Success and challenges in design, implementation, and evaluation of innovative financing for women's health

Ideally, all adolescent girls and young women around the world should be able to pursue their education, careers, and personal growth free from health risks that derail their prospects. Yet in South Africa, many face heightened vulnerability to HIV and unplanned pregnancy, threatening their health, education, and economic futures.

In 2023, the SAMRC partnered with government and philanthropic actors to address these risks by implementing an Integrated Health Policy and Sexuality Education programme across 14 schools. The initiative was financed through the Imagine Social Impact Bond (SIB), which linked payments to measurable improvements in sexual and reproductive health. These included increased coverage of pre-exposure prophylaxis (PrEP), antiretroviral therapy (ART), and contraception, as well as higher rates of antenatal care attendance before 20 weeks of pregnancy.

Building an ecosystem for innovative financing in women’s sexual and reproductive health is a complex task, requiring coordination across the public–private divide and between government departments. The Imagine project faced both challenges and breakthroughs during its design, implementation, and evaluation. To explore these, Emily spoke with Nevilene Slingers, Lee-Ann Davids, and Petro Rousseau at the mid-point of the Imagine SIB.

The conversation offers valuable lessons for decision makers considering innovative financing, as well as insights that may resonate with seasoned practitioners in the field.

Here’s a sneak peek:

Challenges in the design of the Imagine SIB were unsurprisingly regulatory hurdles and poor sub-district data, limiting certainty around baselines and choice of broad versus ambitious outcomes. However, this was counteracted by the fact that this programme was a landmark in South African policy. It was the first health SIB in Africa, which ran parallel to the regulatory innovations within the Public Finance Management Act and the South African Presidential Health Compact. The South African Presidential Health Compact which was signed a year ago committed to creating a “…regulatory environment for innovative financing instruments and a pathway for approvals of innovative financing transactions” (pg17, 2nd Presidential Health Compact 2024-2029). This represented a monumental shift away from conventional financing mechanisms. This ensured that regulatory barriers faced during the Imagine SIB under South Africa’s Public Finance Management Act (treating SIBs as loans) which slowed approvals, are less likely to occur in newer programmes and promise smoother pathways via these recent reforms.

As the SIB progressed from design to implementation, unexpected challenges and successes also arose. Early mobilisation of the project was delayed, compounded from staff turnover, funding reallocations, and electricity blackouts. Yet in despite of this, flexibility was built in, mental health services and injectable PrEP were added mid-programme. Local non-financial investments such as peer influencers, community skill transfers, and upliftment efforts, strengthened buy-in and dignity for service users.

Beyond the program, new drug developments also shed great hope on bringing more effective PrEP or HIV prevention to adolescent girls. The first regulatory trial of lencapavir in adolescent girls and young women occurred in sub-Saharan Africa. Leading experts in Lancet HIV highlighted the significance of this development: “Historically, adolescent girls and young women have been underserved in drug development because of perceived difficulties in doing trials involving people who might become pregnant. But this exclusion has created a paradox: the population most in need of innovations in HIV has been excluded from them” (Lancet HIV, 2024). In the chat, our guests reveal in the podcast the excitement yet also the issue of equitable access. 

With National Health Insurance reform in South Africa on the agenda, the lessons from Imagine on ambition, flexibility, and the centrality of dignity in health care for vulnerable adolescent girls, may shape the future of financing for public health priorities. Crucially, the innovative financing via a social impact bond created a platform for dialogue between government, investors, and implementers on scaling outcomes-based approaches. Finally, what was inspiring was that the Imagine SIB through hard work yet rewarding effort from the South African Medical Research Council created an impetus for future innovations, if we are willing to imagine a better future. 

Reference:

The Lancet HIV (2024) A game-changer for PrEP if access is adequate. The Lancet HIV, 11(9), e567.

Republic of South Africa (2024) Second Presidential Health Compact 2024–2029. Pretoria: National Department of Health. Available at: https://www.health.gov.za/wp-content/uploads/2024/08/Second-Presidential-Health-Compact-2024-2029.p… (Accessed: [ September 2024; 2025]).