Investments in this strategy aim to reduce financial barriers to health services by introducing prepaid, pooled mechanisms for spreading risk across populations (e.g., insurance), fighting rising health care costs through innovative service delivery methods, and implementing new technologies to facilitate payment for services. The sections below include an overview of the strategy for achieving desired goals, supporting evidence, core metrics that help measure performance toward goals, and a curated list of resources to support collecting, reporting on, and using data for decision-making.

What

Dimensions of Impact: WHAT

Investors interested in deploying this strategy should consider the scale of the addressable problem, what positive outcomes might be, and how important the change would be to the people (or planet) experiencing it.

Key questions in this dimension include:

What is the problem the investment is trying to address? For the people experiencing the problem, how important is this change?

Each year, 10% of gross world product—USD 7.3 trillion—is spent on health by governments, individuals, corporations, and other actors in the health system (1). Despite this substantial global investment, people all over the world have difficulty covering the out-of-pocket expenditure (OOPE) required to purchase services at the point of care, which directly impacts health outcomes.

Evidence analyzed by the World Health Organization suggests that, in order to minimize household impoverishment due to healthcare spending, OOPE should be kept below 20% of total national health expenditure. However, OOPE in many countries exceeds this target; for example, only 10 of 47 African countries have OOPE below 20% of their total national health expenditures (2).

Higher OOPE can lead people to neglect needed care; one study associated a 10% higher share of OOPE with 11.6 more female deaths per thousand (13). The global health community’s vision of Universal Health Coverage (UHC) specifically means ensuring people can access the healthcare they need without incurring financial stress. OOPE is perhaps the largest barrier to realizing that vision.

A strategy to combat financial barriers to UHC can improve both financial resilience and health outcomes by:

  1. reducing OOPE by dispersing financial and health risks across populations through health insurance or other prepaid, pooled mechanisms (4);
  2. containing health care costs, which are rising in emerging markets due to population growth and economic expansion, through innovative methods to deliver health services and products (5);
  3. facilitating or simplifying payments for health care through mobile money platforms, often in conjunction with health-insurance mechanisms (6), and;
  4. reaching rural and other hard-to-reach populations with innovative service delivery models, thus reducing their costs associated with seeking care.

What is the scale of the problem?

According to a World Bank estimate, in 2010 808.4 million people worldwide (11.4% of world population) experienced catastrophic health expenditures (7). This indicator actually worsened compared to 2000, when 588.5 million (9.7% of world population) experienced catastrophic expenditures.

Who

Dimensions of Impact: WHO

Investors interested in deploying this strategy should consider whom they want to target, as almost every strategy has a host of potential beneficiaries. While some investors may target women of color living in a particular rural area, others may set targets more broadly, e.g., women. Investors interested in targeting particular populations should focus on strategies that have been shown to benefit those populations.

Key questions in this dimension include:

Who/What is helped through this strategy?

Below are some of the groups that could benefit the most from investments to reduce financial barriers to health services.

People Living in Poverty: By definition, financial barriers to health are the largest for individuals in poverty, who are also disproportionately affected by incidents of catastrophic health expenditure (7). Investments in this strategy could improve health outcomes, financial security, and even human capital.

People without Access to Formal Financial ServicesThe unbanked face particularly acute challenges associated with financial barriers to health care. Investments specifically in mobile payment platforms can reduce their financial barriers to care through easier access to health savings accounts, payments into health-insurance schemes, or other means (6).

GovernmentsThe absence of pooled financial and health risk across populations strains government resources for health (7). Investments in pooled risk schemes can create flexibility for governments to target their citizens' most pressing public-health needs.

What are the geographic attributes of those who benefit?

High-income countries comprise 16% of world population but 80% of global health spending, and they have made much greater progress to date toward UHC (1). Notwithstanding various financial barriers to health care in more developed markets, then, this strategy largely targets emerging markets in Africa, Asia, and Latin America.

Contribution

Dimensions of Impact: CONTRIBUTION

Investors considering investing in a company or portfolio aligned with this strategy should consider whether the effect they want to have compares to what is likely to happen anyway. Is the investment's contribution ‘likely better’ or ‘likely worse’ than what is likely to occur anyway across What, How much and Who?

Key questions in this dimension include:

Is the investment’s contribution ‘likely better’ or ‘likely worse’ than what is likely to occur anyway across What, How Much and Who?

Two main factors will probably contribute, without investment, to progress against the challenges this strategy confronts: (1) economic growth and (2) development toward UHC through social health insurance and other means aiming to decrease OOPE. Concerning economic growth, Brookings Institution economists estimated that, by 2030, the total global population living in extreme poverty will decrease by 200 million, but 438 million will remain impoverished (8). Notwithstanding expected economic growth and progress towards UHC, then, more effort to reduce financial barriers to health care will be needed both at present and in the future.

Investors can augment the potential impact of investments in this strategy by targeting areas experiencing slow growth or stagnant expansion of health coverage. Investments can also take advantage of synergies between these trends; for example, mobile platforms might enable the informal sector to contribute to and take advantage of health insurance.

How Much

Dimensions of Impact: HOW MUCH

Investors deploying capital into investments aligned with this strategy should think about how significant the investment's effect might be. What is likely to be the change's breadth, depth, and duration?

Key questions in this dimension include:

How many can receive the outcome through this strategy?

A WHO report estimates that health expenses annually drive 100 million people into extreme poverty, all of whom would greatly benefit from investment in this strategy (7). Notably, financial distress caused by high OOPE is also frequent in developed markets, including the United States (9).

How much change can beneficiaries experience through this strategy?

The amount of change this strategy can deliver for certain beneficiaries depends on their baseline income and health outcomes, as well as the degree to which the investment targets them specifically. MicroEnsure, for example, a social business offering innovative financial-protection products for the base of the pyramid, partnered with mobile provider Tigo to allow enrollees to purchase basic health and life insurance by making small mobile payments. After launching in 2013 in Dar es Salaam, MicroEnsure spread quickly to the rest of Tanzania; it was East Africa's fastest-growing health insurance product that same year (10).

Risk

Dimensions of Impact: RISK

Key questions in this dimension include:

What risks do investments in this strategy run in terms of either people/planet experiencing impact or society as a whole? What is the probability that those risks happen?

Stakeholder-Participation Risk is the primary risk associated with this strategy, as patients and other stakeholders may require education and awareness regarding specific interventions. Especially for insurance and other prepaid, pooled schemes, terms of payment and other features can be difficult for stakeholders to understand. Jamii Africa, a microinsurance platform in Tanzania that allows users to pay using mobile phones, faced initial obstacles in this regard, which it overcame through extensive educational and outreach efforts (11).

What are likely consequences of these risk factors?

Since Stakeholder-Participation Risk can dilute or even nullify the impact of the strategy, relevant parties should engage requisite stakeholders to ensure they understand the nature of the investment. For example, mobile insurance providers should take great care to inform clients of the basic uses and benefits of health insurance, whereas strategies aiming to reach the poor through innovative service delivery models will require more intensive engagement with providers.

Illustrative Investment

AllLife, supported by a USD 13.9 million investment from Leapfrog Investments, provides affordable life insurance to patients living with HIV in South Africa. Integral to AllLife's model is an adherence program: under the terms of this program, which accompanies all of its products, clients must follow steps to ensure optimal health for those living with HIV, including anti-retroviral therapy and regular blood testing. (HIV-positive clients previously had difficulty accessing coverage, an important market gap that AllLife fills.) The company has grown substantially since its inception. Since then, by leveraging investment, it has also developed diabetes-related products (12).

 

Draw on Evidence

This mapped evidence shows what outcomes and impacts this strategy can have, based on academic and field research.

NESTA: 3
Evaluation of a mHealth Data Quality Intervention to Improve Documentation of Pregnancy Outcomes by Health Surveillance Assistants in Malawi: A Cluster Randomized Trial

Joos O, Silva R, Amouzou A, Moulton LH, Perin J, Bryce J, et al. (2016) Evaluation of a mHealth Data Quality Intervention to Improve Documentation of Pregnancy Outcomes by Health Surveillance Assistants in Malawi: A Cluster Randomized Trial. PLoS ONE 11(1): e0145238.

NESTA: 3
Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya

McConnell M, Ettenger A, Rothschild CW, Muigai F, Cohen J. Can a community health worker administered postnatal checklist increase healthseeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya. BMC Pregnancy Childbirth. 2016 Jun 04;16(1):136.

NESTA: 2
Improvement in Integrated Management of Childhood Illness (IMCI) Implementation through use of Mobile Technology: Evidence from a Pilot Study in Tanzania

Mitchell M, Hedt B, Msellemu D, Mkaka M, Lesh N. Improvement in Integrated Management of Childhood Illness (IMCI) Implementation through use of Mobile Technology: Evidence from a Pilot Study in Tanzania. BMC Med Inform Decis Mak. 2013;13:95.

NESTA: 2
Short message service (SMS) reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda

Haberer JE, Musiimenta A, Atukunda EC, Musinguzi N, Wyatt MA, Ware NC, et al. Short message service (SMS) reminders and real?time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS. 2016;30(8): 1295.

NESTA: 2
Early BCG vaccine to low-birth-weight infants and the effects on growth in the first year of life: a randomised controlled trial

Biering-Sorensen S, Andersen A, Ravn H, Monterio I, Aaby P, Benn CS. Early BCG vaccine to low-birth-weight infants and the effects on growth in the first year of life: a randomised controlled trial. BMC Pediatr. 15, 137 (2015).

NESTA: 3
Introducing rapid diagnostic tests for malaria to drug shops in Uganda: a cluster-randomized controlled trial

Mbonye AK, Magnussen P, Lal S, Hansen KS, Cundill B, Chandler C, et al. (2015) A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria. PLoS ONE 10(7): e0129545.

NESTA: 3
The impact of training informal health care providers in India: A randomized controlled trial

Das J, Chowdhury A, Hussam R, Banerjee AV. The impact of training informal health care providers in India: A randomized controlled trial. Science2016;354:aaf7384.

NESTA: 3
Effect of a micro entrepreneur-based community health delivery program on under-five mortality in Uganda: a cluster-randomized controlled trial

Nyqvist, M. B., Guariso, A., Svensson, J., Yanagizawa-Drott, D. Effect of a Micro Entrepreneur Based Community Health Delivery Program on Under-Five Mortality in Uganda: A Cluster-Randomized Controlled Trial (CEPR Discussion Paper Series DP 11515). London: Centre for Economic Policy Research.

NESTA: 1
Measuring What Works: An Impact Evaluation of Women’s Groups on Maternal Health Uptake in Rural Nepal

Sharma S, Van Teijlingen E, Belizán JM, Hundley V, Simkhada P, Sicuri E. Measuring What Works: An impact evaluation of women’s groups on maternal health uptake in rural Nepal. PloS one. 2016;11(5):e0155144.

NESTA: 4
The Advance Market Commitment Pilot for Pneumococcal Vaccines: Outcomes and impact evaluation

Boston Consulting Group (BCG). The Advance market commitment pilot for Pneumococcal Vaccines: Outcomes and impact evaluation, 2015.

NESTA: 2
A low-cost ultrasound program leads to increased antenatal clinic visits and attended deliveries at a health care clinic in rural Uganda

Ross, et al, 2013. A Low-Cost Ultrasound Program Leads to Increased Antenatal Clinic Visits and Attended Deliveries at a Health Care Clinic in Rural Uganda. PloS One. 2013.

Each resource is assigned a rating of rigor according to the NESTA Standards of Evidence.

Define Metrics

Core Metrics

This starter set of core metrics — chosen from the IRIS catalog with the input of impact investors who work in this area — indicate performance toward objectives within this strategy. They can help with setting targets, tracking performance, and managing toward success.

Additional Metrics

While the above core metrics provide a starter set of measurements that can show outcomes of a portfolio targeted toward this goal, the additional metrics below — or others from the IRIS catalog — can provide more nuance and depth to understanding your impact.