Education and Healthcare for the Poor

“Grameen Bank lends money to extremely poor people, particularly women, without collateral, without any legal instrument, without any group guarantee, without joint liability, and so on. But it works, and the borrowers themselves own it. It has more than four million borrowers–96% of them women–taking loans from the bank and moving out of poverty. More than 50% of the people who have joined the Grameen Bank, so far have moved out of poverty.

One thing we focused on right from the beginning was to make sure that the children of Grameen families go to school. In the early years when we had a very small number of borrowers, we sat down with the borrowers and tried to understand what their daily problems were, what they were looking forward to. We’d go through days and days of this discussion among them, and that culminated into something called the 16 Decisions. These decisions were not taken on one single day. It was spread over several years, and for each one we had a long series of discussion.

One of the decisions was, “We shall send the children to school”. We encouraged everybody to make sure that we honored that decision, sending 100% of the children to school . In Bangladesh, literacy is very low. If you are looking at the poor people, the literacy rate is pitiful. So in those families, we’re trying to create 100% literacy. And luckily for us, it worked. People responded very warmly to that. One reason for that as I look back, is that our borrowers are women. Women paid a lot more attention to their children than their fathers.

A few years later, we noticed that not only were the children going to school, they’re now going to colleges as well. Many of them are going to higher educational institutions; they are going to medical schools to become doctors and engineering schools to become engineers. So, we introduced scholarships for students who are at different levels in high schools and colleges, and performing at the top. They are recognized and applauded with these scholarships. Then we introduced student loans, so that the students can continue with their higher education without worrying whether their parents would be able to finance their education or not. At this moment, there are more than 5,000 Grameen students who are under the student loan program going into medical, engineering, and other departments in universities. And each day the number is increasing because more and more students are coming as days go by.

Many of the 16 Decisions are related to health issues. One big health issue was the availability of drinking water . At that time, drinking water meant surface water, and surface water meant polluted water, which caused many diseases. One disease you hear about in Bangladesh is diarrhoea. Luckily for us, at that time oral saline had already been invented, so we could promote oral saline in a massive way.

For example, if you look at the back page of the Grameen Bank loan passbook, it shows pictures of how to make oral saline solution. Every family is trained to make oral saline in case they need it. So it became a constant reminder for them, and they expressed it in rhymes because you don’t forget the rhymes. Bangladeshi people love rhymes, and remember them very well. Today, diarrhoea still exists, but not the terrible kind of epidemic that it used to be.

We also promoted tubewells and gave loans for sinking tubewells for drinking water. Every Grameen family can access drinking water because now they can have their own tubewells. But something else emerged on the way, which was the arsenic problem in water. The underground water is now producing arsenic, and has become a big health hazard. We had to come up with an alternative – pitcher filters. For this, we had to make a little amendment in the 16 Decisions. Not only do you have tube wells for your drinking water, but also filters to purify the water from arsenic and come up with relatively safe water.

In Bangladesh, a latrine is a kind of rare commodity in the villages. Right from the beginning, we introduced one practice in Grameen Bank: if you are becoming a Grameen Bank member, one of the first things you do to show your good faith in Grameen Bank, is to dig a hole and build a latrine . In the beginning, there was a lot of opposition to it. We explained the risk of going to the toilet outdoors, how that spreads diseases and so on. They were still very reluctant to agree, but we promoted this as a condition for joining Grameen Bank. Then, gradually, people accepted it as a part of their routine.

A few years later, while I was visiting a village, a woman rushed at me and hugged me. She was saying something I couldn’t understand. In Bangladesh, a woman hugging a man in front of everybody is quite a scene. So I was feeling embarrassed, but she wouldn’t let me go. She was saying something in the local dialect that I couldn’t understand. A local colleague persuaded her to stop and explain. Then she said, “You are a great savior. You saved women from the punishment of Hell.” I asked, “What does it mean?” She replied, “Because of those latrines that we built, because you insisted on it…Look, men can answer the call of nature anytime they want, day and night, but women had to wait until the darkness of night. No matter what problem she has, she couldn’t do the same because women are not allowed to do that. Now she can answer the call of nature anytime she wants.” I looked at her, and it really gave me something to think about. We argued about the latrines and so on, so passionately on the health grounds. We never even realized what a difference it makes, on women in a society that restricts them from coming out of the house, and what a punishment it is for that person.”

In 1984, we introduced housing loans and it became obligatory that along with each house built, you must have a sanitary latrine attached. So all the houses that have been built with Grameen housing loans ever since then, have always had a sanitary latrine.

This was a time when night blindness was rampant in Bangladesh. So we started talking to doctors about it. They explained that it’s a Vitamin A deficiency; the only cure is to have vitamins for the children. So we talked to UNICEF and they said, “Okay, we’ll give you vitamin tablets, as much as you want, and you can distribute through your channels, reach out to the children.” We decided not to take any Vitamin A tablets from UNICEF. Our argument was that, “Let’s not make people dependent on tablets. Then every time something happens, they will ask for tablets.” And, UNICEF might run out of money and say, “Sorry, we don’t have the tablets.” Then what do we tell people?

We remembered the other advice we got: “Why don’t you promote cultivation of vegetables by the families, so that they can eat colored vegetables? These will supply Vitamin A and the night blindness will be cured.” So we started campaigning that each Grameen Bank family must grow their own vegetables and eat plenty of them . Then people said, “We don’t have the seeds. Where do we get the seeds?” So we started collecting seeds, and came out with little penny packets of many different seeds. These are beautiful packets with little instructions on them. When we brought these to our weekly central meetings, people loved it.

But we have so many borrowers that gradually demand for vegetable seeds became so big that the government seed supplier couldn’t cope with it. So we became the largest seed supplier in the country. We have been importing and growing our own seeds for the members. In the process, night blindness in Bangladesh became history.

Most of the studies made on Grameen Bank show how people move out of poverty. But one study showed how people couldn’t come out of poverty, even after 10 years or more in Grameen Bank. This researcher found that in the cases where people couldn’t come out of poverty, the major reason was health. There was a perennially sick person in the family. They have to be cared for, and so whatever money she earns goes into maintenance of the sick person and she cannot bring the family out of the trap of poverty.

We always knew health is a big issue in getting poor people out of poverty, but we didn’t realize it so clearly until this research came to us. So we created a separate health program, introducing health insurance. If we made it expensive, nobody would care for it, so we made it very cheap. A Grameen family has to pay $3 a year for the entire family to come under the coverage of health insurance . You might think that is easy to bring people into health insurance at that cost. But you have to argue and explain why they have to pay $3 to bring the whole family under health insurance coverage.

With that money coming in, we had a whole health company attached to the Bank, with fully qualified doctors, paramedics, health workers, a pathological lab, a medicine supplier, discount prices for medicine, and so on. We have done this for 30 Grameen Bank branches in different areas. Our aim is to recover the whole cost through this operation. By today, we have succeeded in recovering 80% of all operational costs . It’s also available to the non-Grameen people, but they have to pay double the Grameen premium rate. We are trying to popularize it among the non-Grameen customers so that we can get more and more clients, and better cover the cost.

Along with health insurance and clinics, we are adding safe delivery practices as a priority. I think 95% of the children in Bangladesh are born at home. As a result, maternal mortality is very high, and so is child mortality. So we offer a place where the mother can have a child delivered safely. And to make it attractive, we’re using digital cameras to present them with a picture of their newborn baby. The mother gets very surprised that you can have a photograph of the baby right away. We’re also issuing a birth certificate in a nice little frame. In Bangladesh, very few people have a birth certificate.

Healthcare is becoming more and more important for us, particularly when we go into villages. We realized we could easily pay immediate attention to certain issues like cataracts. We trained some doctors to perform cataract operations and intraocular lens implantation in the villages. It costs about $28 for the lens, the surgeon, everything. People are amazed when those who considered themselves blind suddenly have their eyesight restored. And it’s so easy to have it done as an outpatient. It’s done in a schoolhouse or any other enclosed place. It is cleaned up a little bit, we assemble all the patients together and we do the operation.

We are trying to move into a more formal, institutionalized way of doing things. One particular company in Japan is very eager to work with us, and we have just signed an agreement. We’ll have two hospitals and build up a whole healthcare system, covering the villages and provide medicare all the way to the highest level of hospital care, and try to bring absolute state-of-the-art healthcare to the poorest people at an affordable price.

Health is a major issue. Unless we address this, I think we have not done our duty as human beings and fulfilled our responsibility to other human beings.