Scaling and sustaining the impact of a development impact bond programme – what does it take?

In December 2018, the Cameroon Ministry of Public Health joined forces with Global Financing Facility for Women, Children and Adolescents, Grand Challenges Canada, Nutrition International, Fondation Kangourou Cameroun, Fundación Canguro Colombia and Social Finance to address high neonatal mortality rates in Cameroon with the launch of the Kangaroo Mother Care Development Impact Bond (KMC DIB). This DIB programme sought to fund and implement the adoption of Kangaroo Mother Care (KMC), an evidence-based health practice which promotes extended periods of skin-to-skin contact between babies and caregivers, in ten hospitals across Cameroon.

Driven by the need to reduce Cameroon’s critically high rate of neonatal mortality – which averages 20,000 new-born babies a year – the Cameroonian government was keen to get involved. Moreover, having only to pay for outcomes achieved, the DIB was an appealing, low-risk approach to testing the appropriateness of the intervention to diverse hospital contexts around the country.

Although the DIB came to an end this September, its key stakeholders intend to sustain the impact of the programme and scale it up nation-wide. So, what key ingredients enabled the different stakeholders to co-develop solutions for growing the programme beyond the life of the DIB? For this month’s Engaging with Evidence webinar session, we discussed these ingredients with key stakeholders from the programme, which I summarise below.

Embedding sustainability and agreeing on clear long-term outcomes

The Cameroon KMC DIB was designed with long-term sustainability in mind from the onset. Social Finance Director Louise Savell outlined that the model of the DIB was designed to deliberately embed KMC capacity within the public health system in a sustainable way, with an eye on being rolled out more widely at a later point. This involved embedding skills within the public system, such as the train-the-trainer model and supporting hospitals to improve infrastructure. To achieve this, stakeholders set a clear vision from the outset and aligned long-term objectives in the planning stages. This also meant agreeing on a shared vision of what long-term success looks like, with a clear idea of the mechanism which will enable this – including the roles of stakeholders, resource requirements and the financial lever.

As the project was rolled out, ‘life beyond the DIB’ remained at the forefront of stakeholders’ minds, with metrics in place to track progress against longer-term objectives. Indeed, data collection processes were adapted throughout the KMC DIB programme to test new ways of monitoring progress against the agreed intended outcomes.

Buy-in from government

Whilst government involvement may not be the silver bullet for ensuring the success of a DIB, having government at the table throughout a programme could be considered vital for successfully scaling and sustaining impact.

As Dr Martina Baye from the Cameroon Ministry of Public Health explained, the Ministry played a central role across the lifecycle of the KMC DIB - as co-outcomes funder, but also facilitator and coordinator – and was heavily involved in the early stages of programme design. Having the Ministry in the room ensured design remained in-line with national policy and plans to improve neonatal survival rates. Indeed, alignment to wider policy objectives remained a key incentive that drove government to make lasting change beyond the life of the programme. With sustainability in mind throughout, the Ministry have taken the lead in embedding KMC in long-term planning, with the aim to embed KMC in the government’s health sector strategy. Without the engagement of government, it would have been difficult to lay such groundwork for national roll-out of KMC.

But getting engagement and buy-in from government is not easy - if outcomes-based contracts have not previously been used by the government, ensuring sufficient knowledge and skills around the contracting approach can be a challenge. In the Cameroonian context, the Ministry of Public Health had been involved in performance-based financing prior to the DIB, which made government officials relatively informed and refined outcomes funders. In addition, Louise Savell warned that there can be trade-offs that come with government participation, such as speed of delivery, which might be held up by lengthy bureaucratic procedures and procurement processes.

So, while government participation might make a significant impact on sustaining the impact of a DIB programme at scale, the key is finding an outcomes funder (and other stakeholders) driven by long-term, policy-aligned incentives.

Sustainable cross-sector partnerships

At the heart of a successful outcomes-based contract is an effective, cross-sector partnership. These partnerships assemble expertise from across different areas and arm stakeholders with the knowledge and skills to weave a number of strategies together, adopting and adapting new approaches without having to reinvent the wheel.

But for stakeholders who hope to sustain the impact of a programme beyond the life of a DIB, sustaining these partnerships in the long-term is essential. In the case of the Cameroon KMC DIB, the Ministry of Public Health and Fondation Kangourou Cameroon (FKC) remain aligned in their objectives and are keen to continue working together to ensure the effects of KMC are maintained across the country. Indeed Hortance Manjo, Country Program Director of FKC, confirmed that FKC have committed to continuing provision of technical advice, staff training and monitoring progress to refine the delivery of KMC.

The secret recipe here is a sustainable partnership between genuinely invested stakeholders, who remain mutually aligned in their objectives and incentivised for social change beyond the timescale of the DIB.

Using programme to adapt, innovate and test before it is scaled

KMC had already proven to work in Colombia, but there was no guarantee that it would work in the Cameroonian context. Moreover, stakeholders didn't know if KMC would be able to work at scale nationwide, as this would involve covering a range of hospitals, from large urban hospitals to rural district hospitals. Those involved in the project agreed that one of the strengths of using a DIB framework to fund the project was that it allowed flexibility to test, adapt, and refine models of KMC that work across a whole range of contexts before rolling out at scale.

Therefore, when stakeholders are designing a DIB, Louise Savell highlighted that pushing towards structures that have more flexibility is key to allowing adaptation and preparing the programme for scale. Less tightly defined activities and timeframes and more of a focus on relational principles, decision-making structures and metrics of progress may allow more space for problem solving and adaptive management, as well as flexibility when realities on the ground change. Effective data-driven processes are also central to informing programme adaptation and improvement.

So, if a pilot programme is successful, can it necessarily scale?

The session ended with a word of warning from our Academic Director Dr Mara Airoldi. She explained that when a smaller scale project succeeds, there are high expectations for it to work at scale. But small-scale projects tend to have lots of resources pumped into them, an ambitious team with big incentives to prove that the project can deliver, and an array of monitoring processes in place to demonstrate this.

Mara reminded the audience that if stakeholders decide to scale up the programme but do not provide adequate resources or sufficiently incentivise those involved, a scaled-up version of the project risks failure (this can be seen in the example of the Peterborough Impact Bond which suffered from precisely this pitfall). Dr Thomas Kenyon from the World Bank echoed this view, advising those setting up a DIB for scale to think carefully about who needs to do what in the entire service delivery chain, and whether they have the resources, information, and motivation to go through with it.

A promising picture

Ultimately, the potential to scale and sustain the impact of the KMC DIB was unlocked by clear outcomes-setting and policy alignment, significant government engagement, durable collaboration between incentivised partners and adaptive service delivery. Forging effective cross-sector partnerships to improve social outcomes is not easy and lessons from the KMC DIB might not be suitable for every context, but these factors certainly serve to paint a picture of a promising route to scale and sustainability.