10 mins read
February 2019- September 2021
Upfront capital committed
Maximum outcome payments
USD 2,000,000 (Ministry of Public Health) and CAD 1,000,000 (Nutrition International - incl. covering the Independent Verification cost)
Five regions in Cameroon targeting low birth weight or pre-term newborns. Those regions were chosen based on needs (highest newborn mortality rates) and volume of infants admitted in hospitals.
Ministry of Public Health, Cameroon (drawing on funds from the Global Financing Facility); Nutrition International
Kangaroo Foundation Cameroon (Lead service provider); Kangaroo Foundation Colombia (Technical advisor); 10 partnering hospitals (including the KMC Centre of Excellence in the hospital Laquintinie in Douala)
Grand Challenges Canada
Social Finance (Performance Management Advisor); MaRS Centre for Impact Investing and Social Finance (co-design of the impact bond)
Morrison & Foerster; Miller Thompson
Institut pour la recherche, le developpement socio-economique et la communication (IRESCO)
The world has made substantial progress in reducing child mortality in the past several decades. However, even as child deaths have overall decreased, there are approximately 7,000 newborn deaths every day around the world, amounting to 46% of all child deaths under the age of 5 years according to 2017 UNICEF data.
According to UNICEF data, in 2015, Cameroon had an under-five mortality rate of 88 per 1,000 live births. While this represents a 36% decline from its 1990 rate of 138, Cameroon still suffers from a high rate of under-five mortality. In 2016, the newborn mortality rate was still 26 per 1,000 live births according to World Bank data, increasing to up to 39 neonatal deaths per 1,000 live births in rural areas and among the poorest households.
Among these newborns, 60-80% of deaths were due to low birth weight. Low birth weight and preterm births continue to be the leading causes of under-five child deaths in Cameroon (and worldwide) in spite of overall progress on maternal and child survival. Moreover, low birth weight and preterm births can lead to high incidences of health complications, including hypothermia and hypoglycaemia. Even when a child survives, these complications can create additional negative health outcomes, such as neurodevelopmental, many of which can last into adulthood.
The primary goal of this project is to expand quality Kangaroo Mother Care (KMC) in Cameroon through a development impact bond (DIB). KMC is a proven, cost-effective health practice recommended for low birth weight and preterm infants. KMC, named for its similarity to how marsupials carry their young, was developed in Colombia during the 1970s. It was designed specifically for preterm and low birth weight infants who are particularly vulnerable and have difficulties regulating their own temperature. KMC involves providing the baby long periods of skin-to-skin on the mother or caregiver’s chest, ideally feeding them only breastmilk. Newborns and infants who receive this type of care can typically be discharged from the hospital earlier, with caregivers continuing to perform KMC at home. An important prerequisite for infant health and survival is timely and appropriate follow‐up after the infant is discharged. It has also been shown that KMC effectively reduces both infant mortality and hospital-acquired infections.
KMC is an intensive health practice that requires significant upfront investment and a functioning health system. In Cameroon and much of the world, access to KMC remains low, due to a variety of financial and implementation barriers such as poor hospital infrastructure and equipment, lack of qualified personnel and the lack of integration into local health care systems.
The Kangaroo Mother Care DIB‘s objective is to expand quality KMC to five regions in Cameroon to reduce infant mortality levels. The DIB aims to achieve this in two ways:
This aim is aligned with the Cameroon Ministry of Public Health’s five-year operational action plan for improving newborn health.
In September 2021, those involved in the delivery of the programme undertook a multi-stakeholder learning exercise to reflect on the DIB’s decision-making and governance structures, data and learning mechanisms, financial structure, management systems, and how to sustain impact after the DIB. These learnings were recently summarised in an end of programme report, which you can read here.
According to the report, 10 hospitals were equipped to deliver quality KMC, 46 neonatal clinicians were trained to deliver quality KMC, 9 clinicians were trained to train others to deliver quality KMC and 121 community health workers were trained to support KMC hospital transfers. Regarding neonatal outcomes, 1,221 babies received quality KMC in programme hospitals, 80% of KMC babies were exclusively breastfed at point of discharge from hospital and 80% of babies had appropriate weigh gain at 40 weeks gestational age. Grand Challenges Canada received full repayment of outcomes-based investment and risk premium.
As there was no systematic evaluation of the impact of KMC roll-out on neonatal morbidity and mortality for low birth weight and pre-term babies, the DIB did not contribute to the broader evidence base for KMC as a methodology in its own right. However, indicative data from programme hospitals suggests lower mortality rates among babies receiving quality KMC care, and babies that were safely transferred to hospital in the KMC position.
KMC mothers also reported high levels of satisfaction with the approach, citing improvements in confidence and connectedness when caring for their infants. Beyond the direct medical benefits, clinicians trained in KMC believed the KMC practice also discouraged early hospital discharge against medical advice by reducing the costs of hospital care for families compared with more expensive incubator-based care.
There are three outcomes metrics that are used to trigger outcomes payments:
IRESCO, the Independent verification agent, will visit all onboarded hospitals on a quarterly basis to check the above. For metric A, IRESCO will use a checklist. For metrics B and C, IRESCO will audit, based on a predetermined set of criteria, the numbers provided by the implementation team at Kangaroo Foundation Cameroon and survey mothers to assess the quality element, i.e. check the percentage of mothers who are performing skin-to-skin contact appropriately, who are providing appropriate nutrition to their infants and who leave the hospitals at an appropriate time (i.e. not against medical advice).
Grand Challenges Canada has provided CAD $1 million in upfront funding. Kangaroo Foundation Cameroon is using the capital to build critical infrastructure, purchase specialized equipment, and provide professional KMC training for staff and ongoing support in health facilities across Cameroon.
The training will be provided using a “train-the-trainer” model. Kangaroo Foundation Cameroon will train some hospitals to become Centres of Excellence, building their capacity to implement quality KMC and train other hospitals. Those Centres of Excellence will then train other hospitals in their region under the supervision of Kangaroo Foundation Cameroon. This will ensure that the practice of KMC is embedded in the public healthcare system, ensuring sustainability and further scale-up after the DIB.
As outcomes are achieved, the Government of Cameroon via the Ministry of Public Health, with the support of the Global Financing Facility (USD $2 million) and Nutrition International (CAD $1 million), will pay Grand Challenges Canada for each unit of outcomes achieved. If the results achieved are aligned with expectations, Grand Challenges Canada will receive its principal plus interest.
In May 2015, Grand Challenges Canada contracted the MaRS Centre for Impact Investing, with the support of Social Finance, to review its portfolio and identify programs that could benefit from an outcomes-based financing mechanism.
As Grand Challenges Canada reviewed potential DIB projects, Kangaroo Foundation Colombia’s work on KMC stood out for its strong evidence base and the challenge of scaling up the practice in other countries. Grand Challenges Canada thought that the KMC DIB was a good fit for the organisation given its growing focus on how to integrate innovative financing models to support bold ideas.
Grand Challenges Canada therefore supported Kangaroo Foundation Colombia in implementing KMC in Mali and Cameroon. This pilot project resulted in the creation of Kangaroo Foundation Cameroon and the setup of a KMC Centre of Excellence in Douala, Cameroon.
In 2016, Social Finance and MaRS Centre for Impact Investing started a feasibility study for the DIB. In 2016, Nutrition International was approached by Grand Challenges Canada as a prospective partner for the Cameroon Newborn DIB. The Ministry of Public Health also earmarked $2 million of Global Financing Facility’s funding for this impact bond.
Whilst Grand Challenges Canada was initially planning to be an outcomes funder along with the Ministry of Public Health and Nutrition International, it switched to the investor side in July 2018 after another investor unexpectedly withdrew from the programme.
Outcomes contracts (between Grand Challenges Canada and Nutrition International, and between Grand Challenges Canada and the Government of Cameroon’s Ministry of Public Health) were signed in December 2018.
Implementation started in Cameroon.
In the final 12 months of the Cameroon KMC DIB, contractual stakeholders turned their attention to how to both sustain and scale Kangaroo Mother Care in Cameroon and beyond following the end of the DIB.
To inform this planning, the Investor, Grand Challenges Canada, commissioned the Performance Management Advisor, Social Finance, to undertake a two-part, 360 degree stakeholder consultation. This captured lessons from the delivery of KMC in Cameroon at scale, and lessons from outcomes-based delivery of KMC as a health programme.
Programme came to a close. Those involved in the delivery of the programme undertook a multi-stakeholder learning exercise to reflect on the DIB’s decision-making and governance structures, data and learning mechanisms, financial structure, management systems, and how to sustain impact after the DIB. These learnings were recently summarised in the DIB's end of programme report.
The main challenge the outcome funders faced when setting up the DIB was finding a suitable investor. Grand Challenges Canada initially sought to play the outcome funder role in the project, but due to the difficulty in finding a suitable investor, it decided to take on the investor role.
The fundraising was particularly challenging for this DIB as Cameroon is often not a priority country for funders in addition to the difficulties in attracting funding towards impact bonds. First, because the due diligence process takes time and effort, some investors the team reached out to were not willing proceed given the size of the deal. Since impact bonds are new to many organisations, it required time investments to socialise the concept in order for the organisations to determine whether the investor role would align with their strategy and if so, how they could make such an investment.
As impact bonds are new, they are sometimes perceived as risky, even by organisations who typically provide grants for which there is a guarantee that their funding won’t be repaid with no guarantee of outcomes being achieved.
Encouraging country ownership is an important goal of the KMC DIB. The goal of improving newborn health aligns with one the key priorities of the Government of Cameroon and the Ministry of Public Health. To address critical gaps in health and nutrition outcomes, in 2016 the Government of Cameroon led a consultative process with key partners to plan support for partner alignment and government prioritization. The Government of Cameroon used the Global Financing Facility investment case to inform its 2018 national budget, developed at the end of 2017.
The Global Financing Facility seeks to mobilise support for developing countries to end preventable maternal, newborn, and child deaths by 2030, and finance Sustainable Development Goal 3 “Healthy lives.” It was announced at the United Nations General Assembly in September 2014 by the World Bank Group and governments of Canada, Norway, and the United States. The Global Financing Facility process provided the analytical underpinnings for the health sector reforms, including a trigger that commits the government to increase the health budget from 8% in 2017 to 20% by 2020.
As a result of the core priorities of the Global Financing Facility, the Cameroon Ministry of Public Health entered the DIB as one of the outcome funders in the DIB, contributing USD $2 million, funded by Global Financing Facility, to pay the investor if outcomes are achieved. The Ministry also provides operational support and has integrated commitments to extend KMC coverage into its national health plans.
Having the Ministry of Public Health as one partner ensures the sustainability of KMC practice beyond the end of the DIB. Indeed, nine of the ten hospitals expected to be onboarded on the programme are public hospitals. Since a train-the-trainer model will be used to scale KMC, Centres of Excellence will be set up in public hospitals and will be able to train other hospitals after the end of the DIB.
One of the main reasons Kangaroo Foundation Colombia’s KMC work was selected for a DIB intervention was the strength of the evidence supporting its efficacy. The service providers for the KMC DIB (Kangaroo Foundation Colombia and Cameroon) are all experienced with KMC and have been proponents of this intervention for a long time.
Kangaroo Foundation Colombia has a long history working on KMC in Cameroon. Beginning in 1998, Kangaroo Foundation Colombia trained paediatricians and nurses from Laquintinie Hospital in Douala on KMC practices. However, because the KMC practice was not integrated into the local health system, the expertise disappeared when the Laquintinie Hospital paediatric unit chief retired. More recently, in 2015, Grand Challenges Canada supported a Kangaroo Foundation Colombia project that resulted in the creation of a KMC Centre of Excellence in Douala, along with the creation of the Kangaroo Foundation Cameroon increasing the integration of this essential practice for infant health.
For this DIB, Kangaroo Foundation Colombia has collaborated with the other project stakeholders on the DIB design and the development of the project indicators, and it will continue to provide technical support to Kangaroo Foundation Cameroon during implementation.
Communication with Marie-Alphie Dallest, Social Finance (July 2019).
This case study was compiled by Ecorys.
Page last updated: September 2021.