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This report brings together the results of an eight-part series of presentations by leading experts in issues directly related to microfinance institutional sustainability. It is intended for microfinance institution (MFI) board members, managers, and staff members as well as for government regulators, supervisors, and donor staff members. The first four chapters include topics in risk management: (1) risk management systems, (2) good governance, (3) interest rates, and (4) micro-insurance. The last four chapters include four topics in new product development and efficient delivery methodologies: (5) housing microfinance, (6) micro-leasing, (7) disaster preparedness products and systems, and (8) new technologies. The objectives of the series were as follows: i) to strengthen MFIs by disseminating innovative approaches in risk management, cost control, governance, and new technologies; ii) to promote a South-South exchange of experiences and lessons learned; iii) to promote greater ties among the MFIs in the region and between MFIs and government supervisors and regulators; and iv) to highlight the Bank's ability to mobilize international technical expertise in microfinance.

Although access to financing in Pakistan is expanding quickly, it is two to four times lower than regional benchmarks. Half of Pakistani adults, mostly women, do not engage with the financial system at all, and only 14 percent have access to formal services. Credit for small- and medium-size enterprises is rationed by the financial system. The formal microfinance sector reaches less than 2 percent of the poor, as opposed to more than 25 percent in neighboring countries. Yet it is the micro- and small businesses, along with remittances, that help families escape the poverty trap and participate in the economy. 'Bringing Finance to Pakistan's Poor' is based on a pioneering and comprehensive survey and dataset that measures the access to financial products by Pakistani households. The survey included 10,305 households in all areas of the country, excluding the tribal regions. The accompanying CD contains summary statistics. The authors develop a picture of access to and usage of financial services across the country and across different population groups, and they identify policy and regulatory priorities. Reform measures in Pakistan have been timely, but alone are not enough; financial institutions have lagged behind in adopting technology, segmenting customer bases, diversifying products, and simplifying processes and procedures. Gender bias and low levels of financial literacy remain barriers, as is geographical remoteness. However, the single strongest cause of low financial access is lack of income—not location, education, or even gender. 'Bringing Finance to Pakistan's Poor' will be of great interest to readers working in the areas of business and finance, economic policy, gender and rural development, and microfinance.

This edited volume contains eight studies of financial sector challenges in Africa that served as background studies for Financing Africa: Through the Crisis and Beyond. One of the major challenges for African financial systems is to expand financial services to a larger share of the population. The chapters in this area cover microfinance in Africa, the role of technology, reforms of payment infrastructure, and financing agriculture. Two chapters cover challenges in increasing long-term finance; one covers housing finance and the other the role of sovereign wealth fund. The book also contains a detailed discussion of bank regulation and supervision, especially in light of the current regulatory reforms in Europe and North America. The final chapter provides a political economy perspective, discussing the conditions for activist government policies in the financial sector.

In the spring of 2012, the Royal Monetary Authority of Bhutan and the World Bank commissioned a diagnostic assessment of financial practices and strategies among urban and rural Bhutanese. The resulting survey, the Bhutan financial inclusion focus group survey, represents one of the first efforts to capture household financial management practices in the country. The assessment, undertaken at the request of a government working group led by the Royal Monetary Authority, was designed to inform Bhutan's Financial Inclusion Policy by providing information about households' use of and demand for financial services. Since the research mainly captures the perspectives of Bhutanese households, this report does not present recommendations. Instead, its findings from the field research provide qualitative evidence that has informed the financial inclusion policy by highlighting opportunities and challenges in increasing financial inclusion.

This chapter outlines the case of a rural lesbian, gay, bisexual, and transgender (LGBT) client, Joe, addresses common internal and external issues encountered by these individuals, and presents a counseling approach and recommendations for better serving this population. A detailed assessment was conducted that included the frequency, duration, and antecedents of Joe's anxiety. Initial stated goals for counseling included controlling anxiety, becoming less nervous in social situations, and feeling better about himself. Indeed, Joe experienced significant negative attitudes and victimization at an early age, and in his rural area there was no known LGBT community or related resources to provide support. Negotiated goals included feeling increased comfort with his relationships and eventually coming out to loved ones. The chapter presents a combination of three approaches known to be helpful with this population: person‐centered counseling, feminist theory, and cognitive behavior therapy.

Medical mistrust has had devastating consequences during the COVID-19 pandemic, particularly in rural communities. Community Health Workers (CHWs) have been shown to build trust, but there is little research on trust-building by CHWs in rural communities. This study aims to understand the strategies that CHWs use to build trust with participants of health screenings in frontier Idaho. This is a qualitative study based on in-person, semi-structured interviews. We interviewed CHWs (N=6) and coordinators of food distribution sites (FDSs; e.g., food banks and pantries) where CHWs hosted a health screening (N=15). Interviews were conducted with CHWs and FDS coordinators during FDS-based health screenings. Interview guides were initially designed to assess facilitators and barriers to health screenings. Trust and mistrust emerged as dominant themes that determined nearly every aspect of the FDS-CHW collaboration, and thus became the focus of interviews. CHWs encountered high levels of interpersonal trust, but low institutional and generalized trust, among the coordinators and clients of rural FDSs. When working to reach FDS clients, CHWs anticipated confronting mistrust due to their association with the healthcare system and government, especially if CHWs were perceived as \"outsiders.\" Hosting health screenings at FDSs, which were trusted community organizations, was important for CHWs to begin building trust with FDS clients. CHWs also volunteered at FDS locations to build interpersonal trust before hosting health screenings. Interviewees agreed that trust building was a time- and resource-intensive process. CHWs build interpersonal trust with high-risk rural residents, and should be integral parts of trust building initiatives in rural areas. FDSs are vital partners in reaching low-trust populations, and may provide an especially promising environment to reach some rural community members. It is unclear whether trust in individual CHWs also extends to the broader healthcare system.

BACKGROUNDAccess to human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) is often poor in small urban and rural areas because of stigma and long distances to providers. The Iowa Department of Public Health and The University of Iowa created a regional telehealth program to address these barriers (“Iowa TelePrEP”). We describe initial TelePrEP results and share lessons learned. METHODSIowa Department of Public Health personnel in sexually transmitted infection (STI) clinics, disease intervention specialist and partner services, and HIV testing programs referred clients to pharmacists at University of Iowa. Clients could also self-refer via a website. Pharmacists completed video visits with clients in the community on smartphones and other devices, arranged local laboratory studies, and mailed medications. We performed a retrospective record review to quantify rates of PrEP referral, initiation, retention, guideline-concordant laboratory monitoring, and STI identification and treatment. RESULTSBetween February 2017 and October 2018, TelePrEP received 186 referrals (37% from public health) and completed 127 (68%) initial video visits with clients. Median client age was 32; 91% were men who have sex with men. Most clients with video visits (91%) started PrEP. Retention in TelePrEP at 6 months was 61%, and 96% of indicated laboratory monitoring tests were completed. Screening identified 37 STIs (8 syphilis, 10 gonorrhea, 19 chlamydia). Disease intervention specialist and partner services linked all clients with STIs to local treatment within 14 days (80% in 3 days). CONCLUSIONSUsing widely available technology and infrastructure, public health departments and health care systems can collaborate to develop regional telehealth programs to deliver PrEP in small urban and rural settings.

In Malawi, community health workers known as Health Surveillance Assistants (HSAs) can facilitate access to contraception through rural outreach. Self-injectable contraception also shows promise to facilitate contraceptive access, as women can store doses and re-inject on their own. We previously developed the Ndingathe (\"I Can\") intervention via human-centered design to strengthen contraception outreach by addressing HSAs' workflow challenges and enhancing self-injection (SI) counseling and support for interested clients. We piloted Ndingathe in two rural districts from June to December 2023. To assess the feasibility, acceptability, and potential effectiveness of Ndingathe, we conducted: pre- and post-surveys with 60 HSAs; 450 surveys with clients at HSAs' community outreach clinics; interviews with 40 clients, 20 HSAs, four health system stakeholders, and 20 experienced SI users who supported clients; and 20 observations of outreach clinics. We analyzed quantitative data using descriptive and inferential statistics. We conducted a thematic analysis of qualitative data. Intervention components aimed at improving HSAs' workflow, including bicycles, lunch allowances, and workflow planning templates, were well-received by HSAs and health system stakeholders, and appeared to improve outreach clinic frequency and duration: the percentage of HSAs reporting conducting at least one outreach clinic per week rose from 65% to 95% after the pilot and observations suggested outreach clinic hours extended into the afternoon, instead of ending before lunch, which clients appreciated. HSAs' average scores on the Role Conflict and Ambiguity in Complex Organizations and Role Overload Scales decreased after six months (2.9 to 2.3, p < 0.0001 and 3.7 to 3.0, p < 0.001, respectively). Both HSAs and clients positively received Ndingathe's SI mnemonic, designed to aid memory of SI steps, and support from experienced SI users during counseling. Clients' median self-reported fear of needles decreased from 3 (of 4) to 1 after interacting with an experienced user (p < 0.001). Clients felt reassurance when experienced SI users visited their homes for follow-up visits, conducted without HSAs, to offer support for SI. Challenges during the pilot included delays in lunch allowance disbursement, which impacted HSAs' morale and ability to expand outreach clinic hours. The Ndingathe intervention was feasible and acceptable from the viewpoint of multiple stakeholders in rural Malawi. Pilot findings suggest the intervention has the potential to improve contraception accessibility and reduce fear of self-injectable contraception.

Background Rural communities experience unique barriers to food access when compared to urban areas and food security is a public health issue in rural, high poverty communities. A multi-leveled socio-ecological intervention to develop food policy councils (FPCs), and improve food security in rural communities was created. Methods to carry out such an intervention were developed and are described. Methods A longitudinal, matched treatment and comparison study was conducted in 24 rural, high poverty counties in South Dakota, Indiana, Missouri, Michigan, Nebraska and Ohio. Counties were assigned to a treatment ( n  = 12) or comparison (n = 12) group. Intervention activities focus on three key components that impact food security: 1) community coaching by Extension Educators/field staff, 2) FPC development, and 3) development of a MyChoice food pantry. Community coaching was only provided to intervention counties. Evaluation components focus on three levels of the intervention: 1) Community (FPCs), 2) Food Pantry Organization, and 3) Pantry Client & Families. Participants in this study were community stakeholders, food pantry directors, staff/volunteers and food pantry clients. Pantry food access/availability including pantry food quality and quantity, household food security and pantry client dietary intake are dependent variables. Discussion The results of this study will provide a framework for utilizing a multi-leveled socio-ecological intervention with the purpose of improving food security in rural, high poverty communities. Additionally, the results of this study will yield evidence-based best practices and tools for both FPC development and the transition to a guided-client choice model of distribution in food pantries. Trial registration ClinicalTrials.gov; NCT03566095 . Retrospectively registered on June, 21, 2018.

Overdoses are increasing in the province of Ontario, Canada, where northern communities such as Sudbury have witnessed disproportionately elevated rates, with opioid-related deaths double that of the provincial average. To address this issue, governments have implemented supervised consumption services (SCS) where people who use drugs (PWUD) can use their pre-obtained substances onsite under trained supervision. In September 2022, the city of Sudbury opened its first SCS, ‘The Spot’, but the site’s sustainability is contingent on demonstrating benefit to PWUD and the neighboring community. We undertook a qualitative study exploring experiences among clients who used the consumption service inside The Spot. In December 2022, clients of The Spot were invited to participate in a brief survey which collected socio-demographic information and substance use profiles, followed by an in-person semi-structured qualitative interview. Participant survey and interview data were combined with administrative site utilization data provided by site staff of all clients who accessed the consumption service from September 2022 to August 2023 to examine overall service utilization and uptake. Qualitative data were analyzed using iterative thematic analysis techniques, and results were informed by common responses to research questions. The responses were narratively presented. Administrative site utilization data highlighted a relatively stable increase in uptake and utilization of the site since its inception. A total of 20 clients participated in the survey and semi-structured interviews. Participants described the importance of the site in preventing and responding to overdoses, providing a safe and comfortable environment to consume their drugs, and decreasing public drug use, which they suggested may potentially reduce stigmatization in the community. However, clients also suggested challenges, including issues regarding site operational policies that hindered consumption room utilization. Service suggestions made by clients to improve site utilization include the addition of inhalation services, relocating the site to a location in downtown Sudbury where PWUD commonly congregate, and extending operational hours. Positive impacts and recommendations can be drawn on and considered by other northern or rural communities interested in implementing similar harm reduction services.