A mother and her newborn baby in a maternity ward supported by U.K. aid at Lodwar hospital, Turkana, northern Kenya. Photo by: Russell Watkins / DFID / CC BY

Despite strides in maternal health — including a 38% decline in maternal mortality over the past two decades to 211 deaths per 100,000 live births — we’re still short of reaching the Sustainable Development Goals target of less than 70 per 100,000 live births by 2030. According to data from the World Health Organization, virtually all these fatalities occur in low- and middle-income countries, owing to unequal access to quality care.

An estimated $33 billion shortfall affects reproductive, maternal, newborn, child, and adolescent health. To combat the problem, new ways of funding maternal health programs are emerging. Performance-based financing models, which base funding in part on reaching specific targets, have gained traction, mainly because of their results-oriented focus. Such models are a form of incentive under which health providers are — at least partially — funded on the basis of their performance toward specific targets or actions.

Data plays a fundamental role in these performance-based financing models; targets rely heavily on continuous monitoring and evaluation of results.

Data and development impact bonds

One example, the Utkrisht Impact Bond, which launched in November 2017, aims to improve the quality of care among private maternity care providers in Rajasthan state in northern India.

Through this development impact bond — or DIB — the U.S. Agency for International Development, UBS Optimus Foundation, Palladium, Population Services International, Hindustan Latex Family Planning Promotion Trust, and MSD for Mothers hope to prevent 10,000 maternal and newborn deaths over five years. In recent years, the region has significantly improved maternal mortality rates, which sank by 45 points from 244 maternal deaths per 100,000 live births in 2011-2013 to 199 deaths in 2014-2016.

“We rely quite heavily not only on real-time data that our partners are keeping track of and sharing with us, but also [on] the verification of the result [from] a third party.”

— Priya Sharma, senior policy and innovative financing adviser, USAID’s Center for Accelerating Innovation and Impact

DIBs get private investors to pay up front for the cost of an intervention whose success is measured by clear, predetermined metrics. If the intervention or program succeeds in achieving its goals, the “outcome” funders — typically donor agencies, foundations, or companies — pay the investors back based on performance.

Christine Sow, former senior director of Palladium’s health programs, who recently took up the position of president and CEO at Humentum, told Devex she helped to coordinate the Utkrisht bond, the world’s first DIB in maternal health.

“We do see within the actual implementation of the intervention a real need for flexibility, and that data really helps. It’s symbiotic,” Sow said, explaining the need to collect data to inform iterations and changes.

DIBs depend heavily on data in both their design and implementation. Critically, data shapes the outcome payer metrics, as well as the levels of impact or success that should trigger the outcome payment.

“Then, during the implementation, there is the ongoing project data that needs to be collected, managed, and analyzed, and used for course correction during project implementation,” Sow said. “Data is really critical to a successful DIB process.”

For Priya Sharma, senior policy and innovative financing adviser at USAID’s Center for Accelerating Innovation and Impact, data and evidence drive everything for performance-based financing.

“One of the things that's very appealing about the impact bond structure is that our funding is essentially tied to the achievement of impact or outcomes,” Sharma said.

“We rely quite heavily not only on real-time data that our partners are keeping track of and sharing with us, but also [on] the verification of the result [from] a third party.” The verification agency Mathematica provides this data for the Utkrisht DIB.

As the outcome funder working with MSD for Mothers, USAID relies on verification data to trigger payment.

“The data Mathematica provides signals to us — as the outcome funder — and to the investor, whether the agreed outcomes have been met,” Sharma said. “It's sort of the trigger for our payments back to the investors.”

Sharma explained that none of this would function without having the appropriate monitoring and evaluation needed to make sure partners are on track and doing what they said they were going to do.

Attracting more funding for maternal health

To investors like the UBS Optimus Foundation, innovative financing models can be vehicles that help bring new people into impact investing — either through a DIB or a different mechanism, Sow explained.

Having actors like UBS Optimus Foundation engaged in these kinds of funding mechanisms is helping to provide a role model, setting the bar for other banks or corporate entities looking for new ways to engage, she added.

Most investors in this space want to see some type of social good emerge from their investment. Data is key to demonstrate this.

“The better that we can get at proving that their investment has impact … increases or strengthens their incentives to [engage],” Sharma said.

For USAID, results-based financing mechanisms such as DIBs are “a nice way of making sure that we’re being expectant and efficient with our resources and targeting them towards areas where we know we're having outcomes,” she said.

Lessons learned from Utkrisht

During the design phase of the Utkrisht bond, a policy shift forced a major course correction. The new policy, called PM-JAY, meant that more families were covered by a new government health insurance scheme, resulting in fewer patients seeking care at private sector facilities.

To evaluate whether the DIB would capture sufficient patients to have an impact, the program undertook a statewide mapping exercise.

“Through that, we were able to confirm our actual eligibility pool and then make a few corrections that allowed us to keep on doing what we had been planning — and being pretty sure that we will get to our outcome numbers,” Sow explained.

The Palladium team also learned that the type of data you collect matters.

“Being pretty prescriptive with partners about what the definition of each metric is — and how we expect that data to be collected — has been crucial,” Sow said, adding that for the Utkrisht bond, that meant clearly defining the data needed.

For example, investors wanted to ensure that the DIB was working in facilities with at least three employed midwives. But the data revealed inconsistent collection practices among implementing partners: One partner was providing the specific number of midwives, whereas another was documenting midwife presence at facilities with a simple “yes” or “no.”

This practice needed to be shifted, as gathering specific metrics allows for greater depth of analytical power, Sow said.

Collecting and sharing the right data

A review of three health DIBs by the Center for Global Development in 2018 recommended further study of their impact. It cited a need for tighter guidelines and agreements on outcomes.

“Agreed principles for evaluating prospective and implemented DIBs can create foundations for comparability among DIBs with other funding structures,” the review found. It also mentioned the need for independent documentation and evaluation to create reliable evidence to act upon.

“One of the things that we are hoping to get out of these early pilots in the impact-bond space is a richer data set and understanding of what it costs to improve quality of care if we’re only paying for outcomes,” USAID’s Sharma explained.

“We're contributing to that global body of knowledge to be able to understand, at a high level, what are the benefits of actually structuring something like a DIB versus a traditional grant,” she said.

The Maternity Matters series is sponsored by MSD for Mothers, MSD’s $500 million initiative to help create a world where no woman has to die giving life. The content of this article is the responsibility of the author(s) and does not necessarily represent the official views of MSD. MSD for Mothers is an initiative of Merck & Co., Inc. Kenilworth, N.J., U.S.A.

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