

poverty line were organized into SHGs established with a mixture of government subsidy and

credit from investment banks. The main aim of these SHGs was to bring the poor families

above the poverty line and concentrate on income generation. The SHGs are aided,

supported and trained by non-governmental organizations (NGOs), community based

organizations (CBOs), individuals, banks and self-help promoting institutions.

Self help groups are perceived to influence health outcomes, particularly maternal and child

health knowledge and service utilization, a priority area for Millennium Development Goals

(MDGs) 4 and 5. SHGs are regarded as the most exciting and least recognized resource for

improving public health (Humphreys & Ribisl, 1999). The social capital generated through

women’s participation in community organization influence health outcomes, as argued, by

Nobles and Fankenberg (Nobles & Frankenberg, 2009) and DeLoach and Lamanna (DeLoach

& Lamanna, 2011). Social capital is defined by Putnam (Putnam, 1993) as features of social

organization, such as trust, norms and networks, that can improve the efficiency of society by

facilitating coordinated actions. Woolcock (Woolcock, 1998) further split social capital into

three connecting strands: bonding social capital i.e. ties between immediate family members,

neighbours and close friends; bridging social capital i.e. ties between people from different

ethnic, geographical, and occupational backgrounds; and linking social capital i.e. ties

between poor people and those in positions of influence in formal organizations such as

banks, schools etc. It is believed that self help groups are mobilized by existing bonding

social capital, and then build linking social capital as the group members get involved in

activities (Kanak & Iiguni, 2007). NGOs like SEWA, BRAC, and Grameen Bank have

extensively engaged in promoting health related activities through SHG participation.

Studies have shown the positive effect of SHGs on exclusion (Mohindra, Haddad, &

Narayana, 2008), improved childcare and contraceptive use (Hadi, 2001, 2002), and neo-natal

mortality (Tripathy et al., 2010). However, Nayar (Nayar KR, 2004) noted that the few

success stories noted are in the context of large organizations that incorporate self help

activities as just one component. Therefore, it is hard to tease out the contribution of self

help independent of other concurrent activities or the organizational infrastructure. Much of

6

the existing evidence that contributes to the cause and effect relationships has also been

criticized as consisting of choice based sampling and self-selection bias (Pitt, Khandker,

McKernan, & Latif, 1999).

As a result, despite decades of existence, and national programmes to promote SHG

strategies, evidence of the link between SHGs and improved health outcomes is limited to

that derived from small pilot level interventions in India. There has been an absence of

sufficiently substantial data to carry out an analysis to find this evidence. According to Nayar

(Nayar KR, 2004) there is as yet no convincing evidence that in societies with unmet demand

for regulated health care, SHGs can become a "third option" to replace ailing government

health services. While there exist large panel datasets to examine the association between the

poverty alleviation effort and health outcome in Bangladesh (Islam & Maitra, 2011), there

was no conscious effort in India to collect such information. DLHS-3 had a question on the

presence of a SHG in its village level questionnaire. This gave us an opportunity to analyze

and report in this paper on the influence of SHGs on the reproductive and child health (RCH)

knowledge and practices of the women in those villages. Even our analysis can provide only

a partial picture, as it does not have information on the women’s participation in SHG

activities. However, with information on 643,944 ever married women from 22,825 villages

in India, this presents our best available option to analyze the influence of the presence of

SHGs on women’s RCH knowledge and practices.

Data and descriptive statistics

We used data from the third round of the District Level Household Survey (DLHS-3)

conducted in 2007-08 in 601 districts from 34 states and union territories of India.

Information was collected from 22,825 villages in India (through the village questionnaire)

and from 643,944 ever married women (15 – 49 years) through the ever married women’s

questionnaire. DLHS-3 adopted a multi-stage stratified systematic sampling design which

resulted in national and state-representative samples after applying sampling weights to

control for complex survey design (IIPS, 2010). The DLHS-3 is designed to provide

information on family planning, maternal and child health, reproductive health of ever

married women and adolescent girls, and utilization of maternal and child healthcare services

at the district level in India. In addition, DLHS-3 also provides information on new-born

care, post-natal care within 48 hours, role of the Associated Social Health Activist (ASHA) in

7

enhancing reproductive and child health care, and the coverage of Janani Suraksha Yojana

(JSY), a conditional cash transfer programme to increase births in health facilities. At village

level DLHS-3 asked questions about presence of SHGs in the village. Unit level data from

the village file and ever married women file were merged to conduct the analysis.

As per DLHS-3 data, 57.9 percent of Indian villages have a self help group (Figure 2). The

majority of these groups are present in southern and north-eastern India, followed by

Maharashtra, Chhattisgarh, Rajasthan and Madhya Pradesh.

8

Figure 2: Self help group in India

Our main hypothesis is that the presence of a SHG in a village is associated with higher

demand for family planning and maternal health service uptake. In this paper we have used

four measures of women and child health knowledge and practices: institutional delivery;

feeding newborn colostrums; knowledge about family planning services; and ever used

family planning. We measured knowledge and use of family planning by women who were

aware of and practiced at least one of the following methods: female sterilization, IUD, oral

contraceptive pills, emergency contraception and female condom. Indicators were

9

transformed into binary measures by re-coding all Yes as 1 and No as 0. For place of

delivery: deliveries at hospital, dispensary, urban health centre (UHC)/urban primary health

centre (UPHC), community health centre (CHC)/Rural hospital, primary health centre (PHC),

Sub center, Ayush hospital/clinic, NGO/Trust clinic, Private hospital/clinic, and on way to

hospitals were re-coded as 1, and delivery at home and work place were re-coded as 0. Data

analysis was done using SPSS Version 19.

The descriptive statistics (Figure 3) show some interesting findings on the four measures of

women and child health knowledge and practices. The overall use of family planning was

found to be very low. The presence of a SHG has a positive and strong correlation with all

four measures of knowledge and practices. Households in villages with a SHG are more

likely to go for institutional delivery, more likely to feed newborns colostrums, more likely to

have knowledge of and use family planning products and services, compared to households in

villages without a SHG. Members engaged in self help activity feel the sense of connectivity

and discuss issues ranging from place of delivery to feeding the baby, and family planning

products and services.

Figure 3: Study variables in villages with and without SHG

61%

84%

99%

65%

34%

73%

90%

55%

Institutional

Delivery

Feeding Colostrums Knowledge of Family

Planning

Ever used Family

Planning

Characteristics of study variables in

villages with and without SHG

Yes No

10

Variables

Outcome variables

We used four measures to estimate maternal health service uptake in this analysis:

institutional delivery, colostrums feeding to the newborn, knowledge of family planning, and

ever used family planning. The last two variables refer to at least one of the modern family

planning methods estimated by the DLHS-3 survey. In this study, institutional delivery was

defined as deliveries at sub-centre, primary health centre, dispensary, urban health centre,

community health centre, rural hospital, hospital, Ayush hospital/clinic, NGO/Trust clinic,

private hospital/clinic, or on way to hospital.

Explanatory and control variables

Pitt (Pitt et al., 1999) identified three sources of bias in estimating cause-effect relation:

choice-based sampling, individual heterogeneity bias, and village heterogeneity bias. To

address unmeasured individual and village attributes that affect both programme participation

and health outcome, we instituted some controls. For individual heterogeneity we controlled:

respondent education (illiterate, primary, middle and higher secondary and above), work

status, heard or seen health messages; and for village level heterogeneity we controlled:

village connected through all weather road, accessibility of community health centre/rural

hospital (CHC/RH), beneficiaries of JSY in last one year, and health and sanitation

committee in village. Choice-based sampling is addressed by the sample size, and the

national nature of the survey that can tease out the contribution of self help groups

independent of other concurrent activities or the organizational infrastructure. Table 1 shows

the number and percentage distribution of responses by selected characteristics.

Table 1: Predictor and control variables used in the analysis

Variable Percentage Number

Predictor variable

Village have SHG 57.9 13,211

Individual control variables

Respondent work for cash or kind 37.0 237,968

Heard or seen health messages 85.9 553,225

11

Mother’s level of education

Illiterate

Primary (1-7)

Middle (8-10)

Higher secondary and above (11+)

46.7

23.5

20.0

9.9

300,526

151,048

128,739

63,631

Village control variables

Village connected through all weather road

Health and sanitation committee in village

Accessible CHC/RH

Beneficiary of JSY

85.4

28.7

77.4

90.1

19,486

6,554

16,609

16,853

Numbers are unweighted

Statistical models

To account for the clustering effect of DLHS-3 survey design, we applied primary sampling

unit (PSU) weight to the dataset using the ‘weight cases’ command in SPSS. This controls

for the unobserved factors at village-level that influence the outcomes. We computed

forward stepwise logistic regressions adding different level of control variables to a base

model that regressed our four outcome variables (institutional delivery, feeding colostrums,

knowledge of family planning, and ever used family planning) on the availability of SHG in

the village. For each of the four outcome variables, three models were estimated. In Model

1, the effect of presence or absence of a SHG in village was modelled. This model

represented the total variance in the four outcome variables with the presence or absence of

SHG. In Model 2 only individual level control factors (respondent education, work status,

and heard or seen health messages) were included. In Model 3 individual and village

background controls: village electrification, education facility available in the village, village

connected through all weather road, distance from nearest hospital, beneficiaries of JSY in

last one year, and health and sanitation committee were included. This modelling method

treats individuals as the sampling unit, meaning that any similarity of individuals within a

village, and between-village variability is not accounted for. The focus of the analysis was the

change in coefficient of availability of SHG. The results are shown as odds ratios (ORs) with

95 per cent confidence intervals (CIs). The magnitude of the change was interpreted as

percent change equals to (exponentiated coefficient – 1.0) x 100. The small variance

12

inflation factor of 1.09 (not reported) indicated the absence of any significant collinearity

between explanatory variables in the regression model.

Estimation results

Predictor of institutional delivery (Table 2): SHGs presence in a village is associated with 33

percent higher odds of mother’s delivering in an institution (CI: 1.32 – 1.34), holding other

variables constant. The reduction in odds from 2.77 to 1.33 in presence of individual and

village level controls indicates the influence of other factors affecting the outcome. Model 2

adds individual control. The coefficients of individual control variables illustrate that

mother’s education, heard or seen health messages are important mediating pathways to

influence institutional delivery. Interestingly women’s work status does not have an

influence on delivery decision, suggesting a level of autonomy not directly proportional to

earning. At the village level, the presence of a health and sanitation committee in village

(OR: 2.66), and beneficiary of JSY (OR: 1.87) are important mediating pathways that

influence institutional delivery. Surprisingly, accessibility of CHC/RH while positive, have

weak association with institutional delivery.

Table 2: Stepwise logistic regression of institutional delivery

Institutional delivery Only predictor

variable

Individual

control

Full model

Presence of SHG 2.77 (2.76-2.79) 1.92 (1.90-1.93) 1.33 (1.32-1.34)

Mother’s education 2.50 (2.49-2.51) 2.28 (2.27-2.29)

Respondent work for cash or kind 0.71 (0.71-0.72) 0.69 (0.69-0.70)

Heard or seen health messages 2.21 (2.19-2.23) 1.94 (1.92-1.96)

Village connected through all weather road 1.22 (1.21-1.23)

Health and sanitation committee in village 2.66 (2.64-2.68)

Accessible CHC/RH 1.07 (1.06-1.08)

Beneficiary of JSY 1.87 (1.85-1.89)

Figures are odds ratio with 95% Confidence Interval

Predictor of feeding colostrums (Table 3): SHGs presence in village is associated with 15

percent higher odds of increase in colostrums feeding (95 percent CI 1.14 – 1.16). Mother’s

13

education, and heard or seen health message are important individual level mediating

pathways, while beneficiary of JSY (OR: 1.52), health and sanitation committee in village

(OR: 1.64), and village connected through all weather road (OR: 1.22) are important village

level mediating factors predicting colostrums feeding. Accessibility of CHC/RH does not

appear to influence the outcome.

Table 3: Stepwise logistic regression of colostrums feeding

Colostrums feeding Only predictor

variable

Individual

control

Full model

Presence of SHG 1.86 (1.85-1.88) 1.36 (1.35-1.39) 1.15 (1.14-1.16)

Mother’s education 1.76 (1.75-1.76) 1.64 (1.64-1.65)








Knowledge about Family Planning (Table 4): Households in villages with a SHG are at 44

percent higher odds of knowing at least one modern family planning method. Model 1 shows

an odds ratio of 2.33, thus indicating the strong influence of heard or seen health messages in

knowledge generation about family planning. More educated women are more likely to have

family planning knowledge. Accessibility of CHC/RH, and beneficiary of JSY are another

village level variables influencing the outcome.

Table 4: Stepwise logistic regression of knowledge of family planning

Knowledge of family planning Only predictor

variable

Individual

control

Full model

Presence of SHG 2.33 (2.29-2.38) 1.42 (1.39-1.45) 1.44 (1.42-1.47)

Women’s education 1.62 (1.60-1.64) 1.63 (1.61-1.66)



14



Accessible CHC/RH 1.26 (1.23 -1.28)



Ever used Family Planning (Table 5): Presence of a SHG is associated with 41 per cent

higher odds of ever using family planning. Interesting education of women while positively

influence knowledge of family planning in community, the association is negative with ever

use of family planning. Individual level factors: women’s employment, and heard or seen

health message; and village level factors: health and sanitation committee in village,

accessibility of CHC/RH, village connected through all weather road, and beneficiary of JSY

are important mediating pathways influencing use of family planning.

Table 5: Stepwise logistic regression of using family planning

Ever used family planning Only predictor

variable

Individual

control

Full model

Presence of SHG 1.51 (1.48-1.53) 1.63 (1.60-1.66) 1.41 (1.38-1.43)

Women’s education 0.86 (0.86-0.87) 0.84 (0.83-0.84)








Discussion

The association between presence of a SHG, controlling for individual and village level

factors, and maternal health service uptake measured through institutional delivery, feeding

colostrums to newborn, knowledge and ever used family planning, were examined in this

study. The study shows respondents from villages with a SHG were more likely to have

15

delivered in an institution, fed newborns colostrums, known about and utilized family

planning products and services. Community agents like networks of microfinance and self

help groups are new ways to involve communities in the oversight, planning or operations of

health services. They also give the communities avenues to voice their concerns. These

groups provide a unique space, in which solidarity is created through promoting shared

visions and goals and combining collective strengths. The trust and social capital empower

communities and positively influence individual and community health. However, on their

own, SHGs can have limited impact. This is explained by the relatively low odds ratio in

presence of individual and village level controls. Clearly, in order to have maximum impact

on community health, there is a need for additional complementary health programmes to

build on the solidarity and social capital generated as a result of the group. Our study shows

women’s work status, and the presence of a health and sanitation committee in a village have

minimal effect on maternal health service uptake. While the former points to lack of

autonomy in decision making, the later indicates the need to strengthen village health and

sanitation committee to take a more active role in the community.

The study had some limitations, which need to be considered when interpreting the results.

First, we did the analysis at the aggregate country level. This masks the variation in spread

and intensity of SHG activity in India as depicted in Figure 2. Second, presence of a SHG in

the village could only partially explain the level of activity. Women’s participation in SHG

(Schurmann & Johnston, 2009), availability of credit (Islam & Maitra, 2011), and duration of

association (Hamad & Fernald, 2010; Mohindra et al., 2008) are other key predictors that the

DLHS-3 survey, due its scope and intent, did not collect. Nonetheless this large national

level dataset deals with two important biases discussed in previous studies: choice based

sampling (Pitt et al., 1999), and teasing out the contribution of self help groups in the

organizational infrastructure (Nayar KR, 2004). Third, our modelling method treats

individuals as the sampling unit, and any similarities of individuals within a village, and

between-village variability is not accounted for. Hence, while we expect little difference in

odds ratio, standard errors for village level variables may be slightly higher than reported.

The fourth limitation relates to the nature of the DLHS-3 survey, such as self reported

information of respondents and the cross sectional nature of the survey, as described by Jat et

al (Jat, Ng, & San Sebastian, 2011). Therefore, we could only examine the association

between explanatory variables and four indicators of maternal health services uptake and

could not draw conclusions about causality.

16

Conclusion

The study concludes that the presence of SHGs in a village is associated with higher demand

for family planning and maternal health service uptake in rural India. Also our results

indicate the need for additional complementary health programmes to build on the solidarity

and social capital generated as a result of the group, in order to have maximum impact on

community health. Our analysis of the national level data shows there is a strong case for

policy makers to work closely with these groups and better leverage their power for health

improvement and poverty reduction. This has implications for low and middle income

countries where barriers to access to health services, and information and cultural barriers,

prevent the poor and vulnerable groups from benefiting from public spending. Self help

groups are an innovative way to combine poverty alleviation and community health

interventions into an integrated strategy that leverages existing resources to achieve greater

impact and scale. By linking financial services for the poor with proven community health

interventions, two fundamental needs can be met simultaneously. Some highly effective, low

cost interventions to promote health and sanitation awareness that can be carried out with the

help of these groups include: provision of health savings accounts and loans in case of major

illness, encouraging the adoption of better sanitation practices and clean water, provision of

low-cost generic drug points, and discounted preferred provider network at the village-level.

To achieve the goal of improving public health, there is a need to better understand the

benefits of systematic collaboration between the public health community and these

grassroots organizations.

Acknowledgement: The research is supported by a Research Higher Degree grant from Nossal

Institute for Global Health, University of Melbourne, Australia, and Welcome Trust Capacity

Strengthening Strategic Award to the Public Health Foundation of India and a consortium of UK

Universities. We acknowledge the statistical advice received from the Statistical Consulting Centre at

University of Melbourne. An earlier version of this paper was presented at the Global Maternal Health

Conference, Arusha, Tanzania.

17

References

DeLoach, S. B., & Lamanna, E. (2011). Measuring the impact of microfinance on child health

outcomes in Indonesia. World Development, 39(10), 1808-1819.

Ensor, T., & Cooper, S. (2004). Overcoming barriers to health service access: influencing the demand

side. Health Policy and Planning, 19(2), 69-79.

Hadi, A. (2001). Promoting health knowledge through micro-credit programmes: experience of BRAC

in Bangladesh. Health Promotion International, 16(3), 219-227.

Hadi, A. (2002). Integrating prevention of acute respiratory infections with micro-credit programme:

experience of BRAC, Bangladesh. Public health, 116(4), 238-244.

Hamad, R., & Fernald, L. C. H. (2010). Microcredit participation and nutrition outcomes among

women in Peru. Journal of Epidemiology and Community Health, 66(6).

Humphreys, K., & Ribisl, K. M. (1999). The case for a partnership with self-help groups. Public Health

Reports, 114(4), 322.

IIPS. (2010). District Level Household Survey (DLHS-3), 2007–08. India. Mumbai: International

Institute for Population Sciences

Islam, A., & Maitra, P. (2011). Health shocks and consumption smoothing in rural households: Does

microcredit have a role to play? Journal of Development Economics, 97(2), 232-243.

Iyer, A., Sen, G., & George, A. (2007). The dynamics of gender and class in access to health care:

Evidence from rural Karnataka, India. International Journal of Health Services, 37(3), 537-

554.

Jat, T. R., Ng, N., & San Sebastian, M. (2011). Factors affecting the use of maternal health services in

Madhya Pradesh state of India: a multilevel analysis. International Journal for Equity in

Health, 10(1), 59.

Jha, A. K. (2000). Lending to the Poor: Designs for Credit. Economic and Political Weekly, 606-609.

Kanak, S., & Iiguni, Y. (2007). Microfinance programs and social capital formation: The present

scenario in a rural village of Bangladesh. The International journal of applied economics and

finance, 1(2), 97-104.

Katz, A. H. (1981). Self-help and mutual aid: An emerging social movement? Annual review of

sociology, 7, 129-155.

McNamee, P., Ternent, L., & Hussein, J. (2009). Barriers in accessing maternal healthcare: evidence

from low-and middle-income countries. Expert Review of Pharmacoeconomics and

Outcomes Research, 9(1), 41-48.

Mohindra, K., Haddad, S., & Narayana, D. (2008). Can microcredit help improve the health of poor

women? Some findings from a cross-sectional study in Kerala, India. International Journal for

Equity in Health, 7, 2.

Nayar KR, K. C. a. R. O. (2004). Self-help: What future role in health care for low and middle-income

countries? International Journal for Equity in Health, 3(1).

Nobles, J., & Frankenberg, E. (2009). Mothers' community participation and child health. Journal of

health and social behavior, 50(1), 16-30.

Pitt, M., Khandker, S., McKernan, S., & Latif, M. (1999). Credit programs for the poor and

reproductive behavior in low-income countries: are the reported causal relationships the

result of heterogeneity bias? Demography, 36(1), 1-21.

Putnam, R. (1993). Making Democracy Work. Civic traditions in modern Italy. Princeton University

Schurmann, A. T., & Johnston, H. B. (2009). The group-lending model and social closure: microcredit,

exclusion, and health in Bangladesh. Journal of health, population, and nutrition, 27(4), 518.

Selvaraj, S., & Karan, A. K. (2009). Deepening health insecurity in India: evidence from national

sample surveys since 1980s. Econ Polit Wkly, 44, 55-60.

Srinivasan, N. (2012). Microfinance India: state of the sector report 2011: Sage Publications Pvt. Ltd.

Tripathy, P., Nair, N., Barnett, S., Mahapatra, R., Borghi, J., Rath, S., . . . Sinha, R. (2010). Effect of a

participatory intervention with women's groups on birth outcomes and maternal depression

18

in Jharkhand and Orissa, India: a cluster-randomised controlled trial. The Lancet, 375(9721),

1182-1192.

Woolcock, M. (1998). Social capital and economic development: Toward a theoretical synthesis and

policy framework. Theory and society, 27(2), 151-208.

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