5 mins read
Maximum outcome payments
USD $8 million
Private health facilities in Rajasthan, and the mothers and newborns they serve
Merck for Mothers and USAID
Hindustan Latex Family Planning Promotion Trust (HLFPPT) and Population Services International (PSI)
UBS Optimus Foundation and co-investment from the implementation manager (Palladium) and service providers (HLFPPT and PSI)
Mathematica Policy Research
Social Finance UK, Instiglio, Reed Smith, Phoenix Legal
Maternal and newborn health is a significant challenge in India. Rates of maternal and newborn mortality remain high compared to rates in other countries. Within India, the state of Rajasthan has one of the highest maternal and neonatal mortality rates. To date, there have been a number of programmes supporting maternal care, including provision of incentives for mothers to give birth in facilities. However, these programmes have not significantly reduced morality rates. This might be due to the quality of maternal and neonatal care provided in facilities.
The Government of Rajasthan has therefore prioritised improvements in the quality of the services offered in public facilities, which have to comply with government standards and benefit from a number of interventions. However, by and large, the Rajasthan government has no direct control over private facilities in terms of quality control. The adoption of NABH and Manyata standards depends on the will of private facilities. Government has set up certain minimum norms to be followed by the private facilities, alongside various schemes that aim to function as catalysts in improving the quality of private hospitals (e.g. the Bhamashah scheme; the Janani and shishu suraksha scheme; the central government funded Ayushman Bharat Scheme).
The DIB is funding two service providers, Hindustan Latex Family Planning Promotion Trust (HLFPPT) and Population Services International (PSI), to support private facilities to (1) improve the quality of care provided to mothers and newborns, and (2) prepare for certification by NABH and Manyata.
First, improvements in quality of care is expected to lead to improved maternal and neonatal outcomes. The intervention is intended to improve outcomes for approximately 600,000 births over five years, leading to a reduction in both maternal and neonatal mortality. Secondly, payments are made when the private facilities have been verified to be ready for NABH and Manyata certification. If private facilities get certified, it will allow them to seek reimbursement from government and participate in cash transfer schemes and insurance programmes, thereby eventually enabling greater coverage of patients.
The impact bond funds support to 360 to 440 private facilities across Rajasthan over three years, to prepare them for NABH and Manyata certifications. Private facilities are required to meet the following eligibility criteria:
Scale: Maximum facility size of 100 beds, minimum of 10 deliveries per month
Infrastructure: 24/7 electricity; 24/7 water supply; operating theatre; labour room
Staff: full-time gynecologist; at least three full-time midwives
Compliance: pollution control registration
The first results are due to be released in 2020.
The expected impacts of the DIB are improved quality of delivery care in private institutions, and concomitant reductions in maternal and newborn mortality. The Utkrisht impact bond is expected to impact the quality of approximately 600,000 institutional deliveries over five years. Estimates of mortality reductions are forthcoming. These are projected impacts of improving maternal care facilities, but will not be measured by the DIB, which will rather focus on facility standards and certification.
The outcome metric is private facilities reaching defined maternal and neonatal quality improvement standards, which align with NABH and Manyata standards.
Outcome payments are $18,000 per facility verified to be at the agreed upon quality standards.
Outcome funders will commit up to $9 million in total, of which $1 million relates to the costs of independent verification and impact evaluation. The remaining $8 million relates to payments to investors and service providers, based on achievement of pre-agreed results.
If 360 facilities are ready for certification, outcome payments would total $6.72 million. The remaining $1.28 million would be paid out should 440 facilitates be ready for certification. Outcome payments are paid biannually, as metrics are achieved and verifications undertaken.
Investors will contribute a total of $4.8 million. This covers the working capital needed to provide support to facilities. This is lower than the outcome funding value, as a portion of outcome payments will be recycled. This DIB involves UBS Optimus Foundation as the core investor, and the implementation manager (Palladium) and service providers (PSI and HLFPPT) as co-investors.
If 360 facilities are reached, the expected internal rate of return (IRR) is around 7.1%. UBS Optimus Foundation will have the first right to distribution of outcome payments, with a capped return of 8%. Any surplus over 8% will be distributed to service providers.
Overall payments including investment return and incentive payments will be capped at 15% of the overall cost of the implementation activities.
The outcome metric is certification readiness; it is expected this quality improvement should lead to lower neonatal and maternal mortality rates. Predefined quality improvement metrics provide service providers with a clear set of targets to work towards. On the other hand, the focus on private facility certification is at the expense of other activities that were initially considered, including wider government capacity building. Additionally, the standard is new, and hence there is limited evidence of impact.
The Rajasthan Government and Palladium start discussing an impact bond
USAID and Merck Mothers join discussions
Meeting in Jaipur to discuss structure. UBS Optimus Foundation joins
Convergence awards Palladium a grant to complete structuring activities and launch the impact bond; Social Finance engaged
There was concern from certain stakeholders that the impact bond structure may not be appropriate for the intervention, given that the quality standard used is new and no direct evidence is available to prove the success of the intervention.
However, stakeholders concluded that the results-based approach and the flexibility the service providers had in delivering the intervention still provide sufficient value and justification to use the impact bond contracting mechanism.
The DIB represents an opportunity to bring together a range of partners that would have otherwise worked in parallel or even against each other. The DIB was able to draw in multiple partners to work collaboratively to fund the same project, rather than supporting separate projects.
This has strengthened the coordination of actors working within the same system, working towards the same outcomes. However, this also presents challenges; aligning the objectives and interests of diverse organisations was difficult. There were extensive negotiations on defining maternal quality of care indicators and metrics, which took around six months in total.
The lack of a DIB template was cited by Utkrisht bond stakeholders as a key challenge. As they essentially had to start from scratch, the design of the DIB was a very time-consuming process.
This case study was compiled by Ecorys UK.
Page last updated: October 2019.
Utkrisht DIB - Overview informationDownload PDF
Save the Children (2018) Investing in Maternal and Child Health - Development Impact Bonds - Potential and Early LearningDownload PDF
Convergence, Palladium, Bertha Centre (2018) The Utkrisht Impact Bond Case StudyDownload PDF
Utkrisht - Data TemplateDownload XLSX