Can we tackle TB in Fiji with a social impact bond?

Published: 16 January 2017

A family in Fiji sitting on the ground outside a building
One third of the world’s population is estimated to have latent tuberculosis (TB).

Unbelievable, isn’t it? One in three people. 10% of them will fall ill with the active form of the disease, of whom around 50% will die. Over 10 million deaths per year (largely concentrated in low and middle income countries) … from a disease that is curable. Yet there is a shortfall in funding, estimated at $2 billion today and increasing to $6 billion by 2020. So how can additional investment be leveraged in to help fill this gap and drive improved outcomes?

In November, to the envy of all my colleagues, I found myself on a plane to Fiji to help answer this question. The TB programme in Fiji has traditionally been largely reliant on grant support from The Global Fund. However, with this funding being phased out, the government is grappling with how to manage the transition whilst continuing to improve health outcomes. I was there to explore whether a social impact bond could provide an effective mechanism to support this.

I spent two weeks travelling around the country meeting with government officials, health workers, volunteers and patients to understand the TB system, the challenges it faced, and whether there were parts of the system that could be well suited to a social impact bond. Other than that, Fiji is a fantastic place to go on a work trip, one of the first things that struck me was that many of the difficulties with managing TB are operational. There are well established and pretty accurate diagnostic tests to identify cases, and clearly defined drug regimens to treat patients with the disease. However, these technologies can only be effective if the right cases are referred in the first place, and if patients actually sustain the course of drug treatment they are prescribed.

Case detection and community treatment support (where volunteers ensure patients take their medication) both lend themselves to the more data-driven, adaptive approach to implementation that a SIB could offer. By incentivising outcomes, not process, a social impact bond would enable adaption to what works on the ground and redirection of funding to the activities that prove most effective. This is especially important in Fiji, given the logistical challenges of operating in a small country with a geographically isolated population spread over 106 different islands.

Scale is an issue. As a country of less than 900,000, the overall TB budget is small, and so it would be important to ensure that set up costs aren’t disproportionate to the overall size of the programme. This could partly be addressed by taking a more pragmatic approach to outcomes measurement instead of adopting gold standard’ methods and their associated costs (which we’ve discussed before). However, there is also a case to be made for investing in the development of a social impact bond in Fiji as a pilot for a new way of improving TB management globally. Many of the component parts of TB prevention and treatment are the same the world over, and many countries face similar challenges. A pilot in Fiji could be used to test the value of delivering TB services through a social impact bond in a particularly challenging operating context, creating valuable learnings of effective practice and potentially a precedent for other countries to follow. Who could imagine a more picturesque testing ground than Fiji’s beautiful remote islands?

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