Cameroon Kangaroo Mother Care Development Impact Bond

This development impact bond (DIB) was designed to implement at scale Kangaroo Mother Care (KMC) in up to 10 hospitals in Cameroon. KMC is an intervention for saving and caring for infants by administering continuous skin-to-skin contact, breastfeeding, and early discharge from hospital with follow-up.

Project Location

Aligned SDGs

INDIGO Key facts and figures

INDIGO project
- INDIGO-POJ-0015
Commissioner
- Ministry of Public Health, Cameroon (via the World Bank’s Global Financing Facility)
- Nutrition International
Intermediary
Investor
- Grand Challenges Canada (GCC)
Provider
Evaluator

Launch date

December 2018
Start of service provision

February 2019
Duration

2 years
Capital raised (minimum)

USD 800k
Service users

2k+

Target population

The project will be implemented across five regions in Cameroon targeting low birth weight (LBW) or preterm newborns. Those regions were chosen based on needs (i.e. newborn mortality rate level) and volume of infants admitted in hospitals.

The problem

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 solution

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:

Roll out KMC in ten hospitals across five regions in Cameroon, with the ultimate outcome to generate significant and verifiable improvements in low birth weight infant health.
Integrate high-quality KMC into Cameroon’s public healthcare system to ensure the DIB investment’s long-term sustainability, including further expansion to hospitals nationwide.

This aim is aligned with the Cameroon Ministry of Public Health’s five-year operational action plan for improving newborn health.

The impact

The DIB successfully equipped 10 hospitals to deliver quality KMC, trained 47 neonatal clinicians and 121 community health workers to support caregivers to use KMC with low-birth-weight and pre-term babies. As a result, 1,221 babies received quality KMC, 28% percent above the DIB target of 951 babies. Furthermore 80% of babies were exclusively breastfed at point of discharge from hospital and 80% percent of babies returning for check-ups had appropriate weight gain at 40 weeks gestational age.

Hospital clinicians reported high levels of patient satisfaction and lower infant morbidity and mortality at programme hospitals, although this was not independently assessed.

The Cameroon Ministry of Public Health is now working to embed national roll-out of KMC in their strategy for Maternal and Newborn health.

Outcomes framework

There are three outcomes metrics that are used to trigger outcomes payments:

Number of hospitals with the prerequisites to implement quality KMC (incl. equipment, infrastructure, trained staff and protocols)
Number of infants who receive quality KMC before being discharged from hospital
Percentage of enrolled infants who come back for their 40-week follow-up with an appropriate weight and having received appropriate nutrition

IRESCO, the Independent verification agent, visited all onboarded hospitals on a quarterly basis to check the above – three cycles of verification were conducted remotely in 2020 due to Covid 19. For metric 1, IRESCO used a checklist. For metrics 2 and 3, IRESCO audited, based on a predetermined set of criteria, the numbers provided by the implementation team at Kangaroo Foundation Cameroon and surveyed mothers to assess the quality element, i.e. check the percentage of mothers who are performing skin-to-skin contact appropriately, who were providing appropriate nutrition to their infants and who were discharged in line with medical advice.

Source: Save the Children (2018) Investing in Maternal and Child Health: Development Impact Bonds

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.

To embed KMC capacity within public hospitals, the training was provided using a “train-the-trainer” model. Kangaroo Foundation Cameroon aimed to train some hospitals to become Centres of Excellence, building their capacity to implement quality KMC and train other hospitals. Those Centres of Excellence then trained other hospitals in their region under the supervision of Kangaroo Foundation Cameroon. This ensured that the practice of KMC is embedded in the public healthcare system, ensuring sustainability and further scale-up after the DIB.

As outcomes were 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), paid Grand Challenges Canada for each unit of outcomes achieved. As programme results exceeded expectations, Grand Challenges Canada received its principal plus interest. The Kangaroo Foundation Cameroon also received a performance related bonus.

Timeline

2015

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.
2016

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.
2018

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.
April – November 2020

Implementation started in Cameroon.
September 2021

Shift to remote verifications as a result of the Covid 19 pandemic.
September 2021

Programme completion (extended from March 2021 due to enrolment delays during the Covid pandemic in 2020.
These learnings were recently summarised in the DIB's end of programme report.

Project insights

Lessons learned
- An active role for government is vital – Beyond their role as outcomes funder, the Cameroon Ministry of Public Health also facilitated hospital engagement, coordination with other health system strengthening programmes and the allocation of clinical equipment and staff to programme hospitals. Their involvement also supported sustainability planning – see ‘What comes next?’ below.
- Regular evaluation enables rapid feedback loops – While frequent outcome verification felt like a strain for the first couple of cycles, the quarterly payment metric evaluation process quickly became a rich source of data for refining and improving programme delivery.
- Engaged cross-sector governance supports adaptation – Quarterly Steering Committee meetings – involving outcome funders, investors, the lead service provider and performance management advisor – enabled contractual elements to be adapted quickly when unforeseen circumstances occurred. A good example of this was the payment metric verification process, which needed to be adapted when in-person hospital visits became unfeasible during the Covid-19 pandemic in 2020. Decisions noted in signed Steering Committee minutes also had the force of contractual variations, saving considerably on legal time and costs.
- Key delivery staff need an adaptive mindset as well as specific skills – A strong commitment to using data to inform and improve service delivery is critically important for staff at all levels, and in both clinical and management roles, to effectively deliver an outcomes-based contract.
- A focus on outcomes creates clear priorities – it is an old truism that ‘you get what you pay for’ and that played out in the Cameroon KMC DIB. The DIB hit maximum outcomes payments for the three contractual payment metrics, but made slower progress towards the non-remunerated system-change objective of creating three new KMC Centres of Excellence. Progress towards new Centres of Excellence was hampered by non-DIB hospital infrastructure projects, high clinician turnover within hospitals, and the COVID 19 pandemic. The programme did however manage to train nine new KMC trainers within the public health system.
Source: Cameroon KMC Development Impact Bond: End of Programme Report, Social Finance, 2021
What comes next?
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. What emerged was a two part strategy for Cameroon:
- The first component involved fully transitioning the operational delivery of KMC – including data capture and analysis, and KMC equipment procurement – to programme hospitals.
- The second component involved the Service Provider, Fondation Kangourou Cameroun, working in partnership with the Ministry of Public Health to:
1. Embed KMC in the National Strategic Plan for Maternal and Child Health;
2. Explore opportunities for creating ongoing financial incentives for KMC within the broader Performance Based Financing programme for health system strengthening; and
3. Embed KMC training into mainstream clinician training and support curricula.
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.
Emerging evidence suggests that starting KMC immediately after birth for pre-term and low birthweight babies can have significant effects on neonatal survival. A WHO study, published in May 2021, found that starting Kangaroo Mother Care soon after birth improves the survival of babies with birth weight less than 1800 grams by 25%, when compared to the current recommendation of starting KMC after stabilisation. This shift has the potential to save up to 150,000 more lives each year.
Outcomes based approaches also have potential to support the successful introduction and roll out of KMC in other contexts. As demonstrated in the Cameroon KMC DIB, this flexible, data driven approach to programme delivery is well suited to adapting to changing contexts and ensuring the delivery of quality KMC within public health systems.
Source: Cameroon KMC Development Impact Bond: End of Programme Report, Social Finance, 2021