Founded in 1979, Trickle Up supports ultra-poor women in India, Central America and West Africa to move out of poverty by enabling them to plan and execute a series of livelihood activities, become active members in their savings and credit groups, and learn skills to strengthen their livelihoods. In 2006, Trickle Up launched a graduation pilot project in West Bengal, India, with support from the CGAP/Ford Foundation Graduation initiative, to introduce several new components into our program, including health.

Given that health expenditures are second only to food expenditures among ultra-poor families, poor health represents a threat to their economic well-being, in addition to lowering their quality of life. Trickle Up established a health component with a two-pronged approach, focusing on education and awareness-raising on health care issues critical to these rural communities, and creating linkages to no- or low-cost government health care services to which they should have access.

Following the pilot project, Trickle Up rolled out a new graduation model, including the health care component, across its entire program in India, supporting 2,350 participants in fiscal year 2011. As the first cohort approaches the end of the 3-year project, Trickle Up conducted in-house research to assess the effectiveness of the health component, and to inform the refinement of the health services offered.

We found that:

• Advocacy by health workers, field workers, senior partner staff and self-help groups resulted in significant progress in important indicators such as children born in government health care centers (instead of at home).
• Improved village-level government health care services and Trickle Up services resulted in improved health indicators such as mosquito net usage and vaccination of children. The relative contribution of Trickle Up’s services is not clear.
• Trickle Up health workers struggled to advocate effectively with government health care facilities to provide services they are required to provide because of the health workers’ relative youth and inexperience. Increasing the minimum education requirement and experience of health workers would improve their ability to advocate and increase their capacity to provide other support to participants.
• Trickle Up can most efficiently address the health needs of ultra-poor families by supplementing, rather than duplicating the services offered by government health care workers and health facilities. Specific gaps were identified in health information and awareness, and certain diseases and health issues not covered by government health workers. Our experience highlights the importance of crafting a health component that takes into account the capacities and limitations of other actors in the community.