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					AT A GLANCE
Trade and Investment Facilitation

The World Bank has upgraded the income categorisation of Thailand and Laos. Thailand moved from a lower-middle
income economy to an upper-middle income economy, and it now has a gross national income per capita of US$4,210.
Laos just surpassed the lower mark of US$1,006 to become a lower-middle income economy.

Indonesia, with a population of 240 million, is on track to surpass Thailand as the region's biggest car market. An official
at the Indonesian Automotive Manufacturers Association, Jongkie Sugiarto, said it would take only two years for Indo-
nesia to overtake Thailand not only in terms of sales but also in production.

The demand for micro‐credit in the rural segment of the Myanmar economy is estimated at around US$470 million,
but estimates revealed only 10% of this demand is met. The UNDP Microfinance Project is presently providing about 80%
of micro-credit through PACT Myanmar, a non-profit organisation. The rural poor rely on relatives, money lenders as
well as pawn shops for small loans.

The postal department of Bangladesh has introduced an innovative mobile financial service, which allows users to
transfer money or pay for goods by simply swiping or tapping their mobile phones against a special reader, though both
parties have to register first at a postal outlet. The "mobile wallet", a banking service that enables people to transact
money or buy anything across Bangladesh with a mobile phone has been rolling out since September 2011.

The so-called "super-rice", a rice breed with the name DH2525, has set a new world record for rice yields in China. In
the first of two trial years required to be officially deemed a success, this breed yielded about 13.9 tons per hectare.
The strain was developed by China's "father of hybrid rice" Yuan Longping who hopes to reach 15 tons per hectare be-
fore he turns 90 (in about nine years).

Health Systems

Contrary to popular perception, rural areas may contribute at least as much to the spread of dengue fever as cities, ac-
cording to a new PLOS medicine study using data from Vietnam. Researchers analysed the interaction between human
population density and lack of tap water as a cause of dengue fever outbreaks to identify geographic areas most at risk.
Rural and semi-urban areas with population densities between 3,000–7,000 people per km2 without access to piped
water, were most at risk.

The United Nations high-level meeting on chronic, or non-communicable disease, was convened in New York. Chronic
diseases kill around 36 million people a year, mostly in low- and middle-income countries where they disproportio-
nately affect people under 60. Governments pledged to work with the United Nations to adopt targets to combat heart
disease, cancers, diabetes and lung disease and to devise voluntary policies to cut smoking and the high salt, sugar and
fat content in foods, by the end of 2012.

Thailand’s Ministry of Public Health is keeping a close eye on outbreaks of avian flu (H5N1) in humans and hand, foot
and mouth disease among children. Total patients with hand, foot and mouth disease between January and August
stood at 8,842 with four fatalities. Public Health minister Dr Paijit Warachit has set up a “war room” at the Department
of Disease Control to monitor the re-emerging epidemics within Thailand and outside the country so that preventive
actions can be taken in time.

A lack of official blood donations has led to a rise in freelance "blood sellers", in Cambodia. The sellers are mostly street
children, who sell their blood outside hospitals. According to reports, doctors are encouraging relatives of patients to
purchase the blood, where donors can make around US$5 to US$10 per donation. Prime Minister Hun Sen recently
appealed to students to donate blood, noting that just three in 1,000 people were donors.
Energy and Security

The province of East Kalimantan, Indonesia, is installing a set of two Independent Power Plants using aeroderivative
gas turbine technology developed by General Electric. These power plants will generate a total of 82MW of power,
which hopes to increase the number of Indonesian households connected to the grid. Over 30% of Indonesians,
mostly in eastern Indonesia, do not have access to grid electricity.

Vietnam recently approved its national power development plan for 2010–2020: the “Power Master Plan VII”. The
plan includes a specific target of 98.6% rural electrification by 2015 and 100% by 2020. The master plan also intro-
duces nuclear power into the national energy mix, with the first plant expected to be operational by 2020.

The Second Forum on Children in the Urban Environment was held in the Philippines. The forum, organised by the
Department of Interior and Local Governments, the Institute of Philippine Culture and UNICEF, discussed the plight
of millions of poor children who are at risk of disease and subnormal development due to lack of food, health ser-
vices, potable water, sanitation and decent housing in urban areas. Topics discussed included health, child protec-
tion, urban planning and even climate change, with an emphasis on the role of local governance.

The World Bank’s Water and Sanitation Programme recently launched a series of reports that highlight the costs and
benefits of investing in sanitation systems. The reports, a part of the Economics of Sanitation Initiative study, use
case studies from Indonesia, Cambodia, the Philippines and Vietnam to show that poor sanitation systems create
massive economic losses and investments in sanitation are needed to recover those losses. The reports recommend
that countries develop viable sanitation markets and disseminate information on household sanitation options to
promote behavioural changes.
Innovations against inequality
In the Asian Trends Monitoring (ATM) Bulletin 12: Rising Asia, Growing Inequalities, we highlighted some inequalities
that still persist throughout ASEAN, despite rapid economic growth. This issue now seeks to highlight several
interventions that have been developed by organisations to close these gaps. Moreover, the examples are meant to
bring life to the numbers and illustrate a range of successful approaches in tackling the inequities highlighted.

The interventions we have chosen vary greatly in size and scope. This allows us not only to provide a clearer picture
of the wide array of currently existing innovations and interventions, but also touch on the strengths and
weaknesses that differentiate the efforts of national governments from those of grassroots organisations.

Our first section discusses interventions in providing basic infrastructure. We showcase three examples of
small-scale, market-driven interventions in the provision of water, rural electrification and clean cooking methods, as
well as a broad overview of national-level approaches in rural electrification. We discuss why these small start-ups
have enjoyed much success in filling the gaps that governments cannot reach, in addition to why these projects may
or may not succeed when replicated on a larger scale. We also touch on the different ways in which governments
can better approach interventions that aim to provide basic necessities, such as electricity, water and sanitation, on
a nation-wide scale.

The Millennium Development Goals gave prominence to global inequalities in health indicators like maternal and
child deaths, galvanising countries to take action to reduce preventable mortality from causes such as birth
complications (mothers) and childhood diseases like diarrhoea. With some way to go to reach 2015 targets in both
maternal and child health, we draw attention to three innovations at both the macro- and micro-levels in selected
ASEAN countries that are helping mothers and children to live healthier and productive lives in our second section.
For chronic disease, we showcase examples of two city-level interventions that are helping to create enabling
environments for residents to live actively and healthily.

In the third section we present four innovative projects, all based on sustainable business models which improve the
livelihood of the poor. In two cases, these are innovative services provided via mobile phones: M-PESA, a mobile
banking service developed in Kenya, and Sana Mobile Health, an application that allows health workers to collect
data in a structured way and then receive a doctor’s diagnosis from hundreds of miles away. Hapinoy is a social
enterprise that combines small storeowners into one branded network in which they enjoy bulk discounts and
entrepreneurial training to enhance their income. The last case is a microfinance product offered by Safesave which
enables even the extreme poor to save up starting from amounts as small as 2¢.

We hope that the cases presented in this issue can provide you with a clearer understanding of why certain
interventions did or did not work, in order to better inform future policy designs and decisions.

We invite you to share the ATM Bulletin with colleagues or friends who are interested in poverty alleviation in
Southeast Asia. The ATM Bulletin is available for download online at
http://www.asiantrendsmonitoring.com/category/downloads, where you can also subscribe to future issues.
Additional content and videos are hosted on the website, where you can share your thoughts with us on this issue.
Thank you again for supporting the ATM Bulletin, and as always, your comments and feedback are welcome.



Johannes Loh
Nicola Pocock
Taufik Indrakesuma
Innovating for access to basic infrastructure
Rolling water into rural communities

                                                   Deciding the appropriate intervention to improve access to clean
                                                   water is a complex policy choice, because there are many different
                                                   types of water access problems. There are two broad categories of
                                                   water access intervention: water supply and water quality1, each
                                                   with a wide range of options for specific interventions. These inter-
                                                   ventions also differ on factors such as scale and cost.

                                              One example of a successful small-scale water supply intervention is
                                              the creation of the water roller. The water roller was first initiated by
                                              the Hippo Water Roller project in 1991 in South Africa. Since then,
the design has been imitated and improved by Wello, the organisation behind the WaterWheel that is sold in India.

The water roller was designed to address the problem of transporting water from its source to the home. One of the
parameters of “access to improved water sources” defined by the WHO is that water sources must be within a radius
of one kilometre from dwellings. For many people in ASEAN, especially in places such as rural Laos and rural Cambodia,
the sources are typically much farther away. The unfortunate consequence is the need to make multiple
time-consuming trips in order to fulfill the daily water needs of a family.

                                                        The solution comes in the form of a large barrel shaped vessel
    Assuming that water rollers can carry               that can be rolled on the ground with the help of a long metal
    350% more water than traditional me-                handle. This allows people to transport large quantities of wa-
   thods, an adult with a walking speed of              ter (around 24 gallons, or one day’s supply of water for a family
  5km/h and who lives 2km away from wa-                 of four) in a single trip, without having to exert as much physi-
                                                        cal effort as when using more traditional methods such as car-
   ter sources can save nearly 20 hours per
                                                        rying jugs or buckets atop their heads.
  week that can now be used for other pro-
     ductive activities such as paid work.                  The main advantage of interventions such as the water roller is
                                                            that they are small-scale and do not require capital-intensive
infrastructure investments such as drilling wells or building networks of pipes that lead to household water connec-
tions. Thus, is it easier not only for charities or other organisations to donate these products rather than build infra-
structure, but also for households and communities to purchase these products via micro-loans or other financing
methods. Furthermore, even if individual households cannot afford to buy their own roller (the Hippo Water Roller is
priced at around US$70–100, while the WaterWheel will be available for around US$20–30)2, the product can give rise
to water jockeys, an occupation which is made theoretically feasible due to the increased efficiency of small-scale
water transport. To date, it is reported that over 32,000 Hippo Rollers have been sold throughout Africa.3

Currently, the availability of these rollers is limited to Southern Africa and India, where the projects originated. How-
ever, there is significant potential to replicate these projects or ship the rollers to ASEAN countries. The Hippo Roller,
for example, has a “local manufacturing” programme, where the company ships the manufacturing machine and an
on-going supply of raw materials abroad instead of shipping the completed product, with the rationale that shipping
completed products will drive up the costs by too much. Entrepreneurs in ASEAN could take advantage of this pro-
gramme and bring not only the products into the market, but also generate local employment opportunities.

However revolutionary these products seem, it is important to remember that they are, ultimately, one-dimensional,
micro-level solutions to macro-level problems in water supply infrastructure. Water rollers may lead to time savings
for water collection and a reduced risk of injury to water carriers, but they do not address core issues such as water
quality and the stability of the water supply. Thus, when considering these kinds of projects for replication, it is also
important to consider the limitations of the intervention, as well as other kinds of interventions that can be used to fill
the remaining gaps.

For more information about the two types of water rollers, visit: http://www.hipporoller.org/ (Hippo Water Roller)
and http://wellowater.org/ (WaterWheel).

Sustainably connecting off-grid consumers

There have been a number of large-scale rural electrification projects around the world based on just extending the
reach of large centralised power grids. One of the problems with this approach is that the projects are very expensive.
For example, one rural electrification project, carried out in Indonesia in 1994–1996, consisted mainly of extending
distribution lines to 851 villages at a cost equivalent to US$130 million in 2010. Another problem, as the Alliance for
Rural Electrification explains, is that rural areas “are often too sparsely populated or have a too low potential electric-
ity demand to justify the extension of the grid”4, which means that these projects, if carried out at all, cannot pene-
trate all rural areas.

However, several projects recognise the need for a different solution, and have instead sought to provide electricity
access through local means of electricity generation, usually utilising renewable energy technology. This allows elec-
tricity access to penetrate remote areas more easily, without requiring massive investments in extending the centra-
lised distribution grids.

The Global Sustainable Electricity Partnership has initiated a number of these projects, including one project in Indo-
nesia and one in the Philippines. The project in Indonesia was a multi-pronged approach in the island of Sulawesi, in-
volving the installation of three micro-hydro power systems which covered roughly 2,500 people, 175 solar home
systems in three villages, and a photovoltaic/wind hybrid system on Rote Island that provides coverage to roughly 600
people.5 The project also entailed setting up and training a number of village-run electricity cooperatives to manage
and maintain these systems. In the Philippines, the organisation built a 200kW hydropower plant in Ifugao province in
order to aid efforts to preserve the Ifugao Rice Terraces World Heritage Site and to provide electricity access to the
local agricultural community around it.

Another fast-growing technology is the use of various forms of waste to power electricity generators. Previous issues
of this bulletin have discussed the potential of electricity generation using agricultural waste such as rice husks in
Thailand. These waste-powered electricity technologies have also popped up in farms in Malaysia in the form of bio-
gas plants that utilise animal manure, as well as in some urban areas like Jakarta and Ho Chi Minh City that are also
trying to solve the problem of urban waste management.

Although the projects highlighted above were mostly implemented by non-government actors, there are also some
governments that have decided to follow the same route of using renewable energy to provide off-grid electrification.

China launched very ambitious rural electrification programmes using renewable energy in the past decade. It started
with the Township Electrification Programme in 2001, which installed a total of 20MW of solar photovoltaic capacity,
200MW of small hydroelectric capacity, and 840kW of wind power to over 1,000 townships.6 After the completion of
this programme in 2005, it continued to expand its rural electrification programme with the Village Electrification
Programme, which aims to provide renewable electricity to 10,000 villages.7 India has recently followed suit, setting
up a solar energy plan that aims to provide solar lighting to 20 million rural households by 2022.8

The main barrier to the interventions above is that, although these projects are more efficient and have a wider reach
than the “traditional” grid expansion method, the generators still require sizeable investments. For example, China’s
Township Electrification Programme cost a total of RMB 1.6 billion9 in total, or about US$250,000 per township (as-
suming an equal distribution of resources). Thus, there will still be difficulties in funding the replication of these
projects throughout the parts of ASEAN that need them most.

Thinking even smaller: the case of ToughStuff
The previous section showed the limitations of large-scale projects in energy provision. Some projects, however, are
so small-scale that they do not require any amount of infrastructure investment. One interesting example of this type
originates from a company called ToughStuff, the winner of the 2011 Ashden Award for Sustainable Energy.

ToughStuff was set up in 2008 with the goal of “providing affordable solar-powered products for low-income people”.
The products they sell include rechargeable battery packs, small solar panels with connectors to mobile phones and
radios as well as LED lamps. These products, as mentioned in their website, “fulfill the three main energy needs of
off-grid consumers: lighting, connectivity, and information”. Currently, this company sells its products primarily in
Africa, although it has expanded into 11 African countries in the last two years, and sometimes gets involved in disas-
ter relief efforts outside of the continent.

In addition to their core business of selling solar-powered products, ToughStuff also engages local communities using
their "Business in a Box" programme, where they recruit and train a number of locals to become distributors of their
products (they refer to distributors as Solar Village Entrepreneurs), which both increases the penetration of their
products to remote areas and provides an additional US$500–1,000 of income for the worker.

This type of business is by no means unique. There are many other companies within the energy sector as well as
other sectors that operate much like ToughStuff, with a mix of low-cost products and employing local people as dis-
tributors. Nokero, for example, is a USA-based company that has almost exactly the same products as ToughStuff,
with even the same Business in a Box concept. It, too, is finding some amount of success in selling solar lanterns and
mobile phone chargers to countries in Africa and South Asia.

However, it is more important to note the business model’s success rather than its novelty. The ToughStuff model
succeeds because, much like the water rollers mentioned in previous sections, it identifies specific problems that can
be solved using low-cost products. In this case, ToughStuff correctly identified the primary uses for electricity in these
off-grid rural communities. Thus, it is able to streamline their product to provide solar-powered electricity for those
specific purposes: LED lamps, mobile phone chargers and radio chargers. It means that production costs are low and
the appeal of purchasing those products is high for people in rural communities.

It is unfortunate that no independent studies have been conducted to show the real impact of these products to
off-grid rural communities, thus judgment is still reserved on whether this is an effective method to provide access to
electricity. However, assuming that ToughStuff sales figures are reliable, its products are currently bringing benefits to
over 140,000 families, mostly in Madagascar and Kenya.10

This information, however, should be taken with a grain of salt. Although the merits of these businesses deserve ap-
plause, they have their limitations. In the case of ToughStuff, their successful business model is also what limits the
utility of the interventions in the long run. By focusing on providing for the current demands for power in the form of
mobile phone and radio chargers and LED lamps, the ToughStuff model does not allow for improvements in rural
electricity access beyond those three services. The batteries are too small to power larger electrical appliances such as
refrigerators or electric stoves, which are equally impactful to the improvement of rural lives.

Whether these products count as providing “access to electricity” is still debatable. The International Energy Agency,
for example, only considers households with access to central or local power grids as “having electricity”, due to the
limited uses of these smaller-scale products. Thus, it must be noted that the much improved reach of this kind of
model comes with the trade-off of a more limited range of possible improvements.

For more information about the product, please go online: http://www.toughstuffonline.com/

Cleaner ways to cook: the Protos stove

Another vital energy necessity that is still lacking in several parts of ASEAN is the availability of clean-burning stoves
that use non-solid fuels. As highlighted in the previous issue, nearly 50% of ASEAN’s population still relies on solid fu-
els for cooking their meals and heating their homes. The regular use of solid fuels, such as firewood, charcoal and
biomass, has several negative health impacts (indoor air pollution from solid fuel use causes increased risks in respi-
ratory tract infections and chronic obstructive pulmonary disease)11, as well as negative impacts on the environment
(solid fuel use emits a high amount of carbon and other air pollutants).

                                                        Factors such as high prices and limited distribution of non-solid
   Men with regular exposure to indoor air              fuels such as kerosene or liquefied petroleum gas (LPG), as well
  pollution from solid fuel use are 1.8 times           as the inability to afford cook stoves, are the main constraints
 more likely to contract Chronic Obstructive            that the poor face in improving their cooking methods. Thus,
   Pulmonary Disease, while women face                  effective interventions to provide cleaner cooking methods
    even greater risks of about 3.2 times.              must not only provide affordable stoves, but also sources of
 Thus, providing clean cooking methods can              fuel that are clean, abundant, and affordable.

      have massive health implications.                 The Protos stove is one such intervention. The Protos stove is a
                                                        plant-oil cooker stove that was developed by the BSH (Bosch
und Siemens Hausgeräte GmbH) Group, a home appliances manufacturer, specifically to address the prevalence of
solid fuel use in cooking. To date, the product has been field tested and distributed in countries such as Guatemala,
India, Indonesia, and the Philippines. The stove has received much international media coverage for being the first of
its kind.

The main strength of the Protos stove is the wide range of fuels that can be used to power it. The stove can run on a
number of different plant oils, such as coconut oil, jatropha, and rapeseed oil, as well as biodiesels and even used
cooking oils. These oils are usually easier for poor rural communities to produce or to access than kerosene and LPG.
This means that there is a lower risk of interventions that fail in the long run, as is the case with kerosene or LPG
                                                 cookers that may end up being re-sold or abandoned because of the
                                                 inability to afford or access fuel. Additionally, the company claims that
                                                 the product was designed to enable local manufacture, which creates
                                                 potential for employment.

                                               There are, of course, several other cook stove designs that can improve
                                               the current conditions faced by the poor. For example, there are stove
                                               designs by Envirofit, an organisation whose stoves still use charcoal or
                                               biomass as fuel, but do so in a cleaner and more efficient way. Of all the
                                               small-scale interventions in this sector, the Protos stove seems to be the
                                               first holistic, market-driven solution that tackles both the health and
                                               sustainability aspects.
Maternal and child health interventions
Laos: piloting free facility-based births

                                           Giving birth in a health facility is an evidence-based strategy that reduces the
                                           risk of maternal death, should a mother face complications during birth.12 In
                                           2008, statistics reveal that for every 172 childbirths in Laos, one mother would
                                           die. Reasons for this are both economic and practical – a high rate of home de-
                                           liveries without medical assistance in rural areas (where just 11% of births are
                                           attended by skilled health personnel), poor transport and communication links
                                           to birth facilities during the rainy season and a lack of health information. Tra-
                                           ditions and beliefs are also a barrier to safer births – World Bank assessments
                                           note that some communities believe that a woman must give birth in the forest
                                           by herself. The government managed Health Services Improvement Project is
piloting free facility-based maternal deliveries and pre- and post-natal care in Nong and Thapanthong districts, sup-
ported by World Bank grants totaling US$27.4 million. This significantly reduces the economic burden for families,
where 75% of the population lives on less than US$2 a day. Preliminary results from the pilot suggest a significant in-
crease in childbirths at health facilities since they became free for service.

For more information, please see: http://bit.ly/qP6bCj

Intervening to immunise

Immunising one’s child against diseases is standard protocol in higher income countries with universal coverage. In
some ASEAN countries, immunisation coverage against the four key diseases13 in the first year of life is still patchy,
particularly in island archipelagos Indonesia (87%) and the Philippines (88%). It is a particular challenge to provide
immunisation services in remote and rural communities and in conflict-ridden areas. Child immunisation is linked to
cognitive ability in later life; using data from Cebu, Philippines, Harvard School of Public Health researchers found that
full vaccination against measles, polio, tuberculosis and DPT in a child’s first two years significantly increases cognitive
test scores relative to children who receive no vaccinations.14 Organisations and partnerships geared toward scaling
up immunisation services are abundant in Southeast Asia. We spotlight those most interesting to us below:

Expanding immunisation in Luang Prabang, Laos

“Public-private partnership” is a generic term that can produce vanguard initiatives. One such example hails from Laos,
where immunisation coverage was just 63% across key diseases in 2009, with expected lower coverage rates among
ethnic minorities. A 16-month pilot programme in Luang Prabang province, rolled out between 2006–7 by the Asian
Development Bank, GlaxoSmithKline, UNICEF and the Laos Ministry of Health, tested strategies to increase communi-
ty demand for childhood immunisation coverage. Following assessments in communities to understand motivations
for immunisation delivery among health workers and parents, the project engaged the Laos Women’s Union and oth-
er non-governmental organisations to mobilise communities to immunise their children. In addition to peer education
efforts, strategies that were particularly effective in low-coverage communities included:

       Frangipani flower immunisation cards with five petals, stamped with the programme’s signature elephant
        stamp for each immunisation visit so that parents could easily keep track;
       Certificates of completion publicly awarded to parents who completed the vaccination sequence by a promi-
        nent individual in the village;
       Target household flags, a pocket of which contained info about the communities next immunisation outreach
        visit. These were placed outside households one to two weeks before each visit;
       Seasonally calendared outreach visits, so that health worker visits did not conflict with peak periods in the
        agriculture cycle;
       Ethnic language radio programmes, which were contracted to run dramas, jingles and knowledge spots about
        immunisation; and
       Inexpensive gifts to incentivise parents whose children were not fully immunised.

Results show that immunisation rates in pilot districts doubled and in some cases nearly tripled over the duration of
the project. One key success factor was building on and mobilising additional national political support to increase
immunisation rates across the country, which helped to ensure appropriate synergies between national and commu-
nity efforts.15,16

Challenges: the short duration of the project (16 months) hampered its ability to generate behaviour change (recog-
nised to take years), develop systems of operation and build capacity in a health system that already struggles to re-
spond to consumer demand. Plans to ensure continuation of project activities with religious groups and the private
sector were not fully explored. The project was also affected by a lack of vaccines for three months in 2007. Bearing
these barriers in mind, it is important to have a continuation plan in behaviour change interventions, contingent on
programme evaluations to determine whether it is cost effective, equitable and sustainable. A continuation plan could
be operationalised by streamlining project activities within a health ministry's programmes or by engaging
non-governmental organisations and private sector partners. Generation of new social norms takes time and requires
sustained institutional efforts.

Engaging both health and education ministries in Aceh, Indonesia

Following the tsunami, privately-funded Project Hope entered Aceh in 2005 to initiate a five year project aimed at im-
proving the health behaviour of mothers and children in Nagan Raya district, supporting the Ministry of Health’s inte-
grated management of childhood illnesses strategy. Before the project was implemented, immunisation was not a
social norm in Nagan Raya. Preliminary assessments showed that health workers were not trained to deliver vaccina-
tions, and demand from communities was low due to cultural prejudices against injections and a lack of knowledge
about immunisation benefits. The project trained health workers to deliver vaccines, upgraded and built posyandus
(local health centres), as well as established a health education programme in partnership with the Ministry of Educa-
tion. Innovative features included:

       Children educating mothers: the child-to-child health education programme has been instrumental to reach-
        ing out to mothers. Elementary school teachers engage fifth grade students to promote the importance and
        benefits of immunisation and other health services to mothers of children below three years old. Students are
        taught about nutrition, immunisation, diarrhoeal disease control, acute respiratory infections, malaria and
        personal and environmental hygiene. Their weekly homework is rather innovative as well: a young child has
        to share information he just learned with his mother. During the programme, teachers assign a mini-survey to
        students to identify two priority mothers with children under three to encourage or remind them to visit the
        posyandu each month. The day before the monthly posyandu session, students visit mothers to remind them
        to visit the posyandu the following day; and
       Feedback loop to posyandus: using project reporting forms, teachers collected information from students
        and shared this with health centre staff.

By 2008, immunisation rates had more than doubled. Deliveries attended by a healthcare provider rose from 44% to
68% between 2005 and 2008. To date, Project Hope has upgraded or established 247 posyandus where there were
previously only 56 functional health posts, and trained 1,200 local health workers and 40 midwives in basic birth deli-
very. This has been accompanied with maternal and newborn care training, and the training of 25 community health
volunteers as breastfeeding support leaders.

Promisingly, project activities are now integrated into regular health and education ministry procedures. But a key
takeaway for implementers was that to stimulate demand, the health system had to first raise its quality of care. In-
terventions aimed at specific groups are generally more successful within the context of broad health system im-
provement.
For more, please see: http://www.projecthope.org/where-we-work/southeast-asia-middle-east/indonesia.html




Chronic disease interventions

Chronic disease risk and prevalence is complex and not attributable to health interventions alone – built environ-
ments must facilitate and encourage physical activity and healthy foods should be accessible in the food supply.
Chronic disease interventions span the spectrum from prevention (e.g. programmes to increase physical activity,
adoption of healthy lifestyles) to management (e.g. patient management of chronic conditions like diabetes). As epi-
demiologists Simon Capewell and Martin O’Flaherty wrote recently in a letter to the Lancet, the need for interven-
tions with already at-risk populations is pressing: “Extensive empirical and trial evidence shows that substantial reduc-
tions in mortality can occur within months of (individual or population-wide) decreases in smoking, and within 1–3
years of dietary changes… Policy interventions which achieve population-wide changes (such as smoke-free legislation
or reductions in dietary salt, transfats, or saturated fat) can be effective and cost saving. Although such policies are
politically challenging, they could achieve substantial and surprisingly rapid reductions in disease.”18

To reach the most number of people, population-wide changes have to go beyond targeted behavioural interventions,
which decades of research have shown to be unsustainable beyond programme duration.19,20 A comprehensive, social
ecological framework of health promotion and disease prevention can be found in the Community Intervention for
Health (CIH) programme, a pilot intervention run by the Oxford Health Alliance. CIH is a dual research and interven-
tion project with a significant evaluation component. The four interventions used include community coalition build-
ing, structural change, health education and social marketing. Authors of a recent assessment note that the CIH is the
“first comprehensive community intervention programme of its kind, addressing chronic disease risk factor reduction
and prevention”, with a 3-year pilot study running in China, India, Mexico and the United Kingdom. CIH programme
evaluation involves three components: individual assessment (surveys); community assessment profile; and assess-
ment of the process required to implement activities.21 We spotlight the Community Health Environment Scan Survey
(CHESS), part of the environmental scan in component 2, as a tool to help policymakers assess how the built environ-
ment interacts with health behaviours and chronic disease risk.




The Community Health Environment Scan Survey: a tool to assess the impact of the built environment on lifestyle
factors

CHESS aims to help stakeholders to understand the link between population health behaviours and resultant health
outcomes. It systematically documents and maps data (using Global Positioning System) to assess the environments in
which people shop, live, work and play as they relate to diet, physical activity and tobacco use. Eight items are as-
sessed – streets, stores, restaurants, street vendors, recreational facilities, parks or gardens, vending machines and
the information environment. An advantage of the CHESS is that it measures community attributes in “real time”,
making it suitable in developing country contexts where data on the built environment (stores, parks, etc) may not be
available.




A recent assessment of schools in the Mexico site revealed extensive interaction between health behaviours and the
environment, as one might anticipate. Using baseline data from a survey of 4,608 young people between 12–14
years-old and scans of intervention and control sites (n=16), results showed a significant association between the
percentage of fast food restaurants in the surrounding area and eating fast food within the last week (over 50%). The
relationship between smoking prevalence and the availability of tobacco showed similar attributes, with the odds of
being a current tobacco user in closer proximity to stores selling tobacco. A greater proportion of stores with a “no
sales to minors” sign was associated with greater use of smokeless tobacco products.
Limitations of the CHESS include that it uses cross-sectional data, which may be limited in highlighting the dynamic
nature of communities. Researchers also note that the ability to measure affordability of food options was hampered
by the variability of units in how fruits and vegetables were sold. However, the CHESS as a diagnostic tool has sub-
stantial potential to guide urban planning and design community interventions that prevent chronic disease.

For more information, please see reference 21 on page 19 and http://www.3four50.com/cih/

Healthy lifestyles campaign in Singapore

Singapore’s Health Promotion Board (HPB) has recently stepped up marketing and outreach efforts in its healthy life-
styles campaign. It is not uncommon to see posters advertising a minimum intake of fruits and vegetable at bus stands
or in the underground mass transit system. Additionally, the city-state’s focus on public housing and providing out-
door exercise equipment in those areas helps to mobilise citizens to do regular exercise, as has the sustained focus on
building sports infrastructure. The Singapore Sports Council records more than 11 million users of their facilities an-
nually, operating 24 swimming complexes, 19 stadiums, 16 sports halls for badminton, basketball & netball, nine ten-
nis centres, four squash centres, two netball centres, five fields for soccer & other team sports, 75 school fields and 15
gyms. That’s one sports facility per 2.6 miles (or per 6.9km2).22




The HPB uses simple healthy lifestyle rules of thumb (heuristics) in its advertising, including: “Aim for 150 minutes of
physical activity every week!” and “Eat 2 fruit + 2 veggies every day for good health!" These simple messages help
consumers to remember what they should do to improve their overall health. The HPB website features interactive
tools like “monitor and manage your diabetes” and a mobile diet tracker that can downloaded on a smartphone.

As shopping is a popular national pastime in Singapore, the HPB organised the "Walk the Mall to better health" pro-
gramme, whereby walks in shopping malls (at a brisk pace) take place on Sundays, which is particularly suitable for
the elderly.

For more information, please see: http://www.hpb.gov.sg
Unbanked and unconnected: interventions that make a difference
Cheaper and easier financial access for the “unbanked”

In many countries we can observe some progress in financial inclusion, but it is usually the result of the slowly ex-
panding conventional banking infrastructure.23 The potential for rapidly reaching a large number of people lies within
mobile banking solutions. Estimates put the number of unbanked people around the globe who have access to a mo-
bile phone at about one billion.24

                                                          The market potential for providing financial services to the
                                                          unbanked is enormous. In recent years, many commercial
                                                          initiatives have been launched, but only some have caught
                                                          on successfully.

                                                          The most notable example is the mobile money service
                                                          M-PESA offered by Safaricom in Kenya. M-PESA is a mobile
                                                          phone-based service for sending and storing money. Cus-
                                                          tomers can sign up at any of the 26,948 merchants who act
                                                          as “agents” for account opening, handling of deposits and
                                                          withdrawals into the customer’s virtual “wallet”.25 The mo-
                                                          bile application allows users to check their balance, directly
                                                          send money to other users per SMS, pay bills, and top up
                                                          their phone airtime.

                                                            The most common barriers to banking outreach, which ex-
                                                            clude the poor from accessing financial services, are mini-
                                                            mum balance for checking accounts, account fees, and re-
                                                            quired documentation.26 Mobile banking has less restrictive
                                                            sign-up procedures, cheaper rates and no minimum bal-
                                                            ances, all reasons why M-PESA has witnessed the spectacu-
lar growth from inception in 2007 to 13.8 million users in 2011. Every day the company records US$19 million of per-
son-to-person transfers. Since its inception, cumulative transactions via M-PESA have reached US$10 billion.

                                                              M-PESA lessens, and in some cases eliminates, many of
  The definition of “unbanked”                                the spatial and temporal barriers to money transfer.27
                                                              Customers save enormous amounts of time previously
  People who have no access to financial services             spent to reach the nearest bank branch for withdrawals
  (including savings, credit, money transfer, in-             or deposits which they can now do at any M-PESA agent.
  surance, or pensions) through any type of finan-            Moreover, M-PESA has helped to facilitate the ur-
  cial sector organisation such as banks, non-bank            ban-to-rural cash flow as well as enhance the financial
  financial institutions, financial cooperatives and          autonomy of women. About 70% of Kenyan adults use
  credit unions, finance companies, and NGOs are              M-PESA, despite less than a quarter of Kenyans having
  considered “unbanked’. Implicit in this definition          bank accounts.
  is that financial services are usually available            An example from seasonal workers in an informal urban
  only to those individuals termed "economically              settlement in Kibera illustrates how affordable mobile
  active" or "bankable".                                      banking can improve the lives of the poor. There are no
                                                              banks near their settlement, but 40 M-PESA agents al-
  – UN Capital Development Fund: International                low workers to deposit their daily wages of about
  Year of Microcredit 2005                                    US$1.30. They save these small sums until they have
                                                              accumulated enough to make lump-sum transfers to
their rural homes. Others just use it to save up money for emergencies.28 It is not even necessary to possess a mobile
phone. Having a SIM card, which can be placed into a neighbour’s or friend's phone, is sufficient to take advantage of
M-PESA money transfers.

In the Philippines, two mobile phone operators Smart and
Globe have been offering mobile banking since 2004. However,
the uptake of the service was much slower than in the Kenyan
example. There were about 3.6 million users in 2009, with
about 50% of them otherwise “unbanked”.29 Recent innova-
tions of the service such as linking up with microfinance pro-
viders and signing up pawnshops and small retail shops, such as
Hapinoy, have contributed to higher adoption rates.30 Certainly,
much room remains for growth of mobile banking in the Philip-
pines, as more than two-thirds of the population remain un-
banked and are forced to rely on informal saving instruments
such as hiding the money, giving to a friend or family, or using a
savings club.

A chain of small retail stores across the country: Hapinoy

There are approximately 800,000 “sari-sari” stores (Filipino word for various kinds) in the Philippines. They are small
shops, often extensions of the owner’s home, which offer basic goods for daily needs.31 These stores account for 40%
of total retail sales in the Philippines for fast-moving consumer goods. The Hapinoy Store Programme covers a net-
work of over 10,000 sari-sari stores clustered along 150 bigger Hapinoy Community Stores.




Founded in 2007 by Microventures Incorporated, the Hapinoy Store Programme originally was intended to aggregate
the small storeowners and provide them with bulk product discounts in order to increase their income. Today, it has
evolved into a “full-service micro-entrepreneur enhancement” programme which encompasses micro-loans for store
owners, the Hapinoy store branding, bulk discounts for goods and services as well as entrepreneurship training. Ha-
pinoy’s concept attracted the interest of SMART, the largest telecommunications operator in the country, Unilab, one
of the leading pharmaceutical companies in the Philippines, and a number of companies for consumer goods. While
SMART assists Hapinoy with technical equipment for its community stores and offers its mobile services in each Ha-
pinoy store, the other partners have varying agreements for bulk supplies, marketing efforts and projects through
their corporate social responsibility divisions. Microventures Inc. takes a small cut before passing on the discounts to
the Hapinoy stores as well as charges companies for activities done with and through the network. This is the business
principle behind the idea, which makes the social enterprise profitable.32

At the centre of the intervention are women micro-entrepreneurs, so-called “Nanays” (Filipino for mother). The Na-
nays, who previously were individual sari-sari store owners, become part of the Hapinoy network. They are usually
able to significantly increase their profits by learning how to run their store more efficiently, gaining access to bulk
discounts (5%–15%), and offering special products of interest to their communities. These products include solar lan-
terns, basic medicine and mobile banking services. In each community the programme establishes one community
store, run by one or several Nanays, to serve as a hub for around 50 to 100 smaller stores in the area. The community
store orders the products in bulk and supplies stocks for the individual Hapinoy Stores; in some areas, it also serves as
a SMART Money Centre providing mobile financial services.

                                                       After initial problems in developing cost-efficient models to
What Hapinoy offers                                    serve their network, Hapinoy has fine-tuned its business opera-
                                                       tions, standardised many of its procedures in setting up com-
       Access to additional loans                     munity stores and reached impressive scales. Their 5-year plan
       Store makeover including painting              foresees an expansion to more than 100,000 sari-sari stores.
        and signage                                    This business model targets those at the Bottom of the Pyramid
       Product discounts and promotions               (largest, but poorest socio-economic group) and it has generat-
        from Hapinoy partners                          ed interest beyond the country’s borders.
       Entreprenuership training                      “We are a new model, the first to blaze this trail and there are
                                                       many outside the Philippines who want to know more about it,”
Before joining Hapinoy, a typical store
                                                       says founder Bam Aquino.33 He continues, “We want our orga-
would make sales of US$10 a day. After a
                                                       nisation to be an example of a model which is sustainable, sca-
successful Hapinoy store makeover, it can              leable and has a true impact on communities, where change is
make US$300 a day.                                     ongoing but at the same time can operate on its own in terms of
                                                       expenses and create value not only for its owners but also their
                                                       partners.”

With millions of small corner shops all over Southeast Asia, a social enterprise modeled after Hapinoy’s approach
could benefit store owners and their Bottom of the Pyramid customers across Indonesia, Vietnam, Cambodia and
Laos.

Supporting health services in remote areas: m-Health

Providing healthcare access to populations in remote rural areas is a tremendous challenge. Often, poor rural com-
munities will receive only rudimentary health services provided by less trained village doctors or nurses. In conse-
quence, more complex disease patterns are not recognised, resulting in misdiagnosis.

A new generation of mobile health applications can help bridge this rural-urban access gap in a simple and
cost-efficient way, so long as their implementation is intuitive to the target group. Sana Mobile Health was developed
by students and alumni from the Massachusetts Institute of Technology and Harvard University with the aim not only
to improve clinical outcomes, but also to streamline the health delivery process.34 It is a mobile phone application that
guides and assists Community Health Workers in treating patients by providing interactive step-by-step instructions
on questions to be asked. Moreover, it can be used to solicit advice from medical experts in urban centres by upload-
ing the collected data to a web-based medical health record system for the doctor to review.

                                                        The application can be customised to meet the specific needs of
                                                        a community. Physicians can create their own medical proce-
                                                        dures and then upload them to the health workers’ smartphones
                                                        in the field. The pre-programmed procedure can integrate pic-
                                                        tures and videos to be displayed as prompted.35

                                                        Beyond this key feature, Sana Mobile Health can also be imple-
                                                        mented to provide built-in training for local health workers and
                                                        nurses. Once downloaded, the software operates offline so that
                                                        the medical guidance is available even in areas without mobile
                                                        connectivity.36 Data uploads are reliable even in poor coverage
                                                        areas due to algorithmically controlled data transfer.

                                                        Improving health outcomes for post-surgical follow-ups

                                                        Patients from rural areas often have difficulties to complete fol-
                                                        low-up routines after undergoing surgery in the city. Distance
                                                        and costs are two factors that prevent patients to travel to the
                                                        city for post-surgical checks. As a result, post-surgical complica-
                                                        tions or infected wounds are mistreated or recognised too late.
                                                        A specific Sana Mobile programme designed to guide health
                                                        workers through wound inspections can significantly lower the
                                                        cost burden for the patient and prevent long-term damage.

Pilot studies with Sana Mobile show promising results

In partnership with eHealth-point Services India (EHP) and the Public Health Foundation of India, Sana developed an
intervention to undertake a cardiovascular disease (CVD) risk assessment. Rural community health workers from Pu-
jab were equipped with phones with the customised Sana software and trained to conduct door-to-door CVD risk as-
sessments.37 Due to the efficiency of the data collection process, EHP has plans to offer this service in all rural clinics
of its global chain.

In Bangalore, Sana has partnered with the Narayana Hrudayalaya Hospitals and Mazumdar Shaw Centre to launch an
early cancer and cardiovascular disease detection programme across the state of Karnataka. As of July 2011, 30,000
people had been screened for oral cancer in Bangalore. The plan is to scale it to 1.5 million people over the next year
in the province.

In the Philippines, plans are under way to launch Sana in conflict regions where severe shortages of doctors leave the
population without adequate health services. Remote diagnosis with Sana’s software will help to alleviate the situa-
tion. Moreover, the Philippines team is designing a Sana system which will improve the identification, management,
and treatment of hypertension, one of the most prevalent disorders striking populations in both the developed and
developing world.38

Initial barriers to adoption

The introduction of mobile health applications is not without problems. Sana had to overcome language barriers by
tweaking its interface to include symbols and voice prompts for taking pictures or videos in order to make the soft-
ware more user-friendly for semi-literate health workers. At the other end of the work flow, convincing physicians to
accommodate these new diagnostic methods and getting them to take ownership of this new technology is hard
work.
Financial services for slum dwellers: SafeSave

The poor often struggle with their day-to-day money management. In absence of savings instruments they find
themselves unable to save up for the future. There are too many essential expenses that eat up their daily or weekly
earnings. With small and irregular incomes, managing their financial affairs takes is a major concern for the poor. Thus,
there is strong demand for a convenient cash-flow management facility on a daily basis.39

Ideally, the facility should allow for small-scale savings of any value at any time with the right to withdraw on demand,
combined with the possibility of taking small loans to smoothen unexpected cash expenditures. These are services
that people in developed countries can utilise at any automated teller machines or via online banking.

Conventional microfinance products do not offer this kind of facility and commit borrowers to regular repayments.
They also rarely include a flexible savings instrument. SafeSave, providing financial instruments in slums in Dhaka,
Bangladesh, offers a service that fills this gap.

SafeSave provides financial services to very poor clients without the usual requirements. There are no group meetings,
joint liability, guarantors, or even fixed weekly loan repayments.40 Originally, it started out as an experiment and
turned out both, extremely popular and sustainable. Despite flexible loan repayments, the repayment rate stands at
97%.

Operating from nine branches, Safesave sends out 66 collectors, all women from low-income neighbourhoods in the
same area, who visit clients' homes or workplaces every day. With a small handheld device they process deposits and
withdrawals and document loan repayments. Clients only have to visit the branches for loan disbursements or large
savings withdrawals.41 The innovation of giving clients the choice of how much to save or how much to repay on a
daily basis, matches the irregular nature of the slum dwellers’ income flows. In consequence, there are no fixed loan
terms. To ensure proper accounting and prevent human error, all collectors are equipped with handheld devices to
electronically record each transaction into SafeSave’s database.

Surprisingly, 44% of account holders do not take loans and prefer
only to save. For accounts with balances above US$15 the organi-
sation pays 6% p.a. interest to account holders, while the interest
rate for loans is 3% monthly. Regular and fast repayment is incenti-
vised by making an increase of the credit limit conditional on how
fast the existing loan is repaid. In 2010, the product range was ex-
panded to include a long-term savings product for three, five, seven
or ten years with 7%, 8%, 9% and 10% interest per year.

Recently, the organisation has started a trial, called P9, in rural areas
following the same model of daily doorstep collection but with the
possibility of offering liquidity in the form of interest-free loans. Im-
mediately, one third of the loan is placed in a savings account. By
sequencing loans to grow each time, clients soon have more cash
deposited than they borrow.42

While some people prefer the rigid repayment discipline required by traditional microfinance providers such as Gra-
meen, the service has filled a gap for all those with more irregular, unpredictable cash-flows. SafeSave has found a
profitable business model that at the same time pushes the boundaries of financial inclusion to the extreme poor.

Accepting deposits of tiny sums as small as US$0.02 allows even those living on less than US$1.25 a day the opportu-
nity to save for a better future. It would be great to see this innovation replicated by major microfinance providers
and brought to scale in more countries in Asia.
Conclusions
The case studies highlighted in this issue are just a few examples of the emerging counter-trend to pervasive inequali-
ties in ASEAN: a persistent stream of innovation. Although these interventions emerged from specific contexts and
may not be fully replicable in other situations, the purpose of this issue is not to recommend specific projects or
products to replicate, but to extract valuable lessons from the successful practices of micro-level organisations.

However, micro-level interventions cannot act as a replacement for large-scale macro-investments in infrastructure,
health systems and internet connectivity. The danger is that governments and major corporate players take a back
seat in community development efforts – with non-government organisations and micro-level organisations doing the
heavy lifting at the frontline. Clearly, political commitment to addressing inequalities and investment in doing so is
required for broad improvements in access to basic services for Southeast Asia’s 250 million poor, living on less than
US$2 a day.

Notably, this issue highlights many infrastructural interventions – such as in water, electricity and information and
communications technology – that were initiated in Africa or South Asia. Not many of these innovative organisations
have started to sell or launch their products or programmes in ASEAN. This shows that not only are inequalities and
access deprivation problems in ASEAN not as well-documented or profiled as they are in Africa or South Asia, but also
significant potential exists for innovative entrepreneurs to make a difference in the market for Bottom of the Pyramid
customers.

Finally, most of the innovations spotlighted were only able to come about after a thorough identification and under-
standing of the problem. Tools such as Participatory Rural Appraisal that involve communities in the identification of
problems and solutions are a prerequisite in generating locally relevant, and ultimately successful, interventions.

We are actively soliciting feedback on our work. If you have any comments on the profiled interventions in this issue
or the data posters in Asian Trends Monitoring Bulletin 12: Rising Asia, Growing Inequalities, please drop us an email
(our contact details are listed on page 21). We also invite you to post comments on
http://www.asiantrendsmonitoring.com, where additional materials are posted online as and when. Once again, we
thank you for supporting the Asian Trends Monitoring Bulletin.
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