One of the main ways to strengthen the health-system capacity by the intersectoral approaches is to promote social health by linking microfinance with healthcare support activities. Up to now, many countries have focused to strengthen the resources for the health system development. At the same time, they have focused on reducing the poverty gap as well as improving health. Therefore, many countries have increased to build their health-system capacity by the intersectoral approaches. One of the main ways that they have promoted social health is by the linking of microfinance with the healthcare support activities. MFIs expand their services to include the health care services. Because, the health care services are the extension of their mission of financial security and social protection of the customers, and healthier customers better serve the MFIs’ goals of growth, and long-term viability. Therefore, the health care services outreach is one of the main ways that they have promoted their operational sustainability. Many MFIs have shown their ability to contribute to improving health care capacity by educating clients, facilitating access to the health care services, providing health financing options and even directly delivering clinical care. MFIs provide the health care services to many households in support of access to the health care services. Many of them live in rural and remote areas beyond the reach of the hospitals and health agencies. Many MFIs already successfully offer the health care services. Increasing numbers also provide health-related services, such as medical care, health financing, and establishing links with medical service providers to facilitate access to health care. However, MFIs offer the health care services, admittedly with challenges to employ the infrastructure for delivery of health-related services to those most in need. The poor people bear a hugely disproportionate share of disease and ill-health, and inability to access the health system emerged as key factors inducing and resulting from poverty [1].
In Vietnam, the operations of formal MFIs have reached 25 provinces and cities with 176 branches and transaction offices in Vietnam. One of the significant missions of formal MFIs are the formulation of the policies that are intended to diversify the health care support activities and to promote the health care services outreach to the microfinance customers. However, to diversify the health care support activities and to promote the health care services outreach are quite the toughs, and challenges for MFIs. The challenges have to face as servicing remote and sparsely populated areas, fast-paced growth needs proper infrastructural planning such as branches, transaction points, which can be dangerously inefficiency without a high degree of diversification in health care support activities, and the health care services success is limited, etc. The studies of MFIs delivering the health care support activities showed increasing evidence of positive impact. Many studies found that adding health care instruction, health education, usually delivered during the microfinance customers group meetings, improves knowledge, and creates confidence that leads to behavioural change. These behaviours are associated with positive health outcomes in diverse areas that are critically important to achieving the health care services outreach [1]. Addressing this gap, the study’s purpose was to examine the interaction relationship between the diversification of health care support activities and the health care services outreach. The research approach is based on the diversification of health care support activities of formal where microfinance is seen as the health care services outreach. The study used a quantitative approach using panel data from the formal MFIs from 2010 to 2019. This study has developed an in-depth analysis of the health care services outreach and an econometric analysis on the interaction relationship between the diversification of health care support activities and the health care services outreach. The research demonstrated that bidirectional interactions and the causal relationship between the diversification of health care support activities and the health care services outreach. The study results will contribute to the theoretical and experimental. Furthermore, the study offers policy implication and new insights for developing a more the health care services outreach of formal MFIs and further emphasizes optimal policies to formal MFIs management; the managers should make conscious efforts and create a balance in the achievement of the goals of health care services outreach in accomplishing the diversification of health care support activities. Therefore, this study is urgently required to balance the goals of health care services outreach. In particular, this study is helpful to decision-makers and other stakeholders of formal MFIs in Vietnam.
Theory
The diversification of health care support activities
The diversification of health care support activities were defined as microfinance outreach indicator, it was measured by diversity indicators in microfinance services indicators, and it had been defined by various researchers differently. The microfinance services diversity was the number of types of microfinance services offered by MFIs [2]. The microfinance services diversity was the number of types of microfinance services contracts supplied. The microfinance services diversity might mean both financial services and non-financial services. The MFIs had ample non-financial services not only because it offered the health care support activities with a variety of terms but also because it offered establishing linkages to health providers to facilitate access to health care, and even directly delivering clinical care [3]. The microfinance services diversity referred to the diversity of services and products beings availed by active customers. This included variety of non-financial services [4]. The microfinance services diversity indicated the number of the types of products and services, and others offered product based on the product lines or the types of product including the number and type of offered product, difference in the number, and the type of the offered voluntary non-finance service [5]. The MFIs promoted the diversification ofproducts and services in line with the operation trends and associated with the development of modern technology to meet the customer needs, that contribute to expand the scope of outreach of MFIs [6]. The number of microfinance products and services showed the number of product and service groups, the number of products and services in each microfinance product and service group. The number of microfinance products and services was manifold, the microfinance product and service diversification contributed to expand the scope of outreach to the microfinance customers. At the same time, the microfinance services diversity might mean both financial services and non-financial services. The microfinance services diversity within a non-financial services might mean educating clients, facilitating access to the health care services, providing health financing options, establishing linkages to health providers to facilitate access to health care, and even directly delivering clinical care [7].
The previous literature showed that the diversification of health care support activities can be measured in different ways. In this study, the diversification of health care support activities refers to the number ofhealth care support activities offered to the microfinance customers. Accordingly, the diversification of health care support activities reflects the number, and type of health education, providing health programs, health promotion programs, adoption of nutrition practices, discussed family planning with spouses, health nutrition knowledge and practice among women, more attention to infant care- nutrition, vaccination, etc., facilitating access to the health care services, providing health financing options, establishing linkages to health providers to facilitate access to health care, and directly delivering clinical care, and different health care support services offered by MFIs.
The diversification of health care support activities is associated with all MFIs' operations, it has been regarded as a prerequisite for continuous improvement the health care services outreach and is influenced by many factors, including:
Firstly, asset growth rate: There was a positive relationship between microfinance services and assets. Thereby, the asset growth rate had a positive relationship with the diversification of health care support activities [2]. The asset growth of MFIs would contribute positively to the development of microfinance products and services, which included diversification of the health care support activities [8].
Secondly, number of branches: A large branch network ensured customers could access more and more convenient the microfinance services, allowing MFIs to provide the diverse microfinance services, including the health care support activities [9]. Thereby, number of branches contributed to diversify the health care support activities of MFIs. Many MFIs provided microfinance services to millions households worldwide. In particular, they provided the health care support activities a million of these households are very poor, many households are lived in remote areas beyond the reach of health agencies. Microfinance sector increased number of MFIs to offer health-related services, such as instruction, clinical care, health-financing and linkages to the health providers. This contributed to diversify the health care support activities of MFIs [10]. Some MFIs had increased the number of branches, expanding the scope of the operations that had provided the variety of microfinance services and promoted diversification of the health care support activities [11].
Thirdly, productivity: The productivity was one of the indicators in microfinance that measured as a ratio of the number of customers to number of staff. This indicator showed how efficiently the available human resource was utilized [12]. Productivity was measured the numbers of customer per staff of MFIs [13]. The staff productivity positively drove the outreach of MFIs. The results showed that the productivity appeared to be a better predictor of MFIs wider outreach. This provided an incentive for MFIs to provide a wide range of products services, including health care support activities [14]. Hence, the productivity had a positive relationship with diversification of the health care support activities of MFIs. Microfinance initiatives have been shown to advance health outcomes. The MFIs always maintain a combination of the productivity and the health care services outreach, and an appropriate productivity growth strategy contributed to diversify the health care support activities of MFIs [15].
Fourthly, the health care services outreach: Services outreach was the term that was used to reflect the health services that mobilized health resourses to provide health services to the population in in remote and rural areas [16]. Therefore, the health care services outreach aimed towards promoting health care services by enhancing health care delivery in communities. Through the health care service providers, communities can improve innovative approaches to challenges related to their specific health needs. Services outreach was the term that was used to reflect the health services that mobilized health resourses to provide health services to the population in remote and rural areas [16]. Therefore, the health care services outreach aimed towards promoting health care services by enhancing health care delivery in communities. Through the health care service providers, communities can improve innovative approaches for the challenges related to their specific health needs. There are many the research on the outreach of MFIs, the outreach of MFIs was measured by the number of people a microfinance institution has extended their services over a specific period [17]. The outreach of MFIs was related to the actual number of microfinance customers [18]. The outreach of MFIs was related to the actual number of poor people reached with services of MFIs [14]. The outreach of MFIs concerned with the efforts to widen service for those who receive inadequate service. The indicators refer to the number of customers, the shifting percentage of served clients and either the types of products or programs [5]. The outreach of MFIs the larger the number of customers the better the outreach of MFIs. Therefore, the health care services outreach could be measured by many ways. This study used the number of customers to measure the health care services outreach [15]. The increase in outreach was undoubtedly to some extent the result of an increase in the services of MFIs. The outreach included the health care services outreach that refered to the goal of extending as many services as possible of MFIs [19]. Many MFIs have increased the outreach to meet the services needs of customers and members, The outreach of MFIs contributed to expand their operations and diversify the health care support activities of MFIs [20].
Fifthly, operational sustainability: Sustainability in the operations was the goal of many sectors and fields, each sector would rely on economic and social characteristics to plan the most suitable strategy for sustainable development. The MFIs would have operational sustainability if their revenue generated from the operations that covered the operating expenses, financing costs and loss provisions. The ability of the organizations to meet their operating cost was defined the sustainability [21]. Sustainability generally meant the ability of an ongoing program to perform activities and services in pursuit of the planned objectives. Operational sustainability of MFIs referred to the ability of MFIs to cover all of its costs through their income, and this was a tangible parameter that was measured continuously to monitor the level of income to cover all costs to ensure that MFIs would develop in long-term [15]. MFIs provided the poor with social services such as the health care service activities and health care instruction. They have increased social sustainability, which provided additional services to particular clientele in remote and rural areas. As a result, the operational sustainability of MFIs contribute to diversify the health care service activities to meet the growing demand of their members and customers [22]. The delivering high-quality care and improved public health were the results of the sustainable health, and care systems. It was easy to imagine a sustainable health and care system, the sustainability of everything that impacted on the health care services such as health promotion, health care instruction, and developing more diversification and sustainable models of health care [23]. This showed operation sustainability had a positive relationship with the diversification of health care support activities.
The Health Care Services Outreach
The health care services outreach was one of the possibilities to increase access to health services, and better mobilization of health resourses to provide health servicesto the population in remote or underserved areas. The health care services outreach was measured by the number of customers of MFIs [16]. The health care services outreach is associated with all MFIs' operations, it has been regarded as a prerequisite for continuous increasing the diversification of health care support activities and is influenced by many factors, including:
Firstly, number of branches: The distribution, making sure that the products and services was available where and when it was wanted. This included such options such as outreach agents, branches. From the customer's perspective, place refered to convenience and accessibility of the product or service being offered by MFIs. Therefore, the number of branches was one of the factors that positively affected the outreach of MFIs [24]. The number of branches was one of the delivery channels for microfinance products and services. Expanding this delivery channels generated convenience and increased accessibility of the product or service being offered by MFIs. At the same time, MFIs were often to improve delivery channels to increase the outreach, and thanks to its distribution network such as the branches and transaction points, many MFIs promoted the health care services outreach [20]
Secondly, productivity: The breadth of outreach was the size or scale of microfinance institutions. The focus on outreach to the customers involved increasing the customers base in MFIs. The staff productivity was significantly positive correlated with microfinance services outreach measure of microfinance institutions. This showed that the productivity had a positive relationship with the health care services outreach of MFIs [25]. The staff productivity positively drove the breadth of outreach of MFIs. The results showed that using the number of customers appeared to be a better predictor of MFIs wider outreach [14]. Thereby, the productivity had a positive relationship with the health care services outreach of MFIs. The increasing in the productivity resulted into more the number of microfinance customers. The fact that MFIs had higher the productivity that obtained better the breadth and there was the interactive relationship between the MFIs' productivity and breadth of outreach in a positive trend. This showed the MFIs always maintain a combination of the productivity and the health care services outreach, and an appropriate productivity growth strategy contributed to improve the health care services outreach of MFIs [15].
Thirdly, equity growth rate: Equity growth rate contribute to improve the financial capacity of MFIs, and financial capacity understood as long-term effects had impact on the microfinance services. Thereby, an improved financial situation was one of the vital factors that contributed to achieving better service diversification, including the health care support services [26]. Many MFIs had a low equity and faced many difficulties in attracting the members and customer. Therefore, the less equity growth rate compared to other financial sources, the fewer improvements in the health care services outreach of MFIs [15].
Fourthly, the diversification of health care support activities: The MFIs diversified to offer the services, i.e, product diversification. The results showed that product diversification by MFIs had a positive impact on the outreach. Thereby, this showed the diversification of health care support activities contribute to advance the health care services outreach of MFIs [27]. Many MFIs diversified to offer the services, i.e, product diversification such as type of different non-financial services offered by formal MFIs. The formal MFIs promoted the diversification of products and services in line with the operation trends and associated with the development strategies, that contribute to increase the outreach of MFIs. In other words, the diversification of health care support activities had a positive impact on the health care services outreach of MFIs [20].
Fifthly, operational sustainability: There was a positive association exists between outreach breadth and sustainability of MFIs. This showed the operational sustainability contributed to expand the services outreach of MFIs [28]. The operational sustainability had a positive relationship with the outreach breadth of MFIs. Many MFIs increased in operational sustainability and lead to advance the health care services outreach of MFIs [15].