Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
Microfinance loans for women in developing countries have not been conceived as a health policy, but could have important health implications. Generally speaking, microfinance has been conceived as an economic and “empowerment” intervention by putting capital resources in a woman’s control, she may be able to start a business, work, or purchase land. With these expanded private resources, she may be more able to participate in family decisions and influence public decisions.
•Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)
An evaluation of this policy is informative because it is unclear whether microfinance as a single intervention will have the intended downstream effects. The relationship between microfinance and the downstream effects could be mediated by a woman’s relationship status (single, married, divorced), the quality of her primary relationship (equitable, non-violent), the number of people who depend on her.
•Specify the outcomes and populations you think most affected or least affected by the policy.
The populations most affected by this policy are women in developing countries and their dependents.
The outcomes related to this policy are economic (changes in income, education, land ownership), family (changes in relationship dynamics, fertility plans), public participation (politics, governance), and health (family planning, childbirth outcomes, chronic conditions, health status of children).
•Propose a study design to evaluate the policy
Microfinance has been rolled out in uneven ways, so a policy evaluation could take advantage of these “natural experiments”. We could consider a pre/post design, differences-in-differences, or even a randomized experiment. In all these designs it is critical to (ethically) have a control group (historical, contemporary, or experimental) that can be compared to the intervention group.
•Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health
A big challenge to drawing inferences about the impact of microfinance on health is that there are a number of different pathways through which causal mechanisms could act. Regarding causal mechanisms, households may make very different decisions about how to spend money first (on children’s education or on health?). Families that prioritize health may be distributed differently in the population or geographically than those who do not. Without a randomized experiment, it would be difficult to account for these difficult to measure confounders. Another big challenge is deciding which health indicators are most likely related to the diverse causal mechanisms. Because microfinance targets women, it makes sense to track reproductive and child health outcomes. However, other areas of women’s health could be neglected by this focus, missing important chronic disease and mental illness—for example.